Sunday, November 20, 2016

Tales of the Profession, part 2

The good news is, I didn't get hit by a truck! Life goes on.

It's been a while since my last entry--the semester seems to overbear everything else. In the fall I and another instructor are responsible for supervising the graduating seniors in their final clinical rotations. Unlike their earlier education (a mere two weeks before they begin again in late August) these experiences are not directly supervised by faculty.

Students are assigned to RN mentors, we call them "preceptors", who work in the various agencies to which they are assigned. Each student has two sites, a "regular" hospital site, and a specialty site. The regular site is what we call medical/surgical or "med-surg", and it's the typical thing you'd see on TV, or have experienced if you've been in a hospital for a routine surgery, or some illness. The specialty site can be pretty varied and includes intensive care, emergency, labor and delivery, inpatient rehabilitation, school nursing, community nursing, and so on.

At 360 hours total, it is the most extensive clinical rotation of any nursing school in the state.

There's a lot I can write about this clinical course and what I observe, but today I'll just begin with how students transform from the idealized world in which we train them up, to the real world in which they will practice.

In the first group of students we ever enrolled in the accelerated second degree program, now some five years past, we all got together at University Park, at the nursing college, and held a day-long orientation. I helped to lead an exercise intended to tease out their preconceptions of nursing and health care, and they were to draw something on the whiteboard that they thought about the profession, health care, or something related to the journey they were soon to undertake.

So this one guy draws a factory on the board, with little stick figure patients going in one side and coming out the other. Although I have thought for many years now that the wonder of the modern hospital isn't its technical wizardry, but its amazing throughput, I was surprised that he saw it the same way--rather cynical, for a young guy. But I thought he was dead-on.

American health care is very expensive, and this is for a variety of reasons. Being able to move a lot of people through quickly saves a bit of money. There are lots of moving parts. Nurses and doctors to be sure, but also respiratory, speech, and physical therapists, nurse aides, maintenance workers, food service, pastoral care (of several faiths), pharmacists, security personnel, tech specialists, bioengineers, lab workers, and even sub-specialists in all these specialties, such as IV nurses, and pharmacists that design certain drug protocols for cancer and heart disease. There are supply chains for drugs, food, medical supplies, and technology. There are layers of administrators, MBAs, lawyers, risk managers, and community advisers.

It probably does feel like one is a chassis on a factory assembly line, when you're going through it.

Throughout the fall semester, my colleague and I visit as many of our students' sites as we can fit in, and we do so while the students are on duty with their assigned nurse-mentors. It's a great experience for the students because they begin to transition into the real world with the help of an assigned person who sticks with them throughout their time on a given unit. It's great for the agencies because they get an "extended interview" experience with a potential hire.

I see a strong difference between the early visits and those scheduled later, near the time we are at now at Thanksgiving. In the beginning, the students are anxious, excited, intimidated, and keen to best the challenge of operating with less faculty supervision. They quickly become attuned to the culture of a unit or community agency; they learn the language and expectations of anyone who would enter the fold as it were.

Later, they begin to assess the discrepancies between the ideals they have been taught in their regular schooling, and the real-world pressures faced by their preceptors as working nurses. My colleague and I read the structured journals they are to submit for review each week. We witness the disturbing events the students have experienced, sometimes it's prejudice, sometimes it's inappropriate care, sometimes it's the futile efforts to save someone that should be allowed to pass unmolested from this life.

But I can see them also becoming a part of the thing that they hope to join--including some of the less than ideal attitudes and behaviors. The stress of clinical work among the very ill, injured, and hopeless often brings out the best in them, but it can also reinforce the negatives. We, the faculty, continually try to reinforce the best in them, to get them to see things in more subtle and complex ways. It is one thing to "put on a smile" when faced with an angry, difficult patient who just seems mean! It is another, higher-level thing to get beyond that and determine what is beneath that anger. Is it a growing neurological reaction to a new medication? Is it despondency? Is it a youth trying to control just one thing in his world? And then what? How do you break through and build a therapeutic moment from that?

It's pretty high level thinking, that. And it's very easy to let that be the unachieved thing during a day of call bells and tests and medication passes and anxious family with questions and doctors' orders (which are sometimes in conflict with each other!) and on and on...

And then the RN clocks out. Tomorrow it will happen again. And so it goes every day until the nurse changes positions or finds a comfortable way to retire early (and these are both quite common in nursing). Maintaining a high level of enthusiasm in The Factory is difficult. One recent study found that nursing's high turnover is often directly related to declining levels of intellectual challenge and sense of control over one's practice, two features of the profession that are being systematically eliminated in favor of throughput and productivity, uniformity of experience (from the patient's perspective), and "quality control."

My RNs tell me that hospital practice is highly regulated, and to my view it seems more highly regulated than when I started out in the hospital. Arguably care is safer and more efficient, although the evidence is conflicting. "Evidence-based practice" is the catchphrase everyone uses now, so much that it starts to sound like Dilbert-esque corporate gobbledygook, it starts to sound like a joke. Nurses still solve problems, and practice still poses intellectual puzzles to challenge the practitioner. But my survey of the field convinces me that a lot of my newly minted colleagues might not stay in the profession very long if they continue to be treated like factory workers.

Evidence-based practice may be a means to reducing unnecessary health care costs, but it won't be the only way, since some of the cost drivers are unregulated drug costs, unnecessary equipment, redundant testing, defensive medical practice, and an emphasis on "customer satisfaction" in a setting in which it's kind of normal to be unsatisfied. I see EBP as having another side: a way to convince practitioners and patients alike that one size of health care fits all. Hardly the art of Medicine or Nursing.

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