Are Nursing Instructors Too Harsh

It has been 30 years since I began my nursing education and I laugh about what I once found stressful, but I’m never sure if I laugh because I think it is funny or out of a stress reaction. I wonder how many nurses from my era cried over care plans/maps or a thousand pages of reading assigned in one week? How many of us went to our clinical rotation after having been up most of the night preparing all the while wondering how we would ever do this for eight patients at a time.

Six months out of school everything seemed easy. I moved from wondering how I would ever do it all to why I ever thought it was hard. Therein lies the problem. I moved from a student who felt the stress to a nurse that was thinking “suck it up”. We all survived and are better prepared to care for patients as a result of those stressful and sleepless nights. But, are we?

When are we asking too much

Having worked at four universities I’ve never made it through a year without a student expressing concern about the workload and the lack of flexibility. Usually, the concern stems from an unexpected emergency, conflicting student activity, or the need to work to help pay tuition. Much of the workload cannot be helped nor can student conflicts. There is a minimal amount of content that must be taught for a student to successfully pass the NCLEX and a minimum number of clinical hours for a student to learn the necessary skills. It is a challenge for faculty and students.

When is the extra assignment too much

I think it would be good for faculty to ask what assignments are actually necessary to facilitate learning and which actually interfere with the ability to learn. If we have students spend all their time reading and doing exercises and no time remaining to reflect on the content is it as beneficial as it could be? Increasingly I believe the answer is no, but I have not found any evidence in the nursing literature to support or refute that belief. Much like the number of clinical hours and the need for content to practice safely and effectively we don’t seem to study it.

If I had an hour to solve a problem I’d spend 55 minutes thinking about the problem and 5 minutes thinking about solutions. – Albert Einstein

I have always thought it would be great to have time to sit and think about the book or the article I am reading, but even now I feel the need to push on to the next task. It is what my nursing education modeled for me?

A Chronicle article from January suggest that 5 pages were sufficient. Obviously, in nursing that is a ludicrous suggestion, but so is the belief that a student can read 500 pages in a week and have multiple assignments. I can imagine a world where we get together and coordinate reading and assignments so that it is reasonable and thus it is possible for the faculty to give more attention per assignment and the students to be able to read, think, and then apply.

What do we do when an assignment is missed

I have almost always had a statement in my syllabus that essentially says that the due date is the latest possible date due so if one is prone to illness, accidents, or the heartbreak of procrastination they need to plan ahead because late work will not be accepted. Of course, it was somewhat dishonest because I clearly intended to make exceptions for births, deaths, accidents, illness, marriages, and all manner of life events. Students are people too and life happens to them. The question is always whether to adjust the grade for the extra time that their peers didn’t get or in the case of a clinical experience whether to add extra work or a makeup day.

As I have gotten older I have mellowed. I don’t think there is any evidence that a single missed clinical day has a measurable impact on performance as a nurse. I do think that adding a makeup day or assignment unnecessarily stresses the student and the faculty member. If we can’t show that it makes a measurable difference and it clearly causes student and faculty stress then why do it?

There must be a creative way to build in a late assignment or absence without encouraging either. If you know the answer please share.


Another Day Another Terrorist With A Gun

“For God has not given us a spirit of fear, but of power and of love and of a sound mind.” 2 Timothy 1:7

I can’t remember the last time I have gone a day without reading about the tragedy that is gun violence or a month without hearing of a mass shooting. This morning I woke to reports of a mass shooting only to realize it wasn’t El Paso, but Dayton. Each time social media is filled with hateful people that cannot, or will not, have a civil conversation about a serious topic. Respectful disagreements can help move people to common ground, but what is most often reflected in society is matched in Congress and the result is more dead bodies and more grieving families. The policy changes that are needed will not be easy, but they are doable without changing the 2nd Amendment. More importantly, we are capable as individuals of changing our neighborhoods and ourselves. We cannot let fear be the enemy of reason. The House of Representatives has taken the first step, but the Senate refuses to do anything, but pray. Clearly, God has answered them with legislation from the House, but they do not have ears to hear.freed-heart-understanding-mind.jpg

For those of us that have lost someone, we love to senseless gun violence each new incident is a reminder that brings the pain rushing back. If you love your guns and the 2nd Amendment more than your neighbors then it will be impossible for you to understand my pain and the pain of every other person who has ever been impacted by gun violence. Each year on September 30 I remember my twin brother who was shot four times (two in the chest, one in the side, and one in the back) and died on my parent’s living room floor.  The bloodstain on the carpet is forever etched into my memory. He was not killed by an intruder, but rather in an argument with our brother. They had fought many times before resulting in typical injuries from fistfights. The problem was that a gun was lying on the table.  Without the gun, he would probably be alive. The police called it a “family matter” and did nothing. In fact, because my other brother was never charged with a crime he legally purchased many more guns.

The argument that the 2nd Amendment is without limit is not true and is usually followed by the statement that “guns don’t kill people, people kill people.” It is reposted without adequate consideration to what this actually means.  In fact, people who own guns are more likely to kill people either accidentally or intentionally. Not all gun deaths come from People with guns do kill people.

This year alone there have been:

  • 33,028 incidents
  • 8,734  deaths
  • 17,308 injuries
  • 251 mass shootings
  • Of those, 390 were children and 1,796 were adolescents (http://www.gunviolencearchive.org/)
  • And how many thousands of grieving families, lost incomes, children without parents, wives without husbands, and parents without children?

Additionally,

In the civilian population deaths from firearms are believed to be a good indicator of firearms violence. The rate of nonfatal gunshot wounds is estimated to be 2.6 times the rate of fatal gunshot wounds. You can find the death rates from firearms by state at http://www.statehealthfacts.org/comparemaptable.jsp?ind=113&cat=2.

The 2nd Amendment is our Constitutional right, but it does not mean that one should own a gun.  I have the right to own a gun and choose not to because I believe they are implements of violence and are designed to take life and only bread evil in one’s soul. Yet this isn’t the only right we have that we can and should decline. Let us decline the right all actions that take a life – abortion, the death penalty, and war. If we value life then sometimes we make decisions not because it is our legal right, but because it is a moral obligation.

It is true that it takes a person to pull the trigger, but without a gun, it is much harder to kill. People do kill people, but people with guns are more likely to do so either intentionally or accidentally. “The dignity of the human person is the foundation of a moral vision for society” (USCCB). The sanctity of human life and the inherent dignity of the human person cannot merely be about abortion or assisted suicide, but must include protecting all life and that means stopping gun violence and all violence.  My wish is for a day that no American chooses to avail themselves of the 2nd Amendment right. Peace is an amazing feeling and it begins in our own homes and hearts. Put fear aside, love your neighbor, and choose life. Don’t let the lust for an instrument of evil that has taken so many lives and caused so much pain replace reason and compassion. Don’t let your fear win.


What is a Worthy Celebration Nathan Bedford Forrest, A Racist

The first time I heard of Nathan Bedford Forrest was in Tennessee history in Junior High School. I’m not sure how much of his background was emphasized, but I also don’t remember him being presented as an honorable man. Prior to the Civil War, he was a repulsive human being who amassed his wealth as a cotton farmer that depended on slave labor and selling human beings into slavery among other business endeavors.

As a Civil War Army General, he was considered to be a good military strategist though clearly not an honorable one. Under his command, he ordered the massacre of Union soldiers, mostly black and some white Tennesseans fighting with them. Even at that time killing people who had surrendered was not honorable.

After the Civil War ended and all of those who had been held as slaves were freed Nathan Bedford Forrest continued a life that dishonored the state of Tennessee and the United States. Since he could no longer hold slaves he became the first Grand Wizard of the Klu Klux Klan which terrorized people of color. He denounced the violence in his later life, but even then apparently lied about his role. All he actually did was change his focus to a different form of slave labor.

After he left the KKK he secured the use of people who had been convicted of crimes to clear his land and work the same land. He used 117 prisoners to grow his wealth. Forced labor of prisoners is a stone throw from slavery at best. It should not go without notice that the majority of those people were black and in that era, the chances they had a fair trial was slim to none. They took black men and women out of the illegal chains and put them in the chains allowed by the law of the time which was incarceration.

It is true that state law in Tennessee mandates an annual proclamation, but it states:

Each year it is the duty of the governor of this state to proclaim the following as days of special observance: January 19, “Robert E. Lee Day”; February 12, “Abraham Lincoln Day”; March 15, “Andrew Jackson Day”; June 3, “Memorial Day” or “Confederate Decoration Day”; July 13, “Nathan Bedford Forrest Day”; and November 11, “Veterans’ Day.” The governor shall invite the people of this state to observe the days in schools, churches, and other suitable places with appropriate ceremonies expressive of the public sentiment befitting the anniversary of such dates.

Tennessee Code 15-2-101

The governor has the ability within the law to interpret appropriate ceremonies expressive of the public sentiment and befitting the anniversary of such dates. It is clearly within his authority to add language to the proclamation that states that it is appropriate to use this as a reminder of the evil of racism, our history of slavery, and the disgrace of being the home of the first Grand Wizard of the KKK. He could use the proclamation to call for a day of service to promote racial justice or as a day he gives clemency to deserving prisoners. There are many ways the law could be fulfilled that don’t continue to celebrate the man that had no honor and does not deserve our respect.

Until the day the Tennessee representatives change what is clearly a law that celebrates our racist past we should all ask and expect the governor to act with honor by preparing an appropriate proclamation. And if he refuses to act in an honorable manner there is nothing that stops us from planning now to make this a day that addresses racial justice in our communities.

When the elected officials refuse to lead with honor it is should never be the case that the citizens remain silent and do not act. We have a year to prepare. Let’s get started.


Help at the Border

We can each find a way to help children at the border.  I remind myself often to give of my time, talent, and treasure. When I was young I had time and as a nurse a skill that many shelters needed. As my career progressed I had little time, but more money. We each have something we can do to help children at the border. What can you do?

Here is a list of some of the places that you can donate money or your skills.

Humanitarian Respite Care needs donations. They accept donations of time, money, or supplies through Amazon Wish List. If donating money it goes to Catholic Charities of the Rio Grande Valley and notes on the check that your donation is designated for humanitarian response.

USA Today published an article on how to assist, How to Assist Families and Children at the Border.  

Rising Together has a list of needs from lawyers wishing to volunteer.

Humane Borders has regular meetings in Tucson. They provide water drops and other activities and accept groups to join them. There was recent media coverage of a person being arrested for water drops and as provoked by the devil as I believe that arrest to be it is something that requires a person to consider the risk they are willing to take for their belief in humanity and justice.

The National Network for Immigrant and Refugee Rights provides a list of border advocacy groups. You will find a list of organizations actively working for just and humane border practices in the United States and Mexico. Many of them have volunteer programs while others provide advocacy tools and ways to get involved.

There are makeshift clinics providing care and volunteer physicians and nurses. The best way to find the clinics is to speak with local advocates.

The Asylum Seekers Advocacy Project has opportunities to donate, get updates, and apply for jobs and internships. Follow them on Twitter @asylumadvocacy.

The Women’s Refugee Commission improves the lives and protects the rights of women, children, and youth displaced by conflict and crisis. They research their needs, identify solutions and advocate for programs and policies to strengthen their resilience and drive change in humanitarian practice. They have a useful list of resources.

The National Association of Social Workers has a list of ways to volunteer to help children separated from parents. It is one of the better lists I’ve seen.

 


Scoop and Run: A Plan for the 4th on the National Mall

The first time I attended the July 4th fireworks in DC it was with a friend’s family who attended every year. As we were on the metro headed to the mall she informed me that when the final volley of fireworks began to “scoop and run”. Pick up all of your stuff and run to the metro as fast as possible to be on the train that would be waiting. Otherwise, we would be stuck in the crowds for hours.

My advice to anyone attending the July 4 celebration this year is to be prepared to scoop and run. Know your exits, know where the metro is, know your way to walk across the bridge if it is too crowded and for goodness sake don’t drive. But also know where there is a safe area close to you. What shops and restaurants are open where you can get through the door and out of the crowd? Be prepared that some places in the event of mass demonstrations will go into lockdown quickly. If you are in you will stay in and if you are out you will stay out.

Events of civil unrest in cities across the United States raise awareness of injustice in our society and they appear to be on the rise. Yet, it is those moments when civil unrest occurs that we often fail to recognize the human dignity of every person. Civil unrest can lead to physical violence as it did recently in Portland. Our instinct may be to respond as we would in a disaster and seek help from police and places like the medical aid stations. However, this may be the wrong action during the unrest. Because of heightened tension between the police and the general population they may view your rapid approach as a threat rather than fear. The presence of police in the medical aid station may not be possible and even if possible, it may only attract the unrest to the area and thus be undesirable.

I doubt there will be any civil unrest at the July 4th fireworks in DC, but if I were ever going to encourage caution this would be the year. Anytime a large, nationally televised event is politicized it increases the risk of clashes. Politization may include the “baby Trump” balloon, flag burning, and white supremacists. We also know that inequalities in society, culture, and finance have resulted in civil unrest, rioting, and intentional violence throughout our history. When one group is given special privileges at an event that has always been egalatarian it increases the risk of problems.

10 tips to a safe July 4th on the National Mall

  1. Stay hydrated and be aware that there are sometimes long lines at vendors. Dehydration alters your ability to think clearly.
  2. Wear sunscreen just because I’m a nurse and we remind you of the obvious.
  3. Dress appropriately for long walks and hot weather. Running or walking shoes will be better than sandals.
  4. Bring your fanny pack first aid kit or put a small one in a bag.
  5. It is always better at large events to carry your belongings in a clear plastic tote bag so that everyone can see there is nothing of danger in it.
  6. Do not bring anything with you that could be perceived as a weapon.
  7. If you see people with weapons other than police move away as quickly as possible and notify law enforcement.
  8. Be aware of your surroundings and know where the exits are located.
  9. Do not engage people who are protesting. Even if you think you agree with them sometimes people surprise you with what offends them and when you are hot and tired your own response may even be a surprise.
  10. Be cool, be calm, be alert, be gone if trouble begins.

I hope everyone has an enjoyable July 4 and remembers that the day is a celebration of our independence. It is a time to celebrate a great nation and remember that children will be present.

Nurse Leaders’ Response to Civil Unrest requires preparation. It is a good time to go through your checklist before the events begin on July 4.

 


Book Review: Voices of the Dead

I received a free copy of Voices of the Dead by John Babb, a retired U.S. Public Health Service, Rear Admiral. I read his first book Orphan Hero which I enjoyed, but this one is different. It is a historical novel set in 1878 and tells of Yellow Fever in Memphis and New Orlean. I could feel the humidity as I read of the nurses and physicians responding to the deadly virus and risking their lives to serve others.

There are plenty of nurse heroes in this book, but also everyone from physicians to Sisters, from Priests to Madames stepped up to help their neighbors and some lost their lives in the effort. Whether you are a lover of historical novels, or epidemiological investigations, or an infectious disease nerd this is a great book.

Of course, it could be that I liked it because it had all the things that fascinate me, steamy southern cities, infectious diseases, legislation like the Quarantine Act, selfless physicians and nurses, and the Marine Hospital Service which lead to the Commissioned Corps of the U.S. Public Health Service. It dealt effectively with the fears of quarantine and what citizens do when quarantine is ordered. In many ways, it is a case study of epidemics prior to modern healthcare.

I don’t want to spoil the book, but if you are a public health worker I think you will love it.


Is Anyone Called to Work in A Concentration Camp

When I was young I wanted to work with what I thought of as the poor and underserved. Over the course of my career, I’ve worked in four types of facilities: mental health facilities, homeless shelters, prisons, and detention facilities. They all share similarities.  I was excited when my first job out of college was at St. Elizabeths Hospital in Washington, DC working on a unit for those who had a mental illness and “no fixed address” which was the systems euphemism for homeless.

The unit and the hospital was largely still as Ervin Goffman described it in Asylums. While the harshest of treatments had long ago ended they were still given donated clothing or hospital purchased clothing to patients and generally not returning their clothing. The food was dismal and best. There were times when the food was so limited that patients checked out against medical advise. The conditions for staff were also not what most would expect. Nursing was chronically understaffed and depended heavily on per diem nurses. There were long periods when nurses were forced to work overtime that could be an additional shift or even an additional day or more. Anyone who thinks forcing people to work multiple shifts of overtime a week improves quality of care or compassion is delusional. I don’t know if any of us complained about or filed protest through official channels or even thought to do so. I do know that many of us donated our used clothing and brought food that we cooked and shared with patients.

I volunteered in shelters and tried to understand what could be done to change a society that allowed so many people experiencing homelessness to go without the medical, mental health, and social services care they needed. There was only one answer, we are still a puritanical society that sees the plight of those experiencing homelessness as just punishment for sloth. I suspect many believe mental illness is a myth and so when the mentally were deinstitutionalized under President Regan with the promise of outpatient care that never materialized people complained and shouted at the wind, but we still don’t have adequate outpatient care?

Mental illness is nothing to be ashamed of but stigma and bias shame us all. – Bill Clinton

After three years I ask for and received a transfer to the Federal Bureau of Prisons in Tucson, AZ leaving the care of one group of people held against their will to care for another. FCI Tucson was in many ways a model facility. It was clean, efficiently run, had fully staffed medical and dental clinics, lab, psychology, and pharmacy. The food was good and most of the staff ate the same food as the “inmates”. Those that worked in UNICOR were paid and a commissary was available to purchase things that were not provided. In fact, many of those who were there for illegal reentry into the U.S. would send some of their money home. It wasn’t what I had in mind when I thought of working with the poor and underserved, but there were many similarities to large psychiatric facilities through the prisons seemed better funded and better staffed. We seemed to treat those in prison with more respect and compassion that either those with a mental illness or those experiencing homelessness.

I was in prison and you came to visit me … I tell you the truth, whatever you did for one of the least of these brothers of mine, you did for me.”
(Matthew 25:36, 40)

It was at FCI Tucson that I began to realize that to make big changes one had to be able to change national policy. The Federal Bureau of Prisons is not luxurious, but most of their federally run facilities comply with the American Correctional Association and National Commission on Correctional Healthcare guidelines. In fact, while I was at FCI Tucson we sought and were accredited by the Joint Commission. If one wanted to be an administrator there was a training program that had to be completed and thus there were standards. Every person working there had to complete annual training and sign off confirming they knew the rules. There will always be bad actors, but they were the exception. In my time there if I ask for anyone to be sent out to the local hospital it was not debated. It happened and generally happened quickly.

In 1997, I became the Health Services Administration at the Buffalo Federal Detention Center. Medical care was run by the Division of Immigration Health Services (DIHS). Many of the people were pending deportation after serving time in prison. When I arrived the medical clinic was still under construction. I hired a physician, two nurse practitioners, an RN, an LPN, two medical records techs, a pharmacist, and a pharmacy tech. We had a dentist and a psychologist that came in on a regular basis. Additionally, we invested in telemedicine equipment which at the time was new and gave us access to other providers. Within fifteen months of opening, we were accredited by the ACA, NCCHC, and Joint Commission. In my time there we had no deaths and provided high-quality care. My biggest complaint was the inability to get patients brought to us in a timely fashion and too often being told someone had been removed from the facility when in fact they were still there.

I became the Chief of Field Operations responsible for administrative oversight of the eleven health clinics in Immigration detention facilities (not contract facilities). I visited most of them and did a thorough review of any deaths. Most of the healthcare staff were U.S. Public Health Service officers and so most were passionate about their work and caring for those in detention. There were exceptions and some people over time became judgmental about the plight of those detained, but in my worst nightmare, the worst case I reviewed, the worst thing ever reported to me doesn’t equal what is happening today with the detained children. More importantly, if any of what is happening now was reported Immigration and DIHS would have immediately sent teams to investigate.

I left DIHS in 2001 after 9/11 when to run the command center for Secretary Thompson’s at the Department of Health and Human Services. I never returned to DIHS and was grateful as I had become increasingly concerned about what I saw as a push to limit the care provided and a move to more contract facilities and more contract staff. Physicians were feeling overworked and nurses were being asked to take on more and more of the care. While I didn’t think nurses were being asked to do anything out of their scope of practice it was a constant battle to not cross that line.  I also knew I was pushing the envelope. I was told at one point, “You will do the right thing no matter the consequences.” It was not meant to be a compliment. The person was angry and my life was becoming more difficult.

In 2007, I went to work for the Administration for Children and Families (ACF) as the director of the Office of Human Services Emergency Preparedness. I worked closely with the Office of Refugee Resettlement( ORR). The reason for the visits was twofold, assess their emergency preparedness and see how they did case management. ORR was considered to have an excellent case management program that moved people from being a new refugee that didn’t speak English to being fully self-sufficient in six months. It was a huge effort that was supported by faith-based organizations. I visited a few of the facilities for unaccompanied children and I did find them depressing, but they were clean, each child had a bed with linens and blankets, age-appropriate clothing, plenty of food, medical care (which I didn’t think was at the level I would have liked), and education though it certainly was not equivalent to elementary or secondary schools in the community. There were around 40 facilities and 1600 beds. They were chronically underfunded even then. What they could do was limited by the funding. Congress and the White House knew it. In fact, the faith-based organizations that ran many of the facilities also knew about the underfunding.

This is my long way of saying I could not believe what I was hearing when the detention facilities were referred to as concentration camps and there was inadequate food, no basic sanitary supplies, inadequate medical care, and children taking care of children. The places I worked and visited were not great, but I called the people working there colleagues and friends. Would we have ever allowed this to happen? I even argued with people the term “concentration camp” was inflammatory and not helpful. When I saw the court recording, the pictures, and heard statements of lawyers I was shocked.

How could healthcare people not speak out? I hope that some of this information is getting out because they are leaking it. Yet, I don’t want to be too quick to forget what it is like to be the nurse in the facility. Each day you go in and see as many people as you can thinking if you aren’t there who will be there to provide the care. You go home and you pray for your patients. Yet the most obvious thing to do is sometimes the hardest. How do stand up to those in charge and say, not on my watch?

I’m outraged, but my outrage doesn’t change the current situation. CDR Jonathan White testified before the Energy and Commerce Committee on February 7, 2019. In his verbal responses, he was clear that people were warned about separating children and parents. He did not address all of the unaccompanied children that cross the border, but I’m sure he was equally concerned about them. Then in April 2019 before the Senate Homeland Security and Governmental Affairs, there was further testimony from CDR White and others.  He appears to care about the welfare of the children and is trying to reunify children that came with parents or family member. In fact, for over a year ago HHS officials have warned about the situation. CDR White clearly states that the problem isn’t of data exchange, but that children were separated. The ORR program was designed for the truly unaccompanied children and not for children separated by the U.S. when apprehended. You can see the disgust on CDR White’s face when he says the issue is that it happened at all. Since July 2018 HHS has been warning the administration and Congress yet there is no positive action.

The Catholic tradition teaches that human dignity can be protected and a healthy community can be achieved only if human rights are protected and responsibilities are met. Therefore, every person has a fundamental right to life and a right to those things required for human decency. Corresponding to these rights are duties and responsibilities–to one another, to our families, and to the larger society.

My question to all of those screaming about the atrocities is what have you actually done to change it? Have you actually written a letter to your representative? Have you donated money to one of the not-for-profits that provide the care at most of the facilities for unaccompanied minors? And to Congress, other than the horrific legislation offered by Senator Graham that ignores the dangers faced by the asylum seekers, Senator Cruz’s Protect Children and Families Through the Rule of Law Act which is more about removal quickly back to the danger they fled, and U.S. Senator John Cornyn (R-TX) and U.S. Representative Henry Cuellar (D-TX-28) who proposed the HUMANE Act has anyone drafted legislation that would actually address the problems in the “concentration camps”?  Is there anyone in the House or Senate that is working together to fix laws that allow this to continue?

If you really think this is inhuman, a concentration camp, and must be stopped then why not work day and night to pass legislation that will stop it? Isn’t that more productive that tweeting? I want to see a Tweet with a link to the legislative fix. I want to see posts about people volunteering with their local churches and community organizations to help support the needs of refugee families. In our parish, it took the hard work of five families to get one family to self-sufficiency. More volunteers are needed in almost every city in the country.

As for the rest of us, here is an interesting fact, anyone in the U.S., any citizen can draft legislation and a member of Congress can introduce it. I will write it if AOC will promise to introduce the legislation. I bet she even has some aides that could help. Likewise, what about all those running for President, where is your draft legislation to fix this?

We don’t need more hypocrisy. We need action that recognizes that our Puritan history must be weeded from our hearts, laws, and policies.

For I was hungry, and you gave me to eat; I was thirsty, and you gave me to drink; I was a stranger, and you took me in. (Matthew 25:35)