Clinical smarts work like me to put our shoulders to the rock and modern healthcare every day pushing up the hill. So, talk of the vote about what our current Healthcare System and how challenging it is to be a nurse in the system today. Guest that image came to me because i really feel that way a lot at work that there is a giant rock and we come in every day and have to move to the top of the hill and then come back to that same rock and same job because of care is so complicated now and not really focused very well on coordination that it can often take a tremendous amount of time and energy for basic ordinary things to happen. So, for example one of the patients in the book who was misdiagnosed with a classic thing that happens they come to the Emergency Department with a medical problem that is perceived to the medical floor and it turns out she turns out she actually has a very serious surgical problem, and i was talking with one of the surgeons involved in on my behalf i felt so angry and they said it happens all the time. Host i dont think the public can appreciate how competed it can be to even try to work harder at coordination. Guest and i dont want to scare people and make them think hospital is a chaotic mess. Thats not the case. Host but it takes a lot of work. Especially nurses who are there every day. Guest and that is a lot of what motivated me to write this book because the average person doesnt know how important verses are to quality patient care and if you do well in the hospital its likely that some of that is going to have to do with your nursing care. Host so the practice in the book is a cancer ward. When i was in the next practice by practicing pediatrics and i sometimes would have people say to me i dont know how you take care of the kids. Im guessing from people that say to you i dont know how you take care of patients that have cancer it seems so depressing. Guest that is exactly what they say. Host but im also struck by the use of humor and health care and in the setting that you normally think of as depressing and difficult, but patients and families and nurses and Healthcare Teams use humor. Talk little bit about the use of humor to talk about the difficulties. Guest i think people not in healthcare can find it offputting but i dont think it comes out of being callous or uncaring. So giving the patient, i didnt know him very long but i got attached to him and i felt this very profoundly. After he died he had a bout of narcotics left over so i needed to get rid of it and another nurse helped me. You have to give a reason why you are wasting. And patient died is not one of the reasons. So together we decide to patient refused to which struck us as hilarious. We were laughing so hard people hurt us in the hallway. Somehow it helped with my grief to the do that. Host you talk about what its like to work in Healthcare System that seems to forget it is working with human beings and that sometimes we are caught up in the bureaucracy and focus on healthcare as a business. See say more about the empathy that is needed to get direct care to patients and the toughness that it may take to be a nurse. Talk about that. Guest its so important to totally be there and its incredibly difficult because we are constantly getting pulled away. The phone is ringing and alarm is going off and when someone needs Something Else from you, that is a constant challenge because sometimes the patient just needs you to be there for them either because they are in pain or scared or all kinds of things. And being able to come to the patient with your whole heart and then at the same time being able to constantly go through door to do list is very, very difficult. And good nurses have to be really good at that turning on a dime. Host is a challenge we hear from patients and former patients who feel the nurses field so busy they dont want to ask them for things that are important even if it is just spending a few minutes with them to explain one of their medications or host and thats tough. I ever member talking to another nurse one day saying if you dont have time to do all the Little Things and she said thats right these are the things that make you feel like youve contributed. Host but shifted to the hospital you talk about that at various points in the buck and we know that their research on the research on staffing has made it pretty clear the more patients a nurse as it is very dependent on how sick the patients are, what the skill level is from the various nursing staff on the unit that they. We know that number may contribute to an increased likelihood of Patient Outcome and about patients who can die. So it is an ongoing concern at the investigation its been a lot of our work in the last few years that we have worked with congress to reintroduce the staffing act. So, talk about how the staffing and Practice Nurses and their patient. Patients. This is a great question and issue and i really applaud them for their supportive work. I picked for patients that is a standard load on the floor but i start with. With four im just hoping all the time and i really want people to understand that because i think initially some people said for patients, whats that, that sounds bad, that sounds like nothing. Then they said now i really get it. And the scary thing to me is ive been doing it for a number of interviews and ive never had fewer than eight patients. Its very distressing to me to think they might be worrying about how to meet all those needs. Host it is difficult and get with the constraints and funding for health care these days, we have defined the right balance to get. It can contribute to bad outcomes and additional work is needed for sure. Do you think patients understand how stressed versus can be and what have you had them say to you in that regard, and maybe how can we engage patients or even individuals who are involved in the Health Care System to better advocate tax guest that thats a great question. I think a lot of patients get it. Youre busy, and ive had others say dont give me that expletive about a change in the shift. So come in either case is really great for the patient to be so frustrated certain needs are not met because i am too busy. So, what i would like is people read my book or learn more about nursing and see how important we are and then if they are going to write to the 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 there is a value in talking about that and also having enough nurses lead to having enough satisfied patients and a creation of enough good nurses able to do the job and patients doing well needs to be even more solidly established into the public to say this is what we want. But i think there are increasing ways 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 were even a simple question about what is the average staffing, what is the average Nurse Staffing for a unit. So theres a great deal of work but i think 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 that patients can go to or individuals can go to and book online if we are getting staffed in that accessing information online. And what would they want to know especially when they have the ability to compare different hospitals, Different HealthCare Healthcare providers, different facilities . Guest that kind of transparency would make a huge difference, because then hospitals would go out of this. The hospital across town has more nurses in general than we do on the floor. We cant tell people how much an mri will cost were in appendix b. For complicated reasons, but surely we can find a way to tell them how to nursing care is. Host absolutely. Im going to shift the image of nurses. You talk about various things in the book that get at the image with relationship among the Health Care Professionals and you give an example about Nurse Practitioners and the practice listed on the board thats up on the walls of individuals cant he who is caring for whom, who is assigned to whom and how those individuals as well as nurses are often listed by first name. So, we use physicians, residents can often listed by their last name. So, say more about the relationship among individuals and what kind of issues to be half an hour settings that keep this challenge as we work on nurse physician relationships or respect among the Healthcare Team understanding about what healthcare members do. Guest there is a clear hierarchy. There is a legal hierarchy in the one sentence of the authority that they do not have, that there is a bigger problem with hierarchy in the nurses find themselves in situations where we feel like our contribution is not fact of being significant and so the doctors are only seeing doctor brown and the nurses seeking to visa it reinforces the sense that the doctor is the Expert Committee authority, and the nurse is something between a waitress and a best friend. I dont mind at all having patients call me treats in fact i like it. I would like the formality that doctors work with them to be dropped and i find it so strange he then you will be talking to a physician and talk about another doctor and sometimes it is a really common last name like doctor brown or doctor miller, and you have no idea who they are talking about. So, on a very basic level, this reinforcing of the hierarchy with titles can get in the way of elementary things about who is the doctor and how do i call that person. Host another example you used in the book is how nurses are certainly trusted to administer a drug that could be very damaging for an individual particularly for an oncology cancer unit. Youre administering medication through the veins, and even countered that example how youre not quite mature enough to use google without filters, so we have we have this dynamic of the trust and yes we have these bigger years that seem to impact the respect we would have for a professional. Host that is a great contrast. On the other hand we are very skilled technicians and despite extensive classes my job provided to give patients therapy, many drugs require very specific knowledge and how we carry a lot of that around with us. Thats quite a responsibility. But then on the other hand, yes sometimes i would try to look at things at the hospital. Like i did look up something about a chemotherapy drug and i wouldnt be able to use google, and it seemed to come and go, that authority. And then another another found out was the way that you could pull up and ekg and use that to circumvent it and somebody found that out. [laughter] but the idea that we are in intelligent people that might actually needed to look something up, no the point is to keep us from getting on facebook i guess. And i just didnt see that happening a lot. Host a little too busy. Guest yes. Host so beside this issue of first name, last name were respect and access to the internet resources that may be needed for patient care, are there any other areas that you can think of them anything else that you have had in your experience in which nurses need to be focused about engineering more respect for their positions and who they are as a key member of the health party . Guest nurses are notorious for this ugly phrase versus either young and i have experienced that. Its really horrible. But we could change that. I think that it happens out of a sense of frustration at not speaking speaking with them too and not being taken seriously. And that anger has to go somewhere. So then some take it out on each other and ive heard all kinds of combinations that can be younger nurses against older nurses, older nurses against younger nurses, new, any combination you can think of as possible and its just bullying that we could stop it if he really looked at it as a management problem in a Work Environment problem. Host y. Arvs nurses so frustrating . You do a great job in about talking about your relationship with obese patients and even some other patients you alluded to that you care you care for you for and youve been in the units previously. Our relationship with patients particularly those that sometimes would come in and out of the hospital so you get to know them more than just a single episode. Our relationships with patients coming in to talk more about that particularly once we have the challenges and Patient Satisfaction scores and the dynamics and we know that for the period of time you send them off and as you say in the book in a cancer ward you hope to never see this again. Guest and we say that to people and ive had people say that to me. To become heart to hearts with people and number as a nurse talking about this with another doctor and she said if you stop caring that when you need to get a different job and i really took that to heart as well. Its going to be really painful sometimes when you get attached to people. Its part of the job. And if that idea i go in and do my best ive done my bit and then i leaned. Say how is mr. Jones doing and then someone who is every bit as good as you are will take care of you. Host youve also talked about other things that impact patient care, paperwork. There is an example of one want to talk about and read from about and as you just mentioned a moment ago you just cant stop bothering her, can you commit a secretary the secretary calls out loud enough standing nearby and this is the moment i find that refuses difficult but when i feel it then i feel it upset. Im not adhering to the expected relationship. Shouldnt that feel a sort of and responsible and instead arent those values for all healthcare professionals. Talk about the physician and nurse a physician and nurse relationships, paperwork that impacts those things that get in the way of you doing the care that we know our patients need. The balance of needing to feel pushy. I will describe my self like being a pushy nurse and my husband says youre not being pushy contest your job. Why dont i just see myself as assertive. As nurses we can be hard on ourselves and the environment doesnt always reward. I thought no, dont say that. He is advocating for his or her patients. Paperwork is a more complicated issue. Its a constant demand to never get away from it but its for the entire shift to be one of the full suspense. And because you didnt have time to do it before. So a lot of nurses feel like more and more paperwork requirements are being placed on it and none of them drop off the dropped off the other end, so we are spending more and more time at the computer and i know that physicians feel this way and respiratory therapists and even chaplains ive heard can feel this way. So we are not alone in this, but again, as a society we need to be thinking about all these paperwork requirements and thinking about how we can streamline them and make them more efficient. What is it we want to know and need to know and say that the paperwork is never going to be more important than actually being with your patient, thats what matters. Host i sometimes think we need to ask ourselves the question how are we going to use this information from the Electronic Health record we are really looking a lot at can we extract information from the record, not a single patient across the board tuesday are there certain things we are doing or arent doing that may contribute to good patient care and negative false patients into those kind of things but there is a lot of documentation. You talk about spending time with sheila and her family. It wasnt on the to do list. It wasnt on your dropdown menu on the Electronic Health record in the patients with lifethreatening diagnosis. So unfortunately, it was like that wasnt one of those waiting to be cut things but we understand from the legal perspective of things certainly need to be documented. But the balance of that balance up out of the balance documentation that care because we know that Patient Value thats what they look for and often thats what they talk about when they leave. Guest thats right that is very important for the patients and their family members and its what nurses are so good at. Its what we are there for. We feel like it isnt legitimate and the paperwork that we wont have time for it because of things like when you take the iv down and on and on. Host exactly. You also talk about how in this day and age i finish Nursing School and did my earliest. I think to a large extent. They are doing classes together better understanding but i think for the most part, and you talk about this in the book they have little idea of what nurses actually do when we check the orders and they dont necessarily understand that they are performing a really independent function. Its the right drug to the right patient and why that is so important making sure the patient is ready for that medication and how you use the phrase our used the phrase our work is often visible to each other. So come see more about that dynamic and what you think we can do to improve that. We talk about respect earlier. But talk about the actual need to understand each others role and work well together to optimize the care that we are giving both in different roles to the patient. Host its so important and that strikes me as very strange nurses dont learn how to work with doctors and doctors dont learn in medical school how to work with nurses. But then you put these two groups together and that is how patient care happens so im not sure how anyone thinks that this is the best way to achieve the results possible. As you said there are programs that are now starting to focus on the interpretation of education. And that is a great start. I think for each of us to have empathy for the other makes a huge difference. Partly to know what they are thinking and what they are doing. And i would love it if doctors would look at writing by nurses and to try to find out what is it that we are actually doing all day, get a sense of how we are training or how we are able to accomplish. I mean, i am thinking of a story where we had a patient who was doing very badly and didnt want to go to the icu but we didnt have a do not resuscitate form but that was okay. Host and explained that means. Guest at this point the patient