Nursing is a calling

Nursing is a calling, so believed Florence Nightingale. She felt that what was required to be a nurse involved both diligence and vigilance, qualities that were not sustainable for many in spite of a desire to serve the ill. Today, nurses have moved into the role of primary caregivers during hospitalizations, in public health, in clinics and physician offices, in emergency rooms and urgent care clinics.  In her many writings, Nightingale claimed that “while it may be the surgeon that saved the patient’s life, it will be the nurse who teaches that patient how to live.” Thus, the role of the nurse is often not appreciated until it becomes clear that the nurse at the bedside is the person holding the hand and health of the patient.

As we move into Accountable Care Organizations, it will become even more evident that the role of nursing holds the key to healthcare quality. This month of May, celebrating the birth of Florence Nightingale and honoring nurses who indeed continue to deliver caring at the bedside, is a small statement of gratitude that cannot go far enough to thank all those who have taken up this mission-driven work.

Pushing further towards more humane medical care, the MCAT, exams required for entrance into medical school, now includes four segments on empathy (NYT, April 13, 2012, ” Pre-Med’s New Priorities: Heart and Soul and Social Science“).  Questions are being introduced that involve social and behavioral sciences, subtle capacities that will translate in more empathy and compassion at the bedside tied to the highest skill levels.   In the New York Times article, references are reluctantly made to the humanities as being perhaps an avenue to bridge what has become the medical gap between the science and person.

Dr. Martha Nussbaum (University of Chicago, School of Law) in her writings on the fragility of human goodness, makes a good case for the humanities being requisite for teaching compassion, empathy, and for learning how to conceive of the experience of others unlike us.  The arts, music, literature, drama, dance…each translate the human condition into a form more universal while being so subjectively interpreted.

In the healthcare setting, human suffering meets science and technology at its best and most detached.  A heart monitor measures the functionality of the human heart, but hardly the condition of the person whose heart it is.  Focusing on the patient experience, on the living and breathing individual whose health has been entrusted to the medical team, requires empathy as well as clinical excellence, one not be sufficient without the other.

And so it is with HCAHPS, the newest “report card” for healthcare organizations. Patients are doing the grading this time. And, organizations are studying diligently, trying to hone in on what matters to patients in ways that can be reflected in the HCAHPS survey.

That the very existence and weight of the ‘test’ is resulting in better outcomes is not a surprise, but is welcome as motivation for moving beyond what other regulatory standards have required. The ability for a consumer-as-patient to compare hospitals in their own community, as is the case with HCAHPS, and have a voice in expressing what he or she has experienced, in many ways allows the words of Florence Nightingale again to be heeded.

In her Notes on Nursing (1864), she wrote, “The symptoms or the sufferings generally considered to be inevitable and incident to the disease are very often not symptoms of the disease at all, but of something quite different—of the want of fresh air, or of light, or of warmth, or of quiet, or of cleanliness, or of punctuality and care in the administration of diet, of each or of all of these.”

Having been involved with the environment of care for over two decades, I have looked extensively at the correlation between a patient’s condition and the surrounding physical environment.

Hospital noise is a natural result in institutional settings that house a lot of people and require a myriad of activities and machines. Noise directly affects those in the environment, resulting in sleep deprivation, increased pain and anxiety, stress and confusion, staff burnout and family distress. Because of the duality of being both an outcome and a risk factor, noise often is uncontrollable and unmanageable.

The good news is some methods have been implemented to control levels of ambient noise. However, the approaches used to lower noise have not been sustainable or consistent from hospital to hospital. This year, with HCAHPS having economic implications and bringing forward the environment of care as a performance standard, it is more important than ever to find a model for a quiet environment.

The bottom line: noise is a cultural trait…and changing that culture…requires a new paradigm of caring.

When so much of the world still faces the horrors of war, the cruelty of poverty, injustice, and uncertainty, I choose to set aside cynicism and disbelief, replacing these with the hope and wonder I had as a child. I feel grateful to be able to write to you using technologies that have made the world more transparent and peoples far away feel connected. We are fortunate to live in a time when scientific discovery has eradicated many fatal illnesses and brought hope for a future of better health. Philanthropy is being redefined as millions of people give a little to help so very many. Now is a great time to be alive, with the world changing so fast that tragedy turns into hope because time thrusts us into the future.

Yes, I am an optimist in this season when it is so easy to forget the Christmas Truce of 1914, a moment when the human spirit triumphed over tragedy and exhausted soldiers singing of Silent Night, Holy Night in Flanders Fields changed what is possible for all of us.

Dallas and I wish each of you a good, warm, and loving holiday, that next year shall renew our collective capacities for peace, hope, health, and an inspired future.
So, I include the Christmas truce carol as it is as appropriate now as it has ever been…
~ Susan Mazer

A Carol from Flanders

In Flanders on the Christmas morn
The trenched foemen lay,
the German and the Briton born,
And it was Christmas Day.

The red sun rose on fields accurst,
The gray fog fled away;
But neither cared to fire the first,
For it was Christmas Day!

They called from each to each across
The hideous disarray,
For terrible has been their loss:
“Oh, this is Christmas Day!”

Their rifles all they set aside,
One impulse to obey;
’Twas just the men on either side,
Just men — and Christmas Day.

They dug the graves for all their dead
And over them did pray:
And Englishmen and Germans said:
“How strange a Christmas Day!”

Between the trenches then they met,
Shook hands, and e’en did play
At games on which their hearts were set
On happy Christmas Day.

Not all the emperors and kings,
Financiers and they
Who rule us could prevent these things —
For it was Christmas Day.

Oh ye who read this truthful rime
From Flanders, kneel and say:
God speed the time when every day
Shall be as Christmas Day.

~ Frederick Niven
   (1878–1944)

The healthcare environment has approached its Fall; meaning, the sounds are of many colors, volumes, and timbres, rendering an almost impenetrable wall of sounds that is deafening nurses to critical alerts.  In October, I was part of a delegation from the acoustic community to attend the first Medical Device Alarm Fatigue Summit in Washington, DC. The topic was exactly as I just described.  The auditory environment in the hospital, with the complexity of multiple alarms for each patient amidst an already highly orchestrated background noise, has finally shown itself to be an actual risk factor.  The outcome of this facilitated workshop, attended by over 300 people from biomedical engineering, to nursing, to medicine, to medical product manufacturers and the FDA and Joint Commission, came up with immediate and long-term measures to reduce the challenges that are now being lived through each day.

The environment of care, as Florence Nightingale so clearly stated, either contributes to recovery or is itself a risk factor.  This identified challenge in the auditory environment illuminates the need to design a healing sound environment, rather than one out of control.

For every patient, their personal focus is the immediate world around them. Watching the news, wars, and politicians telling us about the impossible rather than the possible, the roller coaster economy, and its related stresses over and over is hardly good for patients’ health or ours.

Think about how you can bring a more positive and compassionate approach to your patients’ world. Then be the change.

Blue sky, amazing clouds, mountains...the dynamics of a world in motion.

On Sunday, June 5th, 1983, my mother, Beatrice L. Mazer,  died of a heart attack, sparing her from the terminal cancer that the doctors were going to report to her the next day.  I use the word “spared” because that is how all of us felt.  My Mom skipped the pain, the anxiety, and the long and arduous process of dying from cancer.  She just blinked and was gone.   To this day, 28 years later, when we recount that day, we all agree that Mom “won.”

My Mother was an advocate for the underprivileged in Detroit, teaching in the inner city in a school that was at the heart of where the 1967 race riots ignited.  After teaching 12 years, she became and advocated for educators and schools, working full time for the Detroit Federation of Teachers as a mediator.   She began working with the teacher’s union when collective bargaining was a dream and teachers had neither job security, any benefits, and little real professional status.   She was also on the first Board of Directors of the Health Alliance Plan of Michigan (HAP), the largest HMO in Metropolitan Detroit.

Within my memories of her, I also find my recollection of the Detroit public schools when the worst offense a student could make was to wear a hat in school or chew gum.  It was a time when I could walk to school and, in high school, catch a public bus downtown to Cass Tech which was in the heart, again, of distressed neighborhoods.  And, we lived in integrated neighborhoods, went to integrated schools, and enjoyed the best of Jewish and African-American cultures.  I got a stunning education that took me to Stanford on a graduate fellowship.

In my mothers work with the DFT, she met Bernie and June Fieger, parents of Geoffry Fieger whose name became nationally known as the attorney for Dr. Jack Kevorkian.  Small world, when I think about it.

On June 3, 2011, Jack Kevorkian died.  As the New York Times reported of his life, “His stubborn and often intemperate advocacy for the right of the terminally ill to choose how they die is widely credited with sparking a boom in hospice care in the United States, and with making physicians more sympathetic to their pain and more willing to prescribe medication to relieve it.”   Today, my sister in law, Susan Talon Mazer, is a clinical nurse specialist working in palliative and hospice care.

I am not sure how I would have felt to be able to choose between helping my mother “skip” the dying process and going through the arduous and painful decline of cancer to reach the same outcome.  However,  I am as grateful today as I was then, that the spontaneous heart attack was her ticket out of what would have been a terrible death.     As my cousin, also a nurse, told me, she did not even know she died.

Healthcare today is tending to end of life issues so much more openly than was common 30 years ago…even if it is imperfect in accepting death as an inevitable outcome of life.   The costs involved in end of life care remain high not because dying is expensive, but because denying its inevitability levies extraordinary  human and economic costs.   When my Dad died just 5 years ago, it was not difficult to decide not to prescribe antibiotics when his body became septic as the result of a pressure wound (bedsore).  He was bedridden, never to walk again due to a hip fracture, and for him, the infection was a way out of a life that was no longer worth living.  We knew he had been waiting for some way to get out of where he was…and this was it.

I am not sure how we each can decide in advance how we want the last chapter written.  In older movies, the screen would just come up and read, “THE END.”  Today, we know the movie is over when the credits come up.  So, perhaps the end of life is both about “THE END” and the credits. In either case, end of life is what it is…the end of the last chapter.

Rain makes rainbows. How could it be that easy?

In our time in Hawaii this month, the end of each rainstorm revealed a rainbow…and maybe that is how I would like it.  Lots of sound and lights…thunder and lightning…and then a rainbow.  Philosopher, Alan Watts, wrote, “Spring comes and the grass grows.” And with only these six single syllable words, he put into perspective how nature and life moves on without our permission.  During our  12 days in Hawaii,  it was sunny, warm, rainy, and wet.  And, aside from all the recent natural disasters, the political and economic threats around the globe and at home, the plants still grew, the flowers still bloomed, the waterfalls were rich and the rainbows shined gloriously.

This month, I share with you the views that we saw to remind you as nature reminded us:  Spring comes and the grass grows.  Life is. Enjoy the rainbows.

The waters wash the sands, the clouds decorate the sky...and we get to witness it all...

And, Mom still won.

It is clear that this question is one that has yet to be answered and she would be well within her rights to ask again and again of the same people, about the same social disparity.  As I write this, we are looking at an international crisis in many countries regarding social welfare, support for the poor and a safety net for a middle class weakened by the current recession.  For some the recession may not end for years; for others, it never happened.  Unlike the Great Depression, this recession did not impact everyone the same way.

Amidst the economic challenge is the very difficult and un-resolvable dilemma in the U.S. healthcare system. It makes me think of the automobile industry that was bailed out, the banks that were bailed out…the “too big to fail” excuse for billions  of dollars in federal funding to ensure the whole financial system did not crash.  Well, it is clear that our whole healthcare system is on the brink of failure and the push is to let it fail.  Why are the lives at stake not as important as the money at stake?  Why is it that the sick kids invisible to the system because their parents are invisible, are so expendable when the stock market, and the various big banks were clearly not?

Nightingale would look us all in the eye in disgust for values gone awry.  She would say to each of us who have so much more than we need that we should be ashamed.  And, she would look at the casualties of the many wars we have been engaged in the past 10 years and fight to her last breadth for their right for the best care, as she would fight for a patient’s right to the most compassionate and highly skilled clinician to help them recover.  Furthermore, as she would defiantly stand against a system that at that time and at this time,  would rather let the sick die than change, daring us question the tenet that receiving care is a human right, not an economic privilege.

For additional information on Florence Nightingale and her life, please download the Healing HealthCare System’s 5-part  podcast series: Florence Nightingale in Her Own Words

With all of this, there remains a segment of our population in the U.S. and, as well, whole communities in other countries, who are living in real time, not cloud time, for whom “I phone” implies a communication rather than a device.  There are those for whom Medline, WEBMd, and PubMed are foreign codes for a world that is inaccessible. What does this mean for providers, for physicians and nurses, and for families who remain outside the circle of knowledge which is growing by the gigabyte as I write this?

At the recent National Association of Broadcasters Annual Exposition in Las Vegas, Gordon Smith, the President of NAB, spoke to the continuing value of free, on-air television.  The need that remains for communities to have access to their own neighbors, to know the weather, to receive news relevant to what is happening in their own town.  He spoke of this within the context of the ongoing fight for bandwidth, for IP television streaming, for everything that these communities do not have.  There are health implications in all of this discussion. For example, understanding the importance and effectiveness of hand-washing specifically during the flu season has been touted redundantly on television programs on health…on cable health programs…that are unreachable to an economically challenged senior who has an old television and can’t afford to pay for cable. Recalls of entire food lots because of e-coli contamination, toys that have proven dangerous to toddlers, and defective automobiles have only been successful because of media alerts that go viral.

The C.A.R.E. Channel remains a closed-circuit channel that is easily accessible to everyone who can see a television while in the hospital, everywhere.  It is also provided at not cost to patients and most often as an open channel on the television.  When patients contact us, we can send an ol’ fashioned standard-definition VHS or DVD.  (Yes, VHS is still viable to many an elderly person!) We may remain a diverse society that must care not only for those who are living in the future of now, but also for those whose present is in some ways unencumbered by the pressures of continual access, expectation, and technological wonder.

I think I have a handle on all of this technology.  As many of us, I have and use a smart phone, a laptop computer, an IP Television, wireless internet everywhere that matters to me, and a Kindle app on everything.  In my doctoral work, I have virtually visited and used libraries all over the academic universe, have communicated with scholars internationally that I may never meet, and have done all of this from my laptop wherever I find myself.    However, when I see a much younger person handle all of these, I realize that I am translating through older paradigms…that technology is a second language to me, not a primary one.  Clearly, I am not the only one, with e-readers offering the real look of a virtual turned page to satisfy my own attachment to the past.   I still understand why the controls for DVD’s  look like it did with VHS…when the forward arrow “>” had relevance in the physical world.  However, with non-linear video formats, we can jump around and it is more about the timeline than the actual tape moving across the magnetic heads of a tape recorder.   We borrow still from the manual typewriter to use a qwerty keyboard, which was developed to deal with the physical arms of the typewriter not crunching upon each other.

Studies have continued to show that only through multiple and diverse paths of learning, with the use of both personal and technological tools…accompanied by real people speaking with real people…is information transformed into action.  So, while the future holds the magic of invention and innovation, the relationships around us remain the most powerful in influencing our lives and our health.   And, yes, time will continue to push forward whether we embrace it and jump on the treadmill of an ever faster moving world, or try to hold on to a pace much slower.