Because healthcare is so complicated now and not really focus very well on coordination that it can often take a tremendous amount of time and energy for this very basic ordinary thing to happen. So for example one of the patients in the book is misdiagnosed, the classic thing that happens, the patient comes into the emergency department. A medical problem is perceived, she perceived, she goes to a medical floor, it turns out she has a very serious surgical problem. I was talking with one of the surgeons involved on my behalf i just felt so angry, and he said it happens all the time. Host i dont think the public really appreciates how complicated it can be. It does cause to even try to work harder to coordination. Guest i dont want to scare people and make them think the hospital is chaotic in a mess. That is not the case. Host right, but it takes a lot of work and a lot of effort. On behalf of the entire team and nurses were there every day. Guest yes, that is what motivated me to write this book. I think the average person does not know how important the nurses are to quality patient care. If you do well in the hospital it is likely some of that is going to have to do with your nursing care. Host absolutely. So, your practice setting and the book of course is a cancer ward. When i was in direct practice, i practice in pediatrics. I would sometimes have people say to me i dont know how you take care of sick kids. Im guessing people say to you i dont know how you take care of patients who have cancer, seem so so depressing. Guest yes, thats exactly what they say. Host im often struck by the use of humor and healthcare. Humor in a setting that you normally think of depressing and difficult, but patients and families use humor, certainly nurses and Healthcare Teams use humor. Talk a little bit about the use of humor to talk about difficulty. Guest within the classic of humor which people not healthcare can find very offputting if not to say disturbing. I dont think it comes out of being callous or on caring. But in the book i had a patient die, i had not known him for very long. I got very attached to him. After he died he had a lot of narcotic left over so i had to waste it, get rid of it. Another nurse helps me. You me. You have to give a reason why you are wasting. A patient died is not one of the reasons. So together we decide on patient refuse which struck us as hilarious. We are laughing so hard that people hurt us in the hallway. But somehow it helps, it helped with my grief to do that. Host great example. You talk about how it is to work in a Healthcare System that seems to forget that it is working with human beings and that, you know sometimes we are caught up in the bureaucracy are focused on healthcare as a business. Say more about the empathy that is needed, certainly to give direct care to patients and that mental toughness that it may take to be a nurse. Talk about that. Guest it is so important to totally be there and it is incredibly difficult because we are constantly getting pulled away. The phone is ringing, low alarm is going off, someone needs you, you, someone else need something from you. That is a constant challenge because sometimes a patient just needs you to be there for them. Either because they are in pain, they are vomiting, they are scared, all kinds of things. Being able to come to that patient with your whole heart and at the same time being to go through your to do list is very difficult. Nurses have to be good at turning on a dime. Host i think it is a challenge, we certainly hear from patients and former patients who feel that their nurses seem so busy they do not want to ask them for thanks. Things that are important for them even if it is just spending a few minutes with them to explain the medication. Guest yeah, thats tough. I remember talking to another nurse and saying i just do not have time to do all of the little things. And and she said yeah, thats right those are the things that really make you feel like you have contributed. Host yes. Really. So lets shift a little, we know that research on staffing has made it pretty clear that more patients a nurse has above a certain number, of course it is very dependent upon how sick the patients are, but the skill level is from various nursing staff on the unit that day. We know that number may contribute to an increased likelihood about patient outcome. About patients who could die. So, staffing issues are an ongoing concern at the American Nurses association, it has been a lot of our work in the last few years. In fact, we we have worked with congress to reintroduce that registered Nurse Staffing act. Talk about how staffing impacts nurses and your patience. Guest this is such a great question and an important issue. I applaud the ana for their work on this. For patients is a standard load on my floor. I i start with three in the book. To show people what a difference it can make to have three, with 4i am just hopping all of the time. I really want people to understand that. Initially people think that for patients, whats that . That sounds like nothing. Then they read the book and said zero wow, now i really get it. The scary thing to me is ive been doing a number of interviews and nurses safe for patients, ive ive never had fewer than eight patients. The patients that i take care of , it is very distressing to me to say that eight patients may be relying on one nurse. How can one person possibly meet all of those needs. Host it is difficult and yet with the constraints and funding for healthcare these days we have to find the right balance to get the right level of nursing care for the patients, we know it fortunately it can contribute to bad outcomes. Additional work is needed for sure. Do you think patients understand how stretch nurses can be . What if you had patient say to you and that regard . How could we engage patient or individuals who are involved in the Healthcare System to better advocate in the third . Guest thats a great question. I think a a lot of patients get it. Ive had patient say youre busy, dont worry about this, when you get a chance. A chance. Ive heard other patients say dont give me that about change a shift, i need this right now. Neither cases either great for the patient to be so frustrated that their needs are met or to feel like they can ask for something because theyre too busy. What i would like is that people read my book or learn more about nursing, to see how important we are and if they are going to write to legislators or make a point about how to improve hospital care, that they talk about the nursing care. We are very focused on Patient Satisfaction now, which i value and theres value talking about it. But also having enough nurses lead to have a more satisfied patients. The equation of enough good nurses able to do the job and patients doing well needs to be even more solidly established in the public needs to say, this is what we want. Host i think there is ever increasing opportunities to educate the public around what kind of questions they should be asking before they have to go into the hospital or maybe one of their family members has to. Whether they have a magnet designated hospital in their area or even a question about what is the average staffing . What is is the average nursing staffing for unit. So there is a great deal of work that we are all engaged in right now about what are those measures particularly related to nursing care that we would like to see publicly reported, and that patients can go to, or individuals can go to and look online before really and what would they want to know especially when they have the ability to compare different hospitals, different healthcare providers, different facilities. Guest that type of transparency would make a huge difference because that hospitals would know. They can see the hospital across town actually has more nurses, and general than we do on the floor. We cannot tell people how much an mri cost or an apathetic to me for complicated reasons but surely we can tell them how good the nursing care is. Host absolutely. Im going to shift a little bit to the image of nurses. You talk about various things in the book about getting to the issue of image and relationship, among healthcare professionals. You give an example about Nurse Practitioners and physician assistants are not listed on the board. The board is up on the wall so individuals can see who is caring for home. Who is assigned to whom. How those individuals as well as nurses are often elicited by first name but we use physicians, residents residents often are listed by their last name. Say more among the relationship among individuals and what kind of issues to we have in our setting that keep this challenge as we work on nurse, physician relationships or respect among the Healthcare Team. Or understanding what Healthcare Team members do. Guest there is a clear hierarchy. Doctors have Certain Authority that nurses do not have. But theres a bigger problem with hierarchy and that nurses find themselves in situation where we feel our contribution is not looked at as being significant. So the dr. Be in doctor brown and the nurse always being, tresa reinforces that sense. That the dr. Is the expert and the authority and the nurses something between a waitress and a best friend. I dont mind at all having patients call me teresa, in fact i like it. I would like the formality that doctors work with us, i find it so strange to be talk into physician and theyll be talking about another dr. And theyll just say dr. Sometime its a really, last name like doctor scott, doctor brown, doctor miller. You have. You have no idea who theyre talking about. So on a very basic level, this reinforcing hierarchy with titles can get in the way of really elementary things like care like who is the dr. . How do i call that person . Host another example used in the book is how nurses are certainly trusted to administer a drug that could be very damaging on an individual particularly in an oncology unit, a cancer unit. You are administering medication through the vein yet you counter that example how you are not quite sure that you can use google without filters. So it is likely have this the dynamic of full confidence and trust and yet we have these barriers that seem to impact respect we would have her professional. Guest that is a great contrast. On the the one hand we are very skilled technicians. I attended quite extensive classes that my job provided to give patients chemotherapy. Many jugs required specific knowledge of how you give them. We carry a lot of that around with us. That is quite a responsibility. On the other hand, sometimes i would try to google things at the hospital like i would look up something about a chemo drug and i would not be able to use google. It seemed to come and go, that authority. Then another nurse said there is another way to pull up the ekg and then there is a way to circumvent it and they found that out. But the idea that we are intelligent people who might actually need to look up something. The point is to keep us from getting on facebook, i guess. I just have been seen that happening a lot. Host youre too busy. Besides this issue of first late name, last name and access to internet resources that may be needed for patient care, are there any other areas you can think of, anything else you have had in your experience in which nurses need to be focused about getting more respect from their physicians and who they are is a key member of the Healthcare Team . Guest nurses are notorious for the phrase, nurses eat their young. I have experience that. It is really horrible. But we could change that. I think it happens out of a sense of frustration. Not being listened to. Not being taken seriously. That anger has to go somewhere. So then nurses take it out on each other. It could be younger nurses again older nurses, new nurses against old nurses, its just bullying. We could stop it if we really looked at it as a management problem and a Work Environment problem. And say why are these nurses so frustrated . Host i would agree with you, absolutely. You do a great job in the book talking about your relationship with these four patients, even smother patients you elude to that you cared for before, or who had been on your unit previously. Our relationship with patient, particularly in your setting, patients who is on time go in and out of the hospital so you get to know them or than just a single episode. They are complex leading relationships with the patient. Talk more about that, particularly when we have the challenges in healthcare about Patient Satisfaction scores in the dynamics of, you know know them for that. Of time and then you send them off and of course is used in the book on a cancer ward you hope to never see them again. Guest yes, we say that to people and weve had people say that to me. I hope you i never see you again. Unless maybe at the mall. I think anyone who goes into nursing, maybe especially ecology or safe you just have that impulse to connect hearttoheart with other people. I remember as a new nurse talking about this and she said that she when you stop caring thats when you need to get a different job. I really took that to heart as well. The idea that sometimes it is going to be really painful and youll get attached to people, and they will die. And that hurts. But it is part of the job. I look at it as a sort of said idea of i go in, i do my best for these people, i tried to make their lives better, their care good, and i do my bit and then i leave. In our training that really gets reinforce. You show up on the floor together for clinical, you leave together, there is no calling to see how is mr. Jones doing . You do your bit and then someone who is every bit as good as you are is going to take over for you. Host you also talk about other things that impact patient care. Paperwork is one of those things. You use is great example that i want to talk about and read from about your time with the patient you just mentioned a minute ago. You say, teresa you just cannot stop bothering doctor coyne can you. Our secretary calls out loud enough for anyone standing nearby to hear, this is a moment when i find her abusiveness difficult. I try to ignore her. But then i feel it, upset. The secretaries, and suggest suggest i am not adhering to the expected md, rn relationship and it is not the first time as nano pinion 80, even pushing nurse, but why is that . Should i . Should i not feel asserted and responsible instead. Isnt it a core guide used for all healthcare professional. So talk a little bit about physician, nurse relationship. Paperwork that impacts, those things that get in the way of getting in the care that we know our patients knee. The time that you wanted to spend with sheila and her family, and yet this balance of needing to feel pushy and to put ourselves out there. Guest it is interesting that i will describe myself like that, like im being a pushing nurse. My husband says youre not being pushy, thats your job. But he is why dont i see myself as the assertive. Again, i think its a way a way that nurses can be hard on ourselves. The environment does not always reward the outspoken nurse, i was going to say opinionated by thought dont say that because that also sounds negative. Direct, assertive, forceful forceful nurse that is advocating for his or her patient. Paperwork is a more complicated issue. As i show in the book theres just a constant demand and you can never get away from it. It hangs over us for the entire shift. All i still still have to do one my full assessment or at the end of a 12 hour shift and you are turning the stuff that happened at nine in the morning because you do not have time to do it before. A lot of nurses feel like more and more charting, paperwork requirements are being placed on us. But none drop off on the other end. So we are spending more, and and more time at the computer. I know physicians feel this way, physical therapist, respiratory therapist and even chaplains feel this way. We are not alone in this. Again, as a society we need to be talking about these paperwork requirements thinking about how we can streamline them, making them more efficient. What we what we really want to know need to know. Paperwork is never going to be more important than being with your patient. Thats what matters. Host i sometimes think we need to ask yourself the question is, how are are we going to use this information . With the Electronic Health record, we are really looking a lot at how can we extract information from the record, not a single patients but across the board and see, are there certain things we are doing or not doing that may contribute to good patient care, negative falls with patients, those kinds of things. There is a lot of documentation that is not useful. That if we dont think about how we are going to use this information. I certainly think looking for opportunities to streamline that. You talk about spending time with sheila and her family and how that was one of the most important things to do that day yet, it was not on your to do list, it was not on your dropdown menu on the Electronic Health record. Spending time with the patient with a lifethreatening diagnosis, unfortunately that was not one of those things whereas starting id be, giving the medication, all those all those things. We understand from a legal perspective certain things certainly need to be documented. It is that balance, how do we balance documentation and direct care because we know that patients value that time of comfort. That is what they look for. Often, that is what they talk about when they leave. Guest that is exactly right. That is very important for a patient and their family members. It is what nurses are so good at, what we are trained to do. It is what we are therefore along with a bunch of other things. But i feel like it is not legitimated in the paperwork. Or you do not have time for it because like when you hung an iv, and when you took an iv down, and on and on. Host right, exactly. You also talk about how in the same age, of course i finish Nursing School and did my earliest work in the direct care in the hospital setting in the 1980s. It has been a little while. Nurses were educated completely separated from physicians, i think to a large extent that is still the case. Although, we are finding in some schools of nursing, schools of medicine, they are doing some classes together, better understanding roles and those kind of things. I think the the most part and you even talk about it in the book and these have mds have a little idea what nurses do, they do not necessarily understand that nurses are performing independent functions, independent verifications, checking the map, checking the order, making sure the right drug is to right track gets to the right patient and why that is so im