Petty Management-Nightingale minisode #3

[00:00] Michelle: Okay. Welcome back to the Florence Nightingale Miniseries. This is minisode number three, petty management. You're listening to the Conversing Nurse podcast. I'm Michelle, your host. And this is where together, we explore the nursing profession, one conversation at a time. Florence starts this chapter with a preface. "It's very hard in a book to tell someone how to nurse or how to be in charge of the sick and how to manage them." And I think probably around the mid-19th century this would be true. There was not much written on nursing if anything. And I looked. I went to one of my favorite resources, the Library of Congress, and I couldn't find anything before Florence's publication in the 1850s. So if any of you out there know of any other resources, I'm almost certain something has to be written. I can't find it. Today, however, is a different story. You know, we have volumes and volumes of books written on nursing for nurses, by nurses, nursing journals, other publications, blogs, et cetera. Lots and lots of literature on nursing. Florence defines petty management as "knowing how to manage what you do when you are there, so you can know what to do when you are not there." She says you can't always be there. And of course, in today's nursing universe, 100% true. We don't work 24/7/365. We have shifts. We have relief, as it should be. She's saying if you work too much, you're going to give up your health. And if you remember back in the first minisode when I introduced Florence, I told you that Florence worked endlessly during the Crimean War and she contracted brucellosis and got very sick. She was confined to her bed for some time, years, actually. So I think what she says when she basically says you're going to give up your health, it's true. And I can say that because I speak from personal experience. And I'm going to tell you a story about working too much and how it took its toll on my health. This was in the mid-two-thousands, and the hospital where I was working was suffering from a nursing shortage, as we are now, and in our unit, in particular the neonatal intensive care unit, it was growing very rapidly from a level II nursery to a Community level NICU. So that just meant we were taking on sicker and sicker infants with a much lower gestational age and all the comorbidities that go with that. So we were very busy. And I was a Charge nurse and an Admit nurse at the time, an Admit nurse you might not know, or you might know, is a nurse that attends all scheduled cesarean section deliveries and all high-risk vaginal deliveries during the shift. So we had an ever-increasing C-section rate during that time. I think our rate went from like the high teens to around 30% by the mid-two-thousands. The area in which I live is the San Joaquin Valley, and we have a high incidence of mothers with gestational diabetes, preeclampsia, and elderly mothers past the age of 35. Yes, that's really what they're called now. I know, right? Drug use. So our rates of prematurity and all those things were impacting our admission rate and how sick the kids were. Well, our hospital, and of course many hospitals during this time offered an extra shift incentive or a bonus, and our hospital was pretty generous with this bonus, so it solved a lot of the staffing problems in the short term. I happened to have a very intuitive NICU nurse manager at the time who said, to be careful of working too many extra shifts. There needs to be a work-life balance. And I laughed my evil laugh. I don't laugh like that. My late husband and I had two daughters in college at the time, and we just weren't too keen on getting student loans. So it was a perfect win-win situation with me working extra. We were able to put our daughters through college by paying cash only, and life was good. So I worked a lot of extra twelve-hour shifts in a three-year period from about 2006 to 2009. So now it's 2009, and on one morning of a twelve-hour shift, I'm in the shower at zero dark 30. I'm washing my armpits, sorry, TMI, and I felt a lump in the right axillary tail. Now, of course, I wash that area every day and I didn't feel it the day before. So I said to myself, self, that's strange, I didn't feel that yesterday. I wonder what that is. I thought it was probably a lymph node related to shaving. And that's really the only thing I could think of. And the reason for this is pure ignorance. Nobody in my family had ever had cancer, any type of cancer, so I thought I was immune. Of course, now I know that 80% of all women diagnosed with breast cancer have no prior history. I got out of the shower and I told my husband and he said, you need to go to the doctor today. And I did my evil laugh again, of which I'm not going to repeat because I don't laugh like that because I'm not evil, I'm pure niceness. I just looked at him and I said, honey, you don't understand. I'm working a twelve-hour shift. I'm probably going to either be the Charge nurse or the Admit nurse, we have a very high census, we have lots of scheduled C-sections, we have lots of laboring women, and there's going to be zero opportunity for me to go to the doctor today. All those excuses that just scream, they need me, I can't take care of myself, I must work like a machine. But my husband, who was not one for drama, just quietly repeated himself and said, you need to go to the doctor today. You know how when somebody is serious about something and they're advocating for you because they care for you, how it just kind of hits home? That's what happened with me because I would never have advocated for myself before that day. I would have just probably put it on the back burner and thought, it can wait for a few days. And in retrospect, it probably could have. But I sensed the urgency in his voice, and I decided to give it a shot. So I arrived at work, and of course, I was assigned as the Admit nurse. So talk to my Charge nurse, let her know that I found a lump, and I needed to go to the doctor today. And bless her heart, she didn't look at me like I was a cyclops or anything. She said, okay, well, the last C-section is scheduled for 1600, and I can go to that, and you can go to the doctor. So I called, got an appointment, and, you know, I just think Providence was kind of working in my favor that day, and so the rest, they say, is history. I subsequently had a mammogram a couple of days later and then a same-day ultrasound, because they said, we see two masses, and they look suspicious for cancer. The next week, it was followed by a biopsy, and it was cancer and then a right mastectomy in the summer of 2009. So my breast is I think it's buried somewhere. That's how I picture it. The little gravestone over it that says RIP. Anyway, I had five and a half months of chemotherapy, and that sucked. But 13 years now, cancer free. Praise the Lord. So moral of the story is, don't neglect your health. I took a long time to get to the moral, but I just think sometimes hearing people's stories is important for us. There's more important things than money, and your health is definitely one of them. Okay, back to Florence. She gives lots of pearls of wisdom in this chapter, and one of the things she talks about is making sure that your patient is taken care of when you're not there. And of course, in our current hospital system, we have shifts and we have sign-out, which you guys know that's when we share all that information and there's so much, right, we just want to get home. We want to get home to our beds and our families. And I know our NICU worked really long and hard on the sign-out because things were getting missed, important things. And we met our shared governance teams, met with our clinical nurse educator, and we all came up with kind of a Rand card, and I think that improved things a lot. So if you're struggling in your unit with sign-out and things getting missed, take a look at those things. They certainly help. But don't leave out pertinent information. And I know I've done it no one's perfect. I know. I've lived it. I've done it. Let's just try to do better, all right? Florence says we should be protective of our patients' rest. You don't want people coming in when your patient is resting. And, oh, my gosh, can I scream this from the rooftops? We all know how rest is important to recovery, so monitor the visitors of which we do, especially now, post-COVID, kind of a little bit excessively. I'm hoping some of the visitation can come back a little bit more relaxed because I feel like we're losing some of our family-centered care. She says, don't increase the patient's anxiety. And one of the things mentioned in particular is to tell your patient when you leave and when you're going to return. And she also says, whatever a patient can do for himself, he should do for himself. And again, I echoed this sentiment. We all do as healthcare providers, right? We know the more that they can do, they're not bringing us home with them. So they need to be independent before they go home. And so the more that they can do, they should do that, and we should step aside. Now, remember, in minisode number two, Florence was going to tell us how the nurse can get an undisturbed break. Oh, my gosh. I know you guys have been waiting for this. Here's what she says, "One may safely say a nurse cannot be with the patient, open the door, eat her meals, take a message, all at one at the same time. Nevertheless, the person in charge never seems to look the possibility in the face." I mean, yeah, obviously, nobody can do all those things at the same time, but sometimes it feels like we're expected to. I mean, I can remember many times as the Charge nurse being interrupted, all through my break, to silence an alarm or answer a phone, go to a delivery, whatever was needed at the time. And breaks are a big deal. We need them for rest, we need them for rejuvenation, we need them for our mental health. I live in California, and we are lucky that we have a sole nurse dedicated to providing breaks for other nurses because our law says California employers must provide a 30-minute uninterrupted meal break after an employee has worked at least five consecutive hours. And the operative word here is uninterrupted. But it just doesn't always work out that way. In fact, you know what? I just read an article on a nurse that tried to sue in California because her breaks were being interrupted, and the court said, no, you can't sue for that. Sorry. All right, that was just a little side note. There's a passage here where Florence talks about the presence of nurses on a ward, and she is saying that the more nurses present, the less problems, the less deaths, less accidents. And this has actually been proven in research where the nurse-to-patient ratio. The tighter it is, the better the outcomes. In fact, the American Journal of Nursing published a study on this just last fall, in September of 2021, about the reduction in mortality, readmissions, and length of stay when there are fewer patients assigned to each nurse. So I think we're lucky to have these ratios in California. Our patients are certainly lucky. I wouldn't think maybe a lot of hospital administrators would think we are lucky because it's certainly a challenge. The last thing Florence talks about in this chapter of Petty Management is what it means to be in charge. And she says hardly anyone knows what it means. She defines it as not only to carry out the proper measures yourself but to see that everyone else does so too, to see that no one either willfully or ignorantly works to prevent such measures. It is neither to do everything yourself nor to appoint a number of people to each duty, but to ensure that each does that duty to which he is appointed. And then she goes on to say that it's a lot more than just ordering people around. And of course, to those of us that have ever held a leadership position, we know that teamwork, diplomacy, and a knowledge of those positions that you are in charge of, as well as avoiding being bossy, will take you a long way in developing trust with your fellow nurses. Amen. Well, that is all for Petty Management. In the fourth minisode, Florence and I will address noise and how it affects our patient's recovery. And as a NICU nurse, I am excited for this one, because noise is huge in the NICU. We know how devastating noise can be to the sick and the growing premature infant. So stick around for that one. Thank you, and I will see you soon.