Measles, Mumps and Rubella--Oh My!

The author's need for an MMR booster vaccination leads to a brief review of CDC guidelines for the vaccination of healthcare workers. Please click here to read the article posted today on Nurse LinkUp.

The Nursing Shortage: A Global Crisis, Close to Home

(Note: This is my inaugural post under the auspices of the nurse blogger scholarship which I recently received from Value Care, Value Nurses.)

The nursing shortage is here to stay. At least that's where the signs all seem to be pointing. From reports of teachers doing the work of school nurses to a profound lack of nursing faculty, the shortage---predicted for years by many in the know---is an inescapable phenomenon with far-reaching repercussions.

For instance, the Joint Commission (which is responsible for accrediting American hospitals and other healthcare facilities) has stated flatly that up to 100,000 preventable hospital deaths per year in the United States can be attributed to the nursing shortage. Additionally, the Department of Health and Human Services' Agency for Healthcare Research and Quality estimates that adding one patient per nurse per shift in U.S. hospitals increases the risk of hospital-based complications by as much as 17%. But how, pray tell, can hospitals decrease nurse-patient ratios in the face of such massive shortages of personnel?

As individual states consider passing legislation to decrease nurse-patient ratios, some state legislatures---like the Massachusetts Senate---seem deaf to the cries of nurses and patient advocates for mandated nurse-patient ratios that will serve to protect both nurses and patients from unnecessary injury. And in the midst of such a shortage, over-working nurses to the point of attrition from the profession is wholly counter-productive.

When it comes to educating new nurses, the American Association of Colleges of Nursing (AACN) predicts a shortage of up to 500,000 nurses by 2025, exacerbated by a severe shortage of nursing faculty across the United States. With 40,000 qualified applicants turned away from nursing schools in 2007, how will the shortage ever truly be addressed as nurses (and nursing faculty) of the Baby Boom generation begin to retire in droves? This AACN fact sheet apparently says it all, and the picture that's painted is anything but pretty.

As the average age of nurses climbs towards 47; as schools of nursing turn away students in record numbers; as Baby Boomers retire and nursing faculty follow suit---how are we to stem the tide? Faculty salaries cannot keep up with inflation, nurses are recruited heavily from region to region, and overworked nurses burn out as they care for too many patients.

From Canada to Prague to South Africa, more nurses are needed than schools can produce as nurses retire faster than they can be replaced. The story appears to be the same around the world, and governments, facilities and organizations seem to be scrambling for a multitude of solutions.

This writer does not purport to know the answers, and as I read the news, talk with nurses, and read what nurses throughout the blogosphere have to say, the nursing shortage is having a far-reaching ripple effect that touches on every aspect of medicine, health, healthcare, and community.

Nurses are essential to the health of myriad communities. Visiting nurses keep patients safe when they come home from the hospital with acute medical and nursing needs. Hospice nurses provide support for patients and their families as they navigate the dying process. Medical-surgical nurses keep hospital units running smoothly, safely, and efficiently. School nurses dispense medications and tend to the (often complex) medical needs of our children. Office-based nurses serve as the backbone of many private and group medical practices, and advanced practice nurses provide specialized medical care in settings where a doctor is neither available nor necessarily essential to good patient outcomes.

In the coming months, it will be interesting to see how the two major political candidates address---or fail to address---the nursing shortage. Barack Obama may have shadowed a nurse for ninety minutes, but a few hours in scrubs does not a policy make. And when it comes to national healthcare for the masses, if there are no nurses to deliver that care, then the plan is moot from the start. As far as this writer is concerned, any national healthcare policy debate that does not take into consideration the very real shortage of nurses in this country is a debate lacking an essential ingredient.

Yes, the nursing shortage is apparently here to stay---at least for the foreseeable future---and the resolution of this crisis is a goal in which every citizen has a serious stake.

The Ego and the Spirit

Two people have been living in you all your life. One is the ego, garrulous, demanding, hysterical, calculating; the other is the hidden spiritual being, whose still voice of wisdom you have only rarely heard or attended to. As you listen more and more to the teachings, contemplate them, and integrate them into your life, your inner voice, your innate wisdom of discernment, what we call in Buddhism “discriminating awareness,” is awakened and strengthened, and you begin to distinguish between its guidance and the various clamorous and enthralling voices of ego. The memory of your real nature, with all its splendor and confidence, begins to return to you.

You will find, in fact, that you have uncovered in yourself your own wise guide, and as the voice of your wise guide, or discriminating awareness, grows stronger and clearer, you will start to distinguish between its truth and the various deceptions of the ego, and you will be able to listen to it with discernment and confidence.

---Sogyal Rinpoche

Value Care, Value Nurses Scholarship

I would like to announce that I was thoroughly shocked and humbled this week after learning that I was selected as the national winner of the Value Care, Value Nurses Blogger Scholarship. I applied along with many of my nurse blogger friends and colleagues, and never suspected that this honor would be bestowed upon me at this juncture in my blogging career.

Under the auspices of the Service Employees International Union (SEIU), Value Care, Value Nurses is a national campaign to raise awareness by promoting nurses and nurse-based solutions to the current healthcare crisis in the United States. I will be posting several times per month here on Digital Doorway about salient issues related to nursing, healthcare, healthcare reform, and the presidential election, and will actively seek out other bloggers writing about similar topics.

(And never fear, dear Reader! I will also continue my usual postings about spirituality, Buddhism, and my own personal journey as a nurse and a patient with chronic illness, not to mention my regular postings on Nurse LinkUp.)

So, my gratitude to the SEIU and the team at Value Care, Value Nurses. I only hope that I can fulfill the expectations that are part and parcel of this stimulating process, and I hope that you, dear Readers, will follow my progress into these challenging and exciting sociopolitical waters.

"So, You're A Nurse?"

Nursing has many occupational hazards, but there are some more irksome than others. My newest article on Nurse LinkUp explores just what irks me so.

Notes on Hospice: The Gift of a Death at Home

He lay there in the bed, feet extended in permanent contractures, arms curled at his chest, immobile. Ulcers burrow deep into various parts of his body: sacrum, hip, elbow, shoulder, right ear. He is non-verbal, eyes intermittently open, but what---or if---he sees is up for conjecture.

At this point of the end of life process, there are no more fluids being given, and no more food. Morphine is delivered via a pump that sits on the bed-side table like a silent sentinel. A small needle is inserted under the skin in a part of the body where there is still some semblance of subcutaneous fat. Once there is absolutely no fat left, this mode of delivery may not work as well.

A "rattle" is now heard in the chest as fluid builds up in the lungs. One really needs no stethoscope to know what's going on. With the kidneys shutting down, whatever fluid is in the body simply shifts into places where we can hear it make its presence known.

One of the most disturbing things to family members and loved ones is the gurgling in the throat. Fluids with nowhere else to go sit in the throat, and this disconcerting sound can be heard whenever the patient takes a breath. Medications like scopolamine and hyoscyamine are given under the tongue or as a patch behind the ear to dry up these secretions, decrease drooling, and literally quiet the noise.

Speaking of breathing, as the end approaches, periods of apnea ensue, the patient taking a breath and then pausing for five, ten, even twenty seconds at a time before taking another one. Family members witnessing such an intimate and painstakingly slow process can literally be on the edge of their seats as they wait for the subsequent breath. These apneic pauses where breathing simply suspends become longer and longer, until the fateful moment arrives and an apneic pause simply extends into eternity.

The moment of death, long awaited and often dreaded, can be wholly undramatic. The patient takes a final labored inhalation, and the exhalation simply never comes. Last September, we watched my step-father go through this process, and that last intake of oxygen hung in the air like an unfinished promise, all of us anxiously encircling his bed, our own breath held tight in anticipation of an end we knew was so very, very near.

When the life in the body ceases, when all animation leaves the face and the eyes become vacant and literally lifeless, that is the moment when mourning begins. Anticipatory grief now gives way to active grieving for the one who has exited this world.

Death at home is not an emergency, and families can take as much time as they want as they sit with the body of their loved one. Once those informational telephone calls are made, the hospice nurse and the funeral home director will arrive on the scene, and the removal of the body becomes the focus. When my step-father died, I suggested we wait an hour or two before making any official calls, simply taking some time to be in the room with his body, admiring his peaceful demeanor and the way the cessation of all suffering had smoothed his brow. I have encouraged other families to do the same over the years, and now as a hospice nurse, I will make it my mission to allow patients' families that gift of time following death's arrival at the doorstep.

Death is an intimate and beautiful process, and allowing it to happen in the home---where life is a constantly unfolding moment---is one of the greatest gifts that we can give the patient and the family. Years ago, prior to the medicalization of both birth and death, those two very crucial life processes almost always occurred at home. Now, as rare as it may be in our industrialized culture, birth and death have once again gained some ground at home, with many families reclaiming the home-based intimacy and immediacy of beginning and ending life in the family nest, in the crucible of family life.

Death, that most inevitable of processes, is something we know can be given as a gift to both the patient and the family, stripped of unnecessary medical drama, its pathos and emotional gravity intact. With the patient comfortable and free of pain, this passage now becomes one that can occur within the context of home life as children play in the yard and soup cooks on the stove. The patient can now take his or her leave, comforted by the voices of children and the familiar smells of home.

Did I say that a tranquil death at home was a gift? Yes, it is a gift wrapped with love and sealed with the ribbon of compassion.

A Rock and a Hard Place

Last night I underwent the second in a series of sleep studies to determine the best treatment for what appears to be relatively severe obstructive sleep apnea. My apnea was discovered a number of months ago when I underwent my first sleep study due to symptoms of Restless Legs Syndrome. That study did indeed prove that I have Period Limb Movement Disorder, and medication now controls those symptoms exceedingly well. However, when it comes to apnea, I am indeed stuck between a rock and a hard place (when, in fact, I would rather simply have my head on a nice soft pillow).

When one undergoes a sleep study, one is covered with tape, wires and tubes, attached to several machines, and monitored via infra-red closed-circuit TV as you try to sleep in this wholly unnatural and uncomfortable state. Last night was especially uncomfortable, with the room too warm most of the time, and then when the air conditioning kicked on, cold air blew on my face from a vent in the ceiling above the bed. Add to this the periodic sound of the technicians talking (quite loudly) with a neighboring needy patient, irritatingly punctuated by the opening and closing of doors up and down the hall. Yikes. I took this picture of myself around 2am when I was in a state of considerable annoyed exhaustion:


Now, for the past several months, I have been using an expensive custom-made dental device that does indeed help to keep my airway open when I'm sleeping, but unfortunately is causing potentially permanent changes to my bite.

Thus, last night, I elected to spend three hours sleeping while strapped to a CPAP machine in order to see if I can tolerate such an invasive device to control my apnea. Covering one's nose with a soft mask attached by a series of straps to a relatively quiet whirring machine looks sort of like this:


So, dear Readers, what is the long-suffering and apneic nurse to do?

1) Wear the uncomfortable dental device that certainly does control the apnea but may cause permanent and unwanted changes to my bite?

or

2) Wear the uncomfortable head gear and nasal mask attached to aforementioned whirring machine every night for the rest of my natural life?

or

3) Do neither, which will cause the following consequences:

a) Disturbed sleep for my long-suffering wife of 19 years, bless her heart
b) Decreased quality of sleep for me, with increased fatigue
c) Pulmonary hypertension and cardiovascular disease from untreated apnea

I now think I know what I need to do, and I'm afraid it may entail looking something like this every night:


God help me.

Mindfulness and Nursing: An Inquiry

Please be so kind to click here in order to read my new article on mindfulness and nursing, recently posted on Nurse LinkUp. Whether you're a nurse or not, mindfulness and related practices can be powerful tools for personal growth and exploration.

Of Vacations and Relative Privilege

Well, we're back home, pleasantly vacated and rested from the toil of the workaday world.

Now, if only everyone could afford and enjoy even a brief holiday, then there would be economic justice in the world. But alas, only some of us can afford such luxury, and I am very grateful that this is possible for us. While our vacations are modest affairs, they're still vacations nonetheless, and I bear in mind my relative privilege.

Speaking of privilege, sitting here on my porch after a long day in the city is yet another privilege not to be taken lightly. In the urban concrete jungle where I sometimes work (and where my wife works daily), people swelter in the summer heat with very few available ways to experience relief. Hot weather is always worse in the city, as the concrete absorbs the sun's rays and heat is trapped in the streets.

Yes, some of us relish the summer as we drive air conditioned cars and dive into well-maintained pools. Of course we should all enjoy what we are so blessed to have, yet we can still bear in mind those who have so much less.

Vacation!

Dear Readers,

We will be on vacation from July 1st to July 6th. Thus, Digital Doorway will also have a rest.

Be well, and please stop back next week for the continuing saga.....