Saturday, March 20, 2021

Nursing Performance Evaluations


And furthermore, those black bobby pins securing 
your cap are most unprofessional. Use white pins!

Nothing exploits the fault lines of professional nursing quite like the annual performance evaluation. The assorted dynamics are varied, but always divisive; the young vs. the old,  BSN vs. diploma,  'Mericans vs. foreign born, neat fanatics vs. free spirits, and at the root of all conflict, the nurse office sitter academic/administrative complex vs. the lowly bedside nurse.  

The rigid, authoritarian nurse administrator doing the evaluation was once a member of the bedside nurse cohort but ascended the administrative ladder as a result of being totally unfit for direct patient care and also holding anyone who is good with patient care in contempt. Basically, it's a cabal of malcontented  busy bodies whose primary mission in the nursing world is proving their power and mettle at the expense of the lowly bedside nurse.

I love the optimism of  naive, young whippersnapperns who think it's possible to come out of performance  evaluations with an honest assessment of how they are  doing on the floor. Nurse Buff even has a blog post titled, " 8 Ways to Knock Your Performance Evaluation Out of The Park." Maybe things are different today, but in my experience, the nurse is far more likely to get knocked out of the park in this  nursing administration world of bureaucratic incompetence and legendary bullspin. It's a no win ballgame.

 The fur licking, scratching and hissing so common in nursing office settings is  like a magnet for administrative minded  folks. I once received an evaluation that noted I had zero potential for administrative advancement and considered that a high complement. Sitting in an office with these other worldly creatures  would have been like a prison sentence for me. Not everyone wants to climb the so called ladder of success when it involves joining the ranks of administrators.

One of the inherent problems with nursing evaluations is that good patient care is simply not narratable. Long time bedside practitioners develop a 6th sense based on pure instinct. I've worked with nurses who could smell impending death and could assess blood pressure without a syphgmomanometer by applying variable pressure to the radial artery. Long time neuro nurses can actually visualize that pre seizure aura and take appropriate action to nip the convulsion in the bud.  A good bedside nurse is indescribable, but you know one when you see one in action.

The philosophical bifurcation between administrative nurse and bedside care giver is enhanced by the use of lexicon hijacked from the business world. Office sitters have loads of time on their hands for the black art of word play.  In the age of corporate driven medicine the use of high minded sounding goobledegook has flourished. We have phrases like poor time management, customer service, inappropriate consolidation of resources, best practices, building consensus, core competency, paradigm shift, mission critical, or matrix structure. Wow, talk about a tower of Babel.

Here are few of my time proven strategies for dealing with nursing performance evaluations. The first rule is to simply avoid any specialty or area that has a high density of nursing offices. The operating room was a perfect refuge from office sitting navel gazers and misfits. There were no nursing offices in the OR suite and supervisors, like my long time nemesis, Alice, rarely sat down. Her evaluations carried supreme weight and her theory was "If  you don't hear from me, you are doing a great job."

 It's also good job security to excel technically so that your services are valued by the surgeons. That way you have an advocate from the top of the hospital food chain to back you up when the inevitable hits the fan. My favorite general surgeon, Dr. Slambow would body slam just about anyone giving me the business. I had earned his respect through our late night meetings over some gosh awful trauma that we usually  managed to turn the tide on.

Demeanor counts big when on the receiving end of evaluations, so  never, ever, back someone into a corner who is meaner than you, and that accounts for 95% of nurse administrators. Practice this one in front of a mirror. Your facial expression should assume a beacon of baptismal innocence when the dreaded document is being reviewed. Take some measure of control over the situation by signing the blasted thing and making a hasty exit with a broad smile plastered all over your countenance. This is a game you cannot win. Simply grin and bear it then rapidly forget all about it.

If nursing abomination administration genuinely wanted to improve patient care they would provide units with adequate staffing, pay nurses a livable wage, acknowledge circadian rhythms when scheduling, and maintain supplies of equipment to get the job done. Evaluations are small potatoes when striving for better direct patient care.

Although, I've tried to limit my tales of personal woe, there is one evaluation experience that will always haunt me. I was hospitalized with the mother of all Crohn's disease exacerbations and had not been able to eat for weeks. Thankfully,  hyperalimentation was initiated and as I was surrounded by beeping monitors and several infusion pumps a cheery, young nurse popped up at my bedside with news that there was a piece of mail for me.

How nice I thought, some kindly person from work was sending me get well wishes. Upon opening the envelope, I was dumbfounded, it was my annual nursing performance evaluation sent by Helene, my head nurse. I guess she figured that I was never going to recover and return to work so she might as well get it over with. Nursing can be a cold business and, yes, I did return to work just to spite her.

Wednesday, March 10, 2021


 This blog has always been filled with foolishness, it's the underlying theme and glue that holds everything together. Lately, much to my amazement, posts about my experiences at Downey VA Hospital have been the most widely read. Although my tenure at this long term psychiatric warehouse was but a brief snippet of my work as a nurse, it left me with some of the most profound memories of human suffering. The men from Downey were a memorable bunch and will always occupy a special place in my heart.

I felt it was unfair to those with an interest in life at Downey to peruse through a quagmire of other posts completely unrelated to Downey so I set up labels on blogger to categorize my ramblings. I started by categorizing the Downey posts and then got carried away and added some other groupings.  So if you want to see my 1970s paystubs documenting my meager nurse's  salary just view the label "remuneration." If you are curious about the demise of sluice rooms just call up hospital design. You can also learn why old school operating rooms were always on the top floor of the hospital.

I hope this labeling makes things easier for my treasured readers. The labels begin in the right column just below my profile.

Monday, March 1, 2021

Downey V.A. Hospital Was The Home of Polypharmacy and Megadoses


Desperate situations often produce less than optimum results. The patient population at Downey V.A. Hospital was an intractable bunch, tortured by some of the most severe psychopathology known to man. My first time passing medications was a real shocker as one pour soul was ordered 2000mg. of the potent major tranquilizer, Thorazine. Nursing school pharmacology taught me that a usual dose was 75-200mg of Thorazine. A ten fold dosage of 2 gms. was out of the ball park.

Another disturbing trend involved patients dosed with more than one major tranquilizer with some dispensed as many as four. When the V.A. administration discouraged megadoses, polyharmacy was haphazardly substituted. I don't know which practice was worse in fueling disabling side effects like tardive dyskinesia, polypharmacy or megadoses.

When I brought this up to our ward physician, Elihu Howland MD, he agreed that it was a less than desirable situation  and suggested that I do a study enumerating the problem and he would see what he could do. Good luck were his parting words which were uttered in a less than sincere manner.

I eagerly went to work and came up with the following.

There are a significant number of patients at Downey receiving  more than one antipsychotic drug or a witch's brew combination of these neuroleptics. Here on Building 66AB I found a patient receiving three different antipsychotic drugs with a PRN order for a fourth neuroleptic agent. This much chemical restraint could be as disabling as the underlying illness.

Many studies evaluating  polypharmacy under controlled conditions demonstrate that there is no effectiveness over monotherapy. There really is no basis in fact for the existence of polypharmacy as a treatment method nor empirical evidence for its continued use as an effective treatment modality. Additionally, polypharmacy creates an added risk, even a fatal outcome, from a combination of drugs with mutually additive effects. With polypharmacy it is nearly impossible to delineate which specific drug is the culprit inducing untoward side  effects.  Many articles conclude that single drugs are the treatment of choice over polypharmacy.

Furthurmore, a recent review clearly shows that  we have a number of patients on extremely high dosages of antipsychotics. Megadoses   seem related to poly pharmacy in that one poor option is often substituted for the other. When megadoses are discouraged, polypharmacy soon fills the void.

Megadoses indicate  we have a large group of chronic patients who have been receiving a very high dose for a long period of time and whose mental status has stabilized, yet no attempt has been made to reduce their dosage to the lowest effective maintenance level. This maintenance dosage should be as low as suitable for retaining therapeutic progress. Dosage should be gradually titrated down to avoid a sudden emergence of symptoms.

The notion of lowering doses is especially important when megadoses or high doses are ordered. The patient's symptoms , drug history, and general physical condition should be considered when the risk of megadoses is evaluated. The occurrence of side effects must be balanced the benefits in the chronic patient who continues to present psychotic symptoms endangering himself or nursing personnel.

Once control of target symptoms has achieved, the dosage must be be adjusted downward as most all patients could be maintained on a lower dosage level.

Perhaps we should start by eliminating polypharmacy and then carefully titrating down on some of the megadoses.

I submitted this report to Dr. Howland with a listing of the patients receiving polypharmacy and megadoses. While there was some success with reducing polypharmacy, there was much resistance to decreasing megadoses. The main argument was the patient was on these doses for a very long time so there was no rationale to decrease doses.

My frustrations working at Downey reached a boiling point a few months later when my head nurse recommended me for a grade promotion, but  it was rejected by the personnel office because I was 4 days shy of the time required in grade for promotion, but never fear, I could apply again next year.

I resigned from Downey V.A. on May 21, 1976 after working there 1 year, 5 months, and 28 days. It was a very long year and a half and made working in the OR seem like a walk in the park. I happily returned to my favorite stomping grounds in the O.R