Speak Up

In nursing school, pathophysiology and pharmacology are often what takes precedence over other topics covered. Of course, learning what congestive heart failure is or even the way blood pressure medications work is a necessity for a nurse to function efficiently and put into application these notions to take care of patients. However, aside from the subjects based on physiological science, communication, ethics as well as workplace laws and rights are the backbone of this profession. Without their knowledge, it is undeniable that it can jeopardize the safety of the patients we claim to care for.

You see, I never really enjoyed playing the political game within the healthcare system. With today’s nursing climate, it is no news that staff shortage and limited resources place a burden on healthcare providers. Yes, the world isn’t perfect, and we cannot expect the conditions to be either. But, one thing that can be done is to make due with what we’ve got, even if it’s the bare minimum. “Half-assing” the job was never an option for me, especially when the work can make the difference between life or death for a fellow human being. It is natural to want to protect one’s own psyche and physical health; it is rather exceptional to go out of one’s way to protect the vulnerable by using your voice to represent them. Advocacy. That’s what it is.

Advocacy is a skill that everyone possesses but often is afraid to be put into use. When you are venting to a coworker regarding how hard your shift was because of so and so, or how sh*t could have been prevented if this and that were done, it is a form of analyzing the issues and proposing solutions to improve workplace conditions. Oftentimes, people will see this as "complaining", a term that seems to have a negative connotation to it. If you dissect the word itself, you'd be very interested to find out that, in essence, it means to "express grief, sorrow, suffering together". Now, when you look at it this way, it changes your perspective (well, mine anyway). Although one may not fully understand another's suffering, its expression is valid and deserves to be heard. We are, after all, humans, entities that utilize emotions in their daily lives to help one another. "Complaining" aka speaking up, is the only way to "right" a witnessed or anticipated "wrong". Silence is enabling these wrongs to keep occurring or worsen to the point of irreversible damage.

Now you may be wondering why I'm suddenly giving a lecture on advocacy, or yet even using etymology to get my point across. Because I've learned to accept a side of me that many have said I should change to protect myself. After months and months of doubting myself and being told I should "care less" or "let it go", I realized that I would be doing myself a disservice. Letting go of the strong sense of morality that resides within me would make me lose a part of myself that is the main constituent of my identity. Chihuahua Cristine, but one that barks for justice (lol).

One of the pivotal moments of my nursing career was when I decided to leave the first hospital I ever worked at, not because of the poor working conditions, but because of poor management. Believe me, my head nurse and assistant head nurse on my oncology unit were the most devoted individuals and chose to hear me out. The one that chose to dismiss what we as a unit had to say was the nursing director of oncological activities; an individual who barely knew what was occurring at bedside ... And so the story begins.

As you can tell by the many stories I have written so far in this blog, working on an oncology/palliative care unit was the most heartfelt, purposeful, and life-altering experience in my nursing profession. Despite the acuity of the physical and mental health of the patients, being able to provide quality care was rewarding. However, when COVID hit, things changed. COVID took a toll on everyone and forced managers to split resources (most notably, bedside nurses) to prevent our whole healthcare system from further crumbling. With new units opening to accommodate the pandemic, many of us were relocated to COVID wards, nursing homes, and even other hospitals. Although for the whole summer of 2020 I was temporarily transferred to a hockey arena that was used to treat COVID+ elderly patients, that was not what set me off. After the peak of the pandemic passed, it appeared that things would return back to normal; I was back on my oncology/palliative unit. However, I would soon figure out that a new normal was beginning to set in: staff shortage. Because of the creation of a second internal medicine unit at our hospital (initially created to accommodate the overflow patients of other hospitals during COVID), its now permanent status led to nurses from all departments (particularly juniors) to float there for a few weeks. Consequently, this created gaps on their respective units, including mine.

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On one of my twelve-hour night shifts, I realized I would be the only registered nurse once the day shift nurse left. Although I was going to have two licensed practical nurses (LPNs) with me, overseeing eleven patients was overwhelming. As I settled to take report, I could tell that it was going to be a busy night; the only day shift nurse was running like a headless chicken. Mrs. H. wasn't doing so well; she was having difficulty breathing and was complaining of severe abdominal pain. Rather than taking report at shift change, the day shift nurse, one of the LPNs and I rush to Mrs. H.'s room to assess her. At the time, her level of consciousness was fluctuating, until she became unresponsive (but still breathing). A code "2-3" (in that particular hospital, it signified an emergency without cardiac or respiratory arrest) was called. While waiting for the code to be announced overhead (there was a 10-minute delay due to the technical issues with the intercom), we tried to get her vital signs. Obtaining her blood pressure and her oxygen saturation were rather difficult (probably because they were severely low). Taking her heart rate manually revealed that she had a heart rate in the 20s-30s. When the vital sign machine finally was able to capture her oxygen levels, they were in the 80s despite her having nasal prongs in. We switch the nasal cannulas to a mask that would deliver 100% oxygen. As soon as the medical resident and the respiratory therapist entered the room, a bunch of interventions needed to be done. This was the start of a rough and hectic night shift ...

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I will head into the details later, but before I dive in to the story, there are a few things to know:

1. The acuity of cancer patients. Let's not forget that this is only one patient out of eleven. With two years of experience amongst the oncological population, I learned very quickly that once they were ill, they were VERY ill. Not only were some elderly with a weakened immune system and many comorbidities, almost all were severely immunocompromised due to active treatments or due to their cancer. Many required intravenous antibiotics as they had either pneumonia or septicemia (infection in the blood).
   

2. Limited scope of practice for LPNs LPNs are a great resource, but in acute situations, they are limited with what they are legally able to do. LPNs are usually paired with an RN and are assigned stable patients. Although they are not the ones to do the "initial assessments" of patients, they monitor for any changes, and are able to administer all medications except for intravenous ones. In cases of emergencies, the fastest way to give life-saving medications is through the IV lines.
   

3. Most common level of care on the unit As mentioned in point 1, given the age and medical complexities of the patients, most patients did not want CPR done nor did they want to be intubated. Most usually agreed to a level of care "C", which essentially meant no transfers to ICU but maximal interventions to be done on the ward.

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Now, back to the main story. With her critical state, it is much easier to recount the story through a timeline.

19:30: Code 2-3 called due to loss of consciousness, bradycardia, desaturation and hypotension.

20:00: EKG STAT and numerous blood tests ordered: blood cultures, BNP, trops, coags, CBC, Chem10, LFTs, blood gas and lactate. Side note: For those that do not understand these terms, it simply means that we were investigating the cause of Mrs. H.'s vital signs (i.e. electrolyte imbalances, active bleeding, severe infection, organ failure, heart attack, etc.)

20:30: Lasix (a drug to excrete excess volume) 20mg IV x1 STAT (Mrs. H. had congestive heart failure and a BNP > 1000).

21:00: A portable x-ray of her chest and abdomen were done.

21:15: Potassium discovered to be at 7 (normal ranges from 3.5-4.5) and Humulin R (insulin) 10 units and one ampule of Calcium Chloride IV were given. Mrs. H. then became nauseous and Gravol 50mg was given.

21:30: Glycopyrrolate (a drug used to increase heart rate) 0.4mg IV x3 given as her heart rate was still in the 30s

21:45: Another Lasix 20mg IV given

21:50: CBC and Chem 10 repeated as creatinine was at 295 (>100 indicates renal injury)

22:00: Bladder scan revealed 20cc. Urinary catheter inserted to monitor output and obtain urine samples. However, Mrs. H. was anuric (her kidneys were not producing urine). The doctor suspected acute kidney injury secondary to sepsis and started the patient on Tazocin 2.25g IV every 6 hours.

23:10: Repeat blood gas and BNP done.

23:20: Mrs. H.'s blood pressure 84/46, fluid bolus of 500cc given.

00:30: Another 500cc bolus given over an hour

01:00: Potassium at 5.9: 1 ampule of D50W IV , and Humulin R 10 units IV and Kayexelate 30g PO given

01:45: Blood draws repeated and Mrs. H. was finally stable with a blood pressure of 109/55, heart rate at 50 and oxygen saturation at 97% with nasal prongs.

Fortunately, my RN colleague decided to stay until 22:00 to help me out with Mrs. H even though she was coming back the next day. In-between interventions, I had to assess the other eleven patients that still required care. The LPNs distributed the medications they could, I administered the ones through IV. In addition to these tasks, verification of medication sheets as well as charting for each patient had to be done. I was also the charge nurse.

There were many other difficulties encountered throughout this shift, but I believe that Mrs. H.'s story depicted how dangerous short staffing can be. The following morning, after giving report to the day staff, I bawled my eyes out to assistant-head-nurse. At that exact moment, the new head nurse stepped into the lounge. Meeting the new head nurse for the first time with puffy eyes, reddened and dry cheeks from the tears, and snot trying to escape your nostrils was ... awkward. But it is her response to me that proved her authenticity. She brought me into her office and listened with open ears to what I had to say and had promised she would bring this to the higher ups' attention.

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Two weeks later, a staff meeting with the nursing director of oncological activities is set up. Immediately after that night, I had submitted a form to my union to denounce unsafe working conditions. At this meeting, several bedside nurses (including me, who had just finished giving report after my night shift), the assistant-head-nurse, the head nurse and our union representative were present. At the time, our unit was falling into pieces: the patients were sicker, and staff shortage was at its peak. The team brought up several concerns and proposed solutions to them. A few of the solutions included bringing back staff from the medicine unit, and hiring a unit coordinator to work on evenings and weekends to alleviate the load on nurses. Now, here's the big kicker. The response from the nursing director ...

"I understand your concerns, but I would just like to know why you guys are having difficulty managing 12 patients with 1 RN and 2 LPNs. At this other hospital, they are able to manage 14 patients with the same staffing ... " Side note: That other hospital already had a bad reputation for their SEVERE short staffing and questionable quality of care, especially in the ER.

As we were defending our case, throughout the meeting, the patient attendants had to interrupt twice within thirty minutes as there were two palliative patients going into active respiratory distress ... After dealing with those situations, the nursing director acted as if nothing happened and continued to disregard our concerns for patient safety.

It was at that point where enough was enough for me. It was at that point where, despite advocating for my patients, the ignorance of that director proved to me that many individuals in these positions of power only hold their title, but are not true leaders themselves. Despite all the efforts to ensure patient safety, the outcome of that meeting was a slap in the face. I really enjoyed working on that floor, with decent working conditions. And so, with a broken heart, I quit. I quit because I believed I could no longer provide the quality of care I wanted to deliver. I quit because I was seen as a number rather than a human being. I quit because I did not want the poor decisions of that incompetent, heartless nursing director to fall on me when fatal consequences would occur.

Yes, I did quit, but I did not quit without speaking up.