A Day in the Life of a Neuroscience Nurse

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There is no typical day for a nurse. No, really, there isn’t. Every day or shift has the potential to be exhausting, challenging, inspiring, or everything combined. On any given day, nurses often see patients (and their families) at their weakest and most vulnerable, but sometimes at their strongest.

Nurses usually spend more than 8 hours in the hospital tending to the needs of their patients. For neuroscience nurses, 8 hours might not even be enough to do everything that you want and need to do for your patients. Almost all the time, neuroscience nurses handle patients diagnosed with cerebrovascular disease or stroke. However, there are times when patients with autoimmune diseases (i.e. Guillain-Barre syndrome, multiple sclerosis, chronic inflammatory demyelinating polyneuropathy) are admitted in the hospital. These patients warrant almost the same level of care as stroke patients.

It is almost impossible to write about a typical day for a neuroscience nurse given the fact that healthcare workplaces vary and the actual work differs from shift-to-shift depending on the type and number of patients a nurse needs to care for. The following is a broad outline of what a workday might be for a neuroscience nurse in the Philippine General Hospital during an 8-hour morning shift.

Early Bird

A nurse’s day often begins even before the sun is up. Most nurses have taken a bath and / or eaten breakfast before other healthcare professionals even hit their alarm’s snooze button. Those who do not live within the vicinity of the hospital often ride a bus, jeepney, or train to get to the hospital. You are lucky if the commute only lasts an hour or less. On a usual weekday, travel time doubles and sometimes even triples.

Some nurses arrive as early as an hour before the actual shift starts. The time is spent preparing for patients’ medications. Some oral medications (tablets) need to be crushed as they will be given to patients with dysphagia (inability to swallow as a consequence of stroke) via nasogastric tube. A tray will often be filled with vials of antibiotics that are diluted at least 30 minutes before they are administered to patients. Ampules of paracetamol, dexamethasone, and furosemide are immediately broken and aspirated into a syringe one after the other.

Sometimes, a nurse will do a quick round in the ward to see how many are intubated and connected to a mechanical ventilator. He/she then proceeds to prepare materials for tracheostomy or endotracheal tube care which will commence after the handover.

Handover

A hospital isn’t like any other workplace where one shift ends before another begins. Morning, afternoon, and night nurses usually work as a team ensuring that patients receive seamless care. This is made possible through nurse-to-nurse endorsements (handoff of information) at the start of every shift. The morning shift nurses get information from night nurses about what happened overnight, as well as other pertinent patient information or needs that are essential for the next shift. Depending on the number of patients, handovers usually take 30 minutes.

It is also during the handover when nurses check for supplies and inventory to make sure they have enough for their shift. The code cart (emergency cart or e-cart) is typically used for emergency cases such as when a patient goes on cardiac arrest. The e-cart contains essential emergency drugs, including epinephrine, used during cardio-pulmonary resuscitation (CPR). Hence, in the neurology ward (where a high-stress situation could easily arise), it is a-must for nurses to check the supplies contained in the e-cart every shift as one wouldn’t want to run low on supplies during emergency situations.

Morning Rounds

Average days or routine work doesn’t happen when you’re dealing with many patients, especially those in the neurology ward. Mornings are often busy for nurses. A lot can happen during and in-between shifts. Much of the hours in the morning are spent on hourly assessing the condition of patients, taking their neurologic vital signs (blood pressure, heart rate, respiratory rate, temperature, GCS, & pupil size and reaction to light), and monitoring blood sugar of patients with diabetes.

Neurologic diseases often affect cognitive as well as motor/muscle function. As such, more than half of the patients are highly dependent on the nurses. During the morning rounds, nurses often position these patients on high back rest. This is in preparation for various morning care routine and the subsequent tube feeding.

The actual work starts by administering Salbutamol through a nebulizer followed by suctioning of secretions (i.e. sputum, saliva). The ward has only one nebulizer and three cheap portable suction machines that are used for 18 patients. Suction machines use ‘suction’ to pull out pooled secretions in the patient’s tube or mouth to remove obstruction in the airway. Unfortunately, some of these machines have worn out, unable to effectively suck thick, frothy secretions. As a result, some of the patients’ relatives often take the initiative to buy their own machine/s.

After routine morning care and bathing, both oral and intravenous medications are administered to patients. Some patients have multiple antibiotics which are run for 1-2 hours each. Others are given hypertonic saline solution ranging from 150 mL to 400 mL depending on the latest serum sodium of a patient.

Oral medications are mostly given via a nasogastric tube before or after (depends on the medication) tube feeding with osterized (blended) feeding or milk. Patients are left on moderate to high back rest positions after feeding, and observed for drug-related adverse reactions.

Noon

Patients’ vital signs are continuously monitored throughout the shift. Other explicit and implicit needs of patients (e.g. suctioning, bed turning) are also addressed throughout the shift.

Some doctors ask for blood, urine, and sputum samples from their patients to be tested at the hospital laboratory. Neurology nurses often take these samples at or before noon and are eventually collected some time after by a laboratory aide.

Other procedures such as x-ray, ultrasound, and CT scan have varying schedules and these procedures should be taken into account when planning the care of patients. Routine care can be disrupted by these procedures especially when they are ordered stat (medical abbreviation for ‘immediately’ or ‘urgent’).

Some patients who are ordered to be discharged from the hospital are assisted by nurses in accomplishing hospital billing clearance. Most patients in the charity wards go home without paying a single centavo as they are required to enroll in Philhealth (the Philippines’ national health insurance provider). When a patient’s hospital bill is beyond the case rate determined by Philhealth, he/she is automatically referred to other government institutions (e.g. DSWD, DOH, PCSO) for financial assistance.

Patients who are to be discharged are also referred to the hospital’s Dietary Department for nutrition-related lecture conducted by a nutritionist/dietician. Patients with diabetes who are already insulin-dependent are taught by nurses about diabetes and insulin administration prior discharge.

As most days are busy, nurses will often try to take some time for lunch in the middle of the day. This doesn’t always happen though. Sometimes, a ‘lunch’ would be whatever you could grab in-between nursing tasks. Nothing’s guaranteed for nurses, especially a decent mealtime (and even toilet time). Having the time to eat can be a luxury when you’re dealing with an endless list of patients who have immediate needs all day.

Afternoon Rounds

Much like the morning rounds, afternoon rounds kick off by checking if any patient’s status has changed since the last rounds. Some patients require strict hourly monitoring especially when their blood pressure readings are erratic. A patient may be given nicardipine (to decrease BP) or norepinephrine (to increase BP) which is titrated hourly to maintain a specified blood pressure.

By the afternoon, some patients could have been discharged or released but several more will have been admitted in the interim. Nurses can often find themselves managing new patients and administering any medications that need to be given at that time. And of course, during this time, most nurses catch up on charting/documenting nursing care and carrying out doctors’ orders.

The afternoon also include visiting hours. Nurses often use their ‘people skills’ during this period. Nurses are often tasked with updating family members on a patient’s condition. They also educate new patients (and their families) about their diagnosis, treatment and nursing care plans, as well as unit/hospital rules and regulations. Nurses will have to answer patient questions and ensure that both the patient and his/her family have adequately internalized what they need to know.

Handover

Despite the toxicity, one may consider it a good day if no patient went on cardiac arrest or had to be intubated.

Before going home, a neurology nurse will have to make sure that everything has been properly documented. Nurses will have to double-check patient charts and update handover notes for the next shift. Nurses need to make sure that the transition to the next shift goes as seamlessly as it was in the morning so that patients are getting consistent care.

When the afternoon shift nurses arrive, morning shift nurses (usually the charge nurse) will brief them and leave the care of their patients to these nurses with equally capable hands. After the final ward rounds, morning shift nurses go home, enjoy their hard-earned rest, and start again the cycle after 16 hours.

End Notes

There is no typical day for a nurse, especially a neurology nurse. No matter what a nurse does, or where he/she does it, there is always the unpredictability of how a day will start and end. It is an incredibly demanding field, but it can be a rewarding and fulfilling one.

 

New beginning

More than just professional growth, it is the idea of bringing about relevant change in the nursing profession and the healthcare delivery system that primarily motivates me to pursue graduate studies. I have been working in the hospital for almost two years now and it has occurred to me that my experience as a bedside nurse can be an impetus to formulate sound, relevant, and evidence-based health policies. These policies can potentially affect the nursing profession as well as the population it caters: the sick and healthy individual, family, and community.

Ideally, theories are put into practice. However, theories do not necessarily prescribe practice. They facilitate the understanding of the practice. Bedside nurses are faced with the challenge of putting not only theory but also evidence into actual practice. The reason behind this is two-fold: (1) there is no enough evidence to support policy change, and (2) there are no existing policies that support it or existing policies do not necessarily allow it. This understanding of the current state of nursing policy research in the country deeply motivated me to pursue graduate studies. It is my hope that taking this graduate course will help me move closer to fulfilling the career path I wish to take – one that’s anchored in translating research or evidence into health policies.

The war on bugs

In 1945, Sir Alexander Fleming, physician and researcher who discovered penicillin, warned that “the person playing with penicillin treatment is morally responsible for the death of the man who finally succumbs to infection with the penicillin-resistant organism.” Today, we are witnesses to Fleming’s prediction rapidly unfolding as a global reality and disaster.

The introduction of antimicrobials has transformed public health. The discovery of penicillin and other antimicrobial medications, regarded as a modern-day therapeutic revolution, has vastly improved human survival from supposedly fatal infectious diseases. The general public has viewed antibiotics as “miracle drugs” that are able to cure even diseases like colds, bronchitis, and sinusitis for which they are usually ineffective. This perception changed society’s attitude towards the use of antibiotics. This prompted the practice of prescribing broad-spectrum antibiotics to conditions that do not necessarily need them. With the goal of soothing anxieties and meeting expectations of both the physician and the patient, broad-spectrum antibiotics undoubtedly became the easiest and first choice treatment for any condition.

The current abundance and the unprecedented abuse of the use of antibiotics are allowing resistant organisms to survive and thrive. The misuse and / or overuse of antibiotics has led us to an era of antibiotic resistance – a war on ‘superbugs’. To simply put it, we are victims of our own success.

The threat of antimicrobial resistance (AMR) is projected to intensify until 2050 leading to 10 million deaths annually and huge global economic losses. Any nurse or health care professional can attest to the fact that multidrug resistant organisms (MDRO) are a part of daily hospital reports. According to the World Health Organization (WHO), “the most critical group includes multidrug-resistant bacteria that pose a particular threat in hospitals, nursing homes, and among patients whose care requires devices such as ventilators and blood catheters. This includes Acinetobacter, Pseudomonas, and various Enterobacteriaceae (including Klebsiella, E. coli, Serratia, and Proteus), which can cause severe and often deadly infections such as bloodstream infections and pneumonia.”

To address the growing problem on AMR, the Philippines has committed to the 6-point policy package of Global Action on AMR introduced by WHO in 2011. In 2014, President Aquino created the Interagency Committee on AMR through Administrative Order No. 42 directing government agencies to formulate and implement a national action plan that will streamline efforts to combat AMR. Healthcare institutions then began establishing antibiotic stewardship programs (ASP) that implement inter-professional strategies to institute rational drug use – ensuring every patient gets the right antibiotic, at the right dose, administered by the right route, for the right duration. A growing body of knowledge suggests that antibiotic stewardship programs decrease incidence of antibiotic misuse, slow the development and spread of antibiotic resistance thus, improving patient outcomes.

Antimicrobial stewardship has been described as an interdisciplinary approach to minimizing the development of antimicrobial resistance through rational drug use. At present, key activities of antimicrobial stewardship such as (1) monitoring indication for antimicrobial treatment, (2) initiating prompt shift from intravenous to oral therapy, (3) monitoring duration, and drug allergies and side effects, (4) ensuring timely administration of antibiotics, and (5) following up missed doses have fallen in the hands of physicians and pharmacists. However, these activities are sometimes performed inconsistently due to time constraints and high workload.

Nurses are poised to collaborate with ASP implementers and contribute to the inter-professional management of antibiotics across varied healthcare settings as they are considered the primary healthcare providers responsible for reviewing medication orders and in administering these medications to patients. Nurses’ perspectives and engagement are crucial for the successful implementation of antibiotic stewardship programs. However, the extent to which nurses can contribute to these initiatives is often poorly understood. Nursing engagement in infection control has been existing since Florence Nightingale’s innovations in infection management. As frontline healthcare providers, nurses are in an ideal position to enhance ASP through multidisciplinary collaboration and cooperation.

As pharmacologic options for the treatment of infections decrease and the development of new antimicrobials is relatively slow and declining, it is crucial that other initiatives to reduce AMR are effectively implemented. It is imperative, then, for nurses to be informed about antibiotic resistance, antimicrobial stewardship, and other evidenced-based strategies on antibiotic management. Increasing awareness on antimicrobial management and its impact on patient outcomes may enhance antimicrobial therapy, monitoring, and administration.

Although not directly involved in prescribing medications, nurses can greatly influence decision making by (1) encouraging good medication compliance, (2) monitoring prescription decisions, and (3) reducing prescription errors. Antibiotic ward rounds can be established to provide a venue among nurses, physicians, and pharmacists to discuss antimicrobial treatment, indication, and duration. Thus, enhancing inter-professional antimicrobial management and promoting best practices.  Nursing engagement in ASP is empowering nurses to become more effective patient advocates and, could therefore be a time and cost-effective use of resources aimed at improving patient outcomes and quality of care.

Truth be told, the world is running out of antibiotics. And what better way to combat AMR than with the capacity to evolve much like these superbugs? The challenge remains. We must evolve in the way we treat and prevent infections if we are to thrive and survive this war on ‘bugs’. –REINER LORENZO TAMAYO, Nurse, UP-Philippine General Hospital

Published by The Philippine Star on 30 November 2017
Read more at https://www.philstar.com/other-sections/letters-to-the-editor/2017/11/30/1764158/war-bugs#Mr4KPYG32mkvW1xy.99

On the RSA…

UP shouldn’t have control over your life decisions especially the career path you wish to take. Post-graduate studies are not considered RS. But as long as the RSA is fulfilled, I see no reason for UP to hold one’s requirements to just to make sure that you’re taking another health course.

I find it unjust for an institution to hold one’s credentials just to make sure that the course you’re taking is still health-related. What if I like to take economics, creative writing, or even visual arts? Will I not be allowed to take these courses?

If this is the case, then we’re limiting the untapped potential of UP graduates. For an institution that promises holistic growth and development, this action is clearly the opposite of how to achieve that.

Top Ten Lines Lousy and Incompetent Managers Would Say

Good leaders, like good managers, provide vision, inspiration and direction (Morriss, Ely, & Frei, 2014). People want leaders who pursue goals and put emphasis on values (ethics) that are deemed important. People want leaders who respect and promote the dignity, autonomy, and self-esteem of their constituents.

A job title doesn’t make a person a leader. More so, it doesn’t direct a person to exhibit leadership behavior. It is a mistake to refer any person as a leader by virtue of his/her position. Leadership, rather than a mere quality, is more of a function that inspires individuals or groups without the coercive use of power (Roussel, Thomas, & Ratcliffe, 2014). But, let the reality speak for itself. These people actually exist. Many have been fooled by the notion that people holding an office are there because they are good managers or leaders. Some might be but it is not always the case.

While I believe both managerial and leadership skills are learned in the process, this isn’t enough reason for constituents to become minions of their growing tribe; let alone suffer the consequences of working under lousy, weak, and ineffective managers.

In no particular order, here are the top ten things ineffective and incompetent managers (by title) would say:

1) I cannot do anything about it.

This is possibly the worst thing a manager would say. While there are limits to one’s authority or power, anyone who is holding a high position can do something about his/her constituents’ opinion, suggestions, or grievances. He / she is in the position to forward, at least, these grievances to the proper authority for appropriate action. I guess this is the least the manager can do. Well, maybe, unless otherwise stated by law.

2) It has always been this way.

While we love the idea of preserving tradition, we don’t love the idea of being stuck in the old, corrupt, and ineffective system. We shouldn’t be afraid of trying out something new even when it’s scary. It’s always scary when doing things the first time. Traditions stick around because they preserve culture and customs. But if the ‘tradition’ is ineffective, might as well venture out to something new and different and make it the new tradition.

3) I don’t make the rules. I (try to) enforce them.

Is what a manager would say if he / she lived during the dictatorship. We are bound to question rules especially if they affect our welfare. I am not a fan of bending rules. Rules exist to create an organized environment that allows organizations to pursue its goals. Rather than bending rules, question. Revise. Question. Revise. Enforce.

4) I will consider your idea.

Or maybe never? Don’t hear me out. Listen! Maybe the best ideas come from the person we least expect.

5) This shouldn’t be fun.

Says the manager who’d rather live to see satisfactory ratings than a company made of happy, content, and goal-driven constituents. Work could and should be fun. Work, without play, makes Juan (or Juana) a dull boy (or girl). A productive workplace is one which people feel safe – safe to experiment, to challenge, to share information, and to support one another (Harter & Adkins, 2015).

6) You’re better than (insert name).

Or worse, “(insert name) is better than you.”  Stop comparing one employee with another. Spend time discussing one’s strengths and weaknesses. Ang kalaban ay ang sarili. An employee and his/her manager should strive to improve the former’s mere average.

7) Because I’m the boss.

Says the weak manager. Just because he/she is the boss doesn’t mean he/she is right. Yet again, we live in the age where most of our heads are managers by title alone.

8) I don’t have time for you.

Yes, you do. Yes, you should have. Research have shown that managers spend greater than the average portion of their time listening. But doing a lot of listening doesn’t mean managers listen well.  Listening is not the same as hearing.

9) Sh*t, P*ta, T*nga, etc.

Need I say more?

10) (silence)

People value an effective two-way communication. It is the basis and sometimes the foundation of any healthy relationship.  The best managers know and understand that each employee is unique. Each person has his / her own successes and challenges at and away from work. Knowing that employees are people first, managers move towards accommodating their employees’ uniqueness while managing toward high performance (Harter & Adkins, 2015). It is when people feel another person is invested in them that they are more engaged.

 

People leave bosses, not companies. A Gallup study of more than 7000 US adults revealed that one in two had left their job to get away from their manager to improve their overall life at some point in their career. In the case of the nursing profession in the Philippines, nurses leave the country primarily in search of better opportunities abroad. However, some do leave because they’ve grown tired of the system.

For several years, we’ve all been witnesses to countless managers who let titles do their jobs. Let today be the end of that era.#

RSA 2 of 2

December 18 marks the END of my TWO-YEAR RETURN SERVICE. Two years ago, I started working as a research assistant at Health Futures Foundation, Inc. Seven months after, I left the organization to become a staff nurse at the Philippine General Hospital.

I believe I have completed my RSA and is now therefore “free” of liabilities pending the submission of my final RSA report by the end of this year.

What a journey it has been! Hello TOR without the words “for employment in the Philippines ONLY”! Not planning to leave the country though. 🙂

Happy to be of service to the Filipino people! Para sa bayan!

Care for those who care

VIOLENCE IN THE HOSPITAL EXISTS.

We seldom talk about it because we think it’s “part of the job” or that we “signed up for it”. This is a skewed view of what nursing really is. Priority is given to patient care but self-care should be given equal importance. I believe violence in the hospital – be it physical, emotional, or verbal – coming from either patient or fellow HCP is obviously underrated and often unreported or underreported.

We, nurses, often struggle with role conflict between our duty to care for others and one’s duty to self when providing care especially following a critical incident that involves violence.

I believe what we need is an (1) immediate debriefing following a violent incident and (2) a good supportive work environment to prevent violence (both from patient/caregiver and fellow HCPs) and, maybe, enhance resilience.

Much like the lauded newly-established customer care center, we deserve the same mechanism where nurses (and other HCPs) could voice out their concerns, struggles, grievances of any sort without the prejudice of being judged, ridiculed, and sanctioned (especially by seniors) for basically just stepping up for one’s human rights.

We’ve got a long way to go before we finally realize that job satisfaction and quality of life affect the quality of care we render to our patients and the overall patient outcome and satisfaction. While hospital services and health care delivery have been improved in the past months, I cannot help but ask, what about us? People who care for other people also need to be cared for.

I cannot accept that “this has been the practice” and that “we cannot do anything about it”. We shouldn’t stick with practices that are clearly outdated, irrelevant, and ineffective. And yes, we can do something about it and the rest of the many issues and challenges we are facing day after day.

Care for those who care?

UP Manila says ‘No’ to Medical Cannabis Legalization in the Philippines

I agree that:

1) further research on Cannabis’ efficacy and safety should be done under strict protocols (provided by national institutions) to ensure patient safety and safeguard public health.

2) any policy, especially public health policies, should be evidence-based.

“UP Manila says ‘NO’ to Medical Cannabis Legalization”
Download whole document: https://www.upm.edu.ph/node/2264

No to HCP shaming

Pt asks about procedure

Pt: Sabi nung nurse… Pre-res: Wag kayo maniwala sa nurses. Sa amin ka maniwala, sa mga gaya kong naka-white coat.

Conversations like this support the misconception that nurses are dumb and “alila ng doktor”.  Maybe we could simply correct the wrong statement (if indeed it’s wrong) and do away with statements like “wag maniwala”.

A good HCP will strive to make the entire HC team better in terms of knowledge, skills, attitude.

I say no to doctor shaming but I also say no to shaming nurses and other HCPs. We are a team and we use a multidisciplinary approach. 🙂