Time to Sing – The Unsung Heroes

Wishing you all a Happy Nurses’ Day

The theme for nurses’ day 2019 set by International Council of Nurses is “Nurses, A voice to Lead- Health for All”. The Council defined Health for all as “Health brought into reach of everyone in a given country.”

Source: https://www.icn.ch/sites/default/files/inline-images/IND2019%20LOGO.jpg

 

 

It is in consensus with the ‘Ayushman Bharat’ launched in India in 2018 pledging to provide holistic health to all.

No doubt, nurses will and are at the core, to reach people and provide the care in a holistic way. Learn about ‘Nurses day Theme 2019- Health for All’ here: https://www.youtube.com/watch?v=FTjCAbxTfwE

We celebrate nurses’ day every year but do we really ‘celebrate’ being the professionals we are?

“Unpraised, Unnoticed, Unseen, Undervalued”

Sounds familiar? Aren’t these the words we use for ourselves often? I know what you are thinking, it is about nursing so we are bound to use these words.

I beg to differ. One, you are more than JUST a nurse and two why should SOMEONE ELSE define who you are?

You might think, I am probably being unrealistic about it or a little philosophical. You might argue that the ground reality is different. The fellow doctor keeps yelling, the assistants don’t listen to you, your supervisor don’t listen to you or if you are a supervisor your junior do not listen to you. Anything in common here? NOBODY is listening to you J As per a study done at University of Minnesota, immediately after the average person has listened to someone talk, he remembers only about half of what he has heard—no matter how carefully he thought he was listening. Read more here: https://hbr.org/1957/09/listening-to-people

 

Source: https://narcsite.com/wp-content/uploads/2016/12/nobodys-listening.jpg

So, a nurse is not the only one in the world, to whom people are not listening to. Stop worrying about that. But on a serious note, communication is important and you can’t care for your patient if these people were not around.

Celebrate who you are

This nurses’ day, I want you to sit back and have a little perspective what does matter the most, whose opinion defines you as a professional and how do you want the world to look at you. We often use the phrase ‘Unsung heroes’ for nurses but it’s time that we break the curse and celebrated who we are. Recently, I read about something called the ‘Black-white thinking’ which is defining things narrowly like good or bad, this or that. Ironically, since childhood we all are taught to think that way. It is done by all of us but professionally I feel, we nurses use it a lot more.

Can you pick, which of the following is an example of Black-white thinking?

“I just can’t do it”

“I will try to do it”

“I think, I may be able to do it”

If you are thinking, the first one, you got it right. This is the case many a times when we are talking about nursing related issues. Either we are pulling ourselves down or saying it often for nurses.

“We are not appreciated”

“Nobody listens to us”

“We don’t get the opportunity”

 I am aware there are bigger issues like unequal pay, appreciation, not being heard which are for real. But, do understand that, if you keep on repeating something, your brain has the power to turn it true. Particularly your subconscious mind is very powerful. How you direct your thoughts may empower you or make you weak. Read more here: https://foreverconscious.com/research-proves-the-power-of-the-subconscious-mind

You choose to be a nurse, you are good at what you do and you know your job well!

And if you are satisfied with what you do, chances are today or tomorrow people will take you seriously and would appreciate who you are. It doesn’t mean that you don’t stand for your rights or don’t take action when something is not right around you. It means that you do what feels right.

Some brave stories

It is always encouraging to hear something good, positive and progressive but I am sharing the brave stories of nursing heroes, some with happy endings and some with not as these storied needs to be put to light to remind us about some of our great heroes who are/were diligently working towards a better world. Let us look at some of the many nursing heroes who were brought to limelight with their untiring and unbeatable efforts.

Lini Puthussery- India’s ‘hero’ nurse who died battling Nipah virus. I am not even making the title. This is how BBC news honored a nursing hero who died caring for her patients. Salute!

Source: https://ichef.bbci.co.uk/news/660/cpsprodpb/4E4F/production/_101674002_capture.jpg

Firdousa- A brave nurse who walked 40 kms to report on duty to relieve other nurses working in ICU for 2 days despite curfew.

 

Source: https://i2.wp.com/www.greaterkashmir.com/wpcontent/uploads/2017/05/2017_5largeimg214_may_2017_003736423.jpg?fit=480%2C320&ssl=1

Anjali Kulthe- saved 20 pregnant women from the terrorists during 26/11 attacks in Mumbai.

Source: https://www.thebetterindia.com/wp-content/uploads/2018/11/As-262F11-terrorists-wrecked-havoc-at-Cama-hospital-this-brave-nurse-saved-20-Pregnant-Women-2.jpg

Saving people at roadsides, inside the hospital or out of the hospital, there are many incidences you must have heard. Know that you make a difference and without you the pillar of healthcare can never be steady.

Keep Moving forward- Let’s create more Heroes

 

Source: https://cdn.shopify.com/s/files/1/2283/1013/products/419-65-4E_Just_Keep_Moving_Forward-White_1024x1024.jpg?v=1510295222
  1. Make a choice- On this special occasion decide that you will move forward. It is a choice that you make. You can choose to crib or decide to work on it. Find solutions to your problems which are practical. If we convey this to our next generation that ‘nothing is in our hands’ believe me it is not (remember the black-white thinking!).
Source: https://us.123rf.com/450wm/alexlaplun/alexlaplun1611/alexlaplun161100018/66579998-cute-funny-man-on-the-crossroad-with-question-symbol-on-the-blue-background-choice-or-decision-carto.jpg?ver=6
  1. Remember ‘Live and Let Live’- If you believe that you can’t do it so how can your colleague or junior do it? Give chances to grow, open up and be the change you want to see. This is the mantra to progress together as professionals.
Source: https://online.king.edu/wp-content/uploads/Nurses-Support-Young-header-KING.png
  1. Update yourself- Keeping up professionally is easy and you know it. Many nurses do a lot and don’t showcase, but off course the scenario is changing. Try to stick to your guns and move towards what your goals are professionally. Look for options to collaborate and improve what you are doing.

There are many lateral options available other than taking up the many conventional role of nurses. You can work as a counsellor, educator, school health nurse, informatics nurse or a nurse consultant in India and yes these options are available. There are innovations happening in healthcare which are giving opportunities to grow. Carve your niche!

“Nurses use our virtual platform for calls, text, patient survey, health education and counselling for more than 30, 000 patients across India. The results are analyzed and alerts are created around high risk patients” says Dr. Neelesh Bhandari, HealthO5 co-founder of a tech company who vouches for the efforts put in by the nursing team.

Source: https://cognigen-cellular.com/images/nursing-clipart-health-career-11.png
  1. Update yourself- Just checking if I still have your attention J remember to update yourself personally. Don’t forget that you have needs too. Read, learn, pursue a long lost hobby, exercise, go out with your friends you haven’t called for long. Doing something for yourself will not only motivate you but keep your confidence boosted, you will also be less stressful and not pass that stress to your team. So you are actually saving someone else as well if you take care of yourself. Stress is bound to happen and we know nurses undergo a lot whether you talk about resources, physical demand, staff shortage or maintaining work-life balance. An effort is required at your end to keep you sane.
Source: http://www.soidergi.com/wp-content/uploads/yo/young-woman-practicing-yoga-standing-in-tree-vector.jpg
  1. Celebrate success- small things are the big things in life. Celebrating individual or team efforts are worthwhile. Think of a patient who went home without pressure sore after a long stay, the team effort of resuscitating a patient who was saved or may be a colleague who completed their higher education. Make little steps count. After all, this is where you spend half your life after home.

 

Source: http://clipart-library.com/images/8cAbXXqxi.jpg

 

To conclude:

Be brave, challenge yourself and keep moving forward! I stop here with this wonderful quote that aptly describes a nurse. Do share your ‘hero story’ in the comment section.

“HAVE A HEART THAT NEVER HARDENS.

                        A TEMPER THAT NEVER TIRES.

                                                A TOUCH THAT NEVER HURTS” – Charles Dickens

References:

  1. BBC news. Lini Puthussery: India’s ‘hero’ nurse who died battling Nipah virus. 2018 May 22. Available from: https://www.bbc.com/news/world-asia-india-44207740
  2. This dedicated nurse walked 40 km through Srinagar’s curfew and riots to reach her hospital. 2016 July 15. Available from: https://yourstory.com/2016/07/firdousa-rashid
  3. Aranha J. On 26/11 This brave nurse saved 20 pregnant women from the terrorists bullets. The better India. 2018 Nov 26. Available from: https://www.thebetterindia.com/165211/26-11-cama-hospital-attack-hero-kasab-mumbai-news/

Preventing Adverse Events- What nurses need to know?

“Too err is Human: Building a Safer Health System”

The title that shocked the healthcare when Institute of Medicine reported that adverse events were the leading cause of death. It is difficult to think that seeking help caused more damage than good. The change began and continue to evolve to make healthcare a safer place with emphasis on errors which occur due to negligence and can be prevented.

Not so long away, a wrong patient was operated on the leg when he was admitted for head injury. Result, patient underwent an unnecessary procedure, has difficulty walking and still left untreated. In this case, the doctor was blamed for the mishap and was barred from operating without supervision. But the question is, was there no one else who had seen the patient before? The nurse who sent the patient for surgery, assistant who transferred the patient or the operating team (junior doctors, nurses)? The answer is complex but since it was a serious adverse event which caused grave damage to the patient, it was highlighted and the one who had the responsibility (surgeon) faced litigation.

Every day such events happen labelled as ‘Adverse events’ but often go unreported with a fear of consequences one might have to face.

‘Adverse’ a word which is frightening when attached to any situation especially in healthcare where the possibilities are enormous and tosses the mind in all sort of directions when we talk about the word ‘Adverse events’. Nurses are involved in most of the patient care delivery services whether in-patient, outpatient, community health care, name it and nurses are there managing patient independently or assisting doctors to do so.

10 facts on patient safety- An eye opener on adverse events (WHO)

  • Patient harm is the 14th leading cause of global burden of diseases
  • While in hospital, 1 in every 10 patients is harmed
  • Unsafe use of medication harms millions and costs billions of dollars annually
  • 15% of hospital spending is wasted dealing with adverse events
  • Investments in reducing patient safety incidents lead to financial savings
  • Hospital infections affected 14 out of every 100 patient admitted
  • More than one million patient die annually from surgical complications
  • Inaccurate or delayed diagnosis affects all settings of care and harm an unacceptable number of patients
  • Overall medical radiation exposure increase is public health and safety concern
  • Administrative errors account for up to half of all medical errors in primary care

What are the types of adverse events in healthcare?

 

Types of adverse event

  • Adverse event- It is an injury that happens to the patient in healthcare and is related medical management that results in measurable disability, prolonged hospitalization or both. The cause of such adverse events however may not always occur as a result of error on the part of healthcare provider. A common example is adverse drug reaction which is unexpected reaction to a drug administered for therapeutic purpose. Adverse event caused by errors may include:
  1. Commission errors- These include errors which occur as a result of doing something wrong. A common nursing commission error would include administering wrong medication dose to a patient.
  2. Omission errors- These errors include the either delay, partially completed or incomplete care that a patient should have received. For example the most common missed nursing care aspects are ambulating a patient, giving mouth care or turning a patient which could lead more grave consequences such as development of pressure ulcer or pneumonia in ventilated patient. Read more here: https://psnet.ahrq.gov/primers/primer/29/Missed-Nursing-Care
  • Error- It is the failure of a planned action to be completed as intended called the error of execution or the use of a wrong plan to achieve an aim called the error of planning. Number of error happening in healthcare may be large so these errors are classified as the one which are potentially harmful (such as near misses).
  • Near miss- It is a serious error that could have caused an adverse event, but did not occur as it was detected or was interrupted. It is encouraged that a near miss event be reported as no harm was done to patient and the healthcare provider will not face in litigation.
  • Hazards and unsafe conditions- These refer to reporting of hazards that may happen for example look alike and sound alike medicines.

 

Medicine

Types of Adverse events in direct nursing care

As per the literature, the following are the most common types of adverse events reported in direct nursing.

1. Adverse events related to medication administration- One of the commonest type of adverse event. The possibilities of adverse events related to medication administration include:

  • Omission of medicine
  • Miscalculation of dosage
  • Errors during medicine administration
  • Inadequate dosage of medicine
  • Technical administration errors

Learn more about medication safety here:

2. Adverse events related to the monitoring of patient- These events happen as a result of lack of adequate monitoring of a patient which demands nursing attention. These include:

  • Patient fall
  • Displacement of catheters, tubes or drains

3. Adverse events related to the maintenance of skin integrity- Pressure ulcers and disrupted skin integrity of a patient is always directly associated with faulty nursing care. These events include:

  • Pressure ulcers as a result of lack of position change and inappropriate position in bed.

Learn more about pressure ulcer care here:

/product/care-of-patient-with-pressure-injury-bed-sore/

4. Adverse events related to material resources- These are the events which are preventable to quite an extent with efficient management and ensuring quality resources in patient care. Examples of these events related to material resources include:

  • Adverse event due to lack of equipment
  • Adverse event due to defective equipment

Are sentinel event and adverse event same?

Those of you who have participated in the process of accreditation especially Joint Commission International (JCI) must have heard the term Sentinel event. So, is it the same as adverse events?

Sentinel event- JCI defines sentinel event as an unanticipated death or loss of function unrelated to the natural course of the patient’s illness or underlying condition or wrong-site, wrong-procedure, wrong-patient surgery. It is called sentinel because it signals a need for an immediate investigation and response.

Sentinel Event= Adverse event + Near Miss

Sentinel event combines adverse event and near miss and covers the full range of undesirable events with varying degrees of serious outcomes.

Most commonly reported Sentinel events

Joint Commission on Accreditation of Healthcare Organizations (JCAHO) maintains database for the most commonly reported sentinel event which include the following:

  • Patient suicide
  • Operative/postoperative complication
  • Wrong-site surgery
  • Medication error
  • Delay in treatment
  • Patient fall
  • Patient death or injury in restraints
  • Assault, rape, or homicide
  • Transfusion error
  • Perinatal death/loss of function

Evidence based Patient Safety Intervention

The following are evidence based safety interventions based on extensive review which can prevent sentinel events in patient admitted in hospital.

  • Guidelines- Follow antibiotic guidelines to prevent pneumonia and reduce mortality rates.
  • Protocol for catheter insertion and maintenance- Catheter-associated urinary tract infection is a preventable event in healthcare setting. It can be done by giving catheter reminders and stop orders as soon as the requirement is not there. Nurses should be made in charge of assessment and suggest decisions when a patient does not need a catheter.
  • Use of care bundles- Care bundles to reduce rates of central-line-associated blood stream infections (CLABSI) are encouraged and are known to influence the rate of CLABSI. Similarly care bundles for other hospital acquired infections.
  • Use of Clinical pathways to avoid complications is encouraged. Clinical pathways are evidence based set plan of care involving a team of professionals (doctors, nurses, dietician, and physiotherapist) with defined time frames and expected outcomes for a particular disease condition.
  • Promoting multidisciplinary team collaboration and interventions to reduce mortality rates.
  • Multi-component interventions for reducing events like falls and delirium.
  • Encourage exercises to reduce risk of falling.
  • Regular review by pharmacist in the clinical areas to prevent adverse events related to medication and to control medication errors.
  • Increase number of trained support staff to reduce mortality.
  • Nurse-led early-discharge programmes to reduce mortality rates.
  • Creation of rapid response team with defined roles to manage cardiopulmonary arrest.
  • Surgical safety checklist to reduce the risk for surgical-site infections and reduce mortality rates.

What to do if the adverse event has happened?

Despite all the efforts there are times in clinical setting that adverse events happen and the nurse leaders need to take actions. The following image shows the possible sequence of action that must take place to ensure patient safety and to understand what precautions to take next when managing a similar case next time.

 

Step to manage adverse event

How to encourage adverse event reporting?

1. Positive reporting system- A positive atmosphere can promote increased reporting by the health professionals. It is the responsibility of top leaders to encourage professionals to report events and near misses without being fearful about negative consequences.

2. Educate- Organization must ensure regular sessions are organized as per the scope of errors they might come across during patient care, their responsibilities and clinical protocols that must be followed in adverse events.

3. Anonymous reporting and use of software- Anonymous reporting can be encouraged through placement of boxes or use of software for error reporting that a user can report on without disclosing their identities.

Learn more about encouraging reporting adverse event here:

 

Root cause analysis

As the name indicates, earlier root cause analysis was introduced in healthcare to analyze the serious adverse events. Usually, the purview of quality team in a hospital setting now involves the team altogether to understand the sequence of events that lead to a particular event.

Root cause analysis

An example from a real scenario:

A 50 year old patient collapsed in an OPD setting and suffered a cardiac arrest. The only nurse posted in the area approached the patient and started CPR. Code blue was activated eventually and crash cart was brought located on another floor of OPD. Patient could be revived but suffered complications due to delay in first aid.

Root cause analysis was done and it was found that due to delay in receiving the team support and arrival of crash cart, patient suffered complications. What we learnt from this?

  • More crash carts were installed.
  • Support staff were trained in CPR in all areas and trained how to assist in using a crash cart in both inpatient and OPD setting.
  • A team of professionals from the OPD to respond to Code blue was chosen as OPD and inpatient buildings were separate buildings.

Scenario two, same institute:

Another patient suffered an arrest in basement of inpatient building, where patient was undergoing a diagnostic tests. Technician and nurse manage patient. Patient is revived without any complications.

Take away:

One adverse event helped improve overall revival rate in the hospital and enhanced patient safety through the process of root cause analysis and implementation of solutions proposed.

Conclusion:

Adverse events are unfortunate but can be avoided with mutual team cooperation without blaming anyone. Hold your team together, you don’t know who will save you next. Remember before ‘REACTING’ to what your nursing team did wrong, understand how terrible must a person have felt after committing that error and he/she as healer caused more harm to the patient. See the link ‘When nurse becomes victim’-

 

References:

1. Institute of Medicine. To err is human: building a safer health system. Washington, DC: National Academy Press; 1999.

2. Brennan TA, Leape LL, Laird NM, Hebert L, Localio AR, Lawthers AG, et al. Incidence of adverse events and negligence in hospitalized patients: results of the Harvard Medical Practice Study I. N Engl J Med 1991;324:370-6

3. World Health Organization. 10 facts on patient safety. Available from: https://www.who.int/features/factfiles/patient_safety/en/

4. Directorate General of Health Services Ministry of Health and Family Welfare Government of India. National Consultation Workshop on Patient Safety. 2010 May 10-20. Available from: https://www.nabh.co/Images/PDF/patientsafety.pdf

5. Duarte Sda C, Stipp MA, Da Silva MM, De Oliveira FT. Adverse events and safety in nursing care. Rev Bras Enferm. 2015 Jan-Feb;68(1):136-46, 144-54. doi: 10.1590/0034-7167.2015680120p.

6. Ostenberg PR, Reis P. Understanding and Preventing Sentinel and Adverse Events. ICU Management and Practise. 2008; 8 (2).

7. Nursing2019. 10 most common sentinel events. 2004 Nov; 34 (11): 35.

8. Zegers M, Hesselink G, Geense W, Vincent C, Wollersheim H. Evidence-based interventions to reduce adverse events in hospitals: a systematic review of systematic reviews. BMJ Open. 2016; 6(9): e012555. doi:10.1136/bmjopen-2016-012555

9. Kang JH, Kim CW, Lee SY. Nurse-perceived patient adverse events and nursing practice environment. J Prev Med Public Health. 2014; 47(5): 273-80.

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