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.

LABELS

 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.

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

Informed Consent Would Have Annulled This Vow!

 

                                                             A diploma school promise

Time Worn Adjuncts to Mechanical Ventilation - The Good, The Bad, The Ugly

 

Proning is the latest modality for augmenting ventilator 
therapy.  Some vintage measures were not so effective

Recognition of acute respiratory distress syndrome (ARDS) in the early 1970s and treatment with Engstrom ventilators was a game changer, with  mortality plunging from 100% to about 40%. As more experience was gained mortality plunged even further. Deducing what worked and what didn't with ventilators was a rocky road.

It's human nature that clinicians faced with an unstable, critically ill patient want to do everything possible to rescue the person. We referred to situations like this as kitchen sink medicine when just about anything and everything was added to the armamentarium. Sometimes, desperation in medicine results in untoward  outcomes. I'm thinking about radical mastectomies for all breast cancers and surgeries like hemipelvectomies. Some pioneering accompaniments to mechanical ventilation bore little fruit, and did little to avert a vegetative outcome, but just about anything seemed worth a try when the clinical situation seemed so bleak.

Early practitioners in the art of mechanical ventilation were not like the experienced critical care medicine experts of today, but surgeons and anesthetists who saw the benefit ventilators made with ARDS treatment. They were drafted into the new role of managing ventilators and much of what ensued was on the job training..  Science was sometimes, in short supply when empirically based notions were applied as we shall soon see.

Everyone takes in a deep breath from time to time, so why not try this with ventilated patients? It was fairly easy to adapt those ancient, chugging, Engstroms to deliver an occasional deep ventilation, all it took was some monkeying around with that gizmo on top of the Engstrom that looked like an expresso machine, and PRESTO, the "sigh" was invented. A sigh was an occasional cycle with increased tidal volume and the frequency was highly variable.

 Intermittent sighs were a source of dread for sedation deprived ventilator patients, imagine having a hurricane force of air, unpredictably, blasted into your chest via a skinny little tube.  A United airlines pilot recovering from pneumonia said, "Now I know what it's like to suck on an engine of a 747." Unpleasant does not begin to describe the patient experience when the sigh cycle kicked in.

Ventilator driven sighs never really caught on in the hospital where I worked.  Surgeons blamed the sigh cycle for putting undue stress on suture lines and in the event of a rare evisceration, the sigh was always blamed. The elevated intra thoracic pressure was also blamed for barotrauma to vulnerable alveoli. 

Positive end expiratory pressure or PEEP evolved to be the replacement for sighs. PEEP entailed maintaining a low steady pressure (5cm/H20) in the lungs just slightly above ambient atmospheric pressure. Some overzealous physicians figured that if a little bit of PEEP was good, then more is even better. Super PEEP was born with pressure of 25 cm and above which was like blowing an automotive tire up to 100psi. Talk about a rough ride!

Super PEEP worked for a time until complications surfaced. High intra thoracic pressure compromised blood flow in the great vessels which caused big problems. A hemodynamically unstable critically ill patient is not a good thing. Renal problems often developed as a result of compromised circulation. Super PEEP was not such a good idea, but did persist when technology for cardiac output monitoring was developed which enabled fine tuning to allay complications. The father of super PEEP at Montefiore Hospital in Pittsburgh was Arnold Sladen MD. He was either a hero or a scoundrel depending on who you talked to.

Endotracheal tubes exert a seal by an inflatable cuff which contacts and forms a seal with the trachea. Sustained pressure exerted by the cuff can limit the amount of time a patient can be maintained on the ventilator before an invasive tracheotomy must  be done. Long term unremitting pressure from the cuff can cause problems.   Intermittent endotracheal tube cuff inflation was thought to be a way a kinder gentler way of sealing an airway. The cuff was inflated only on inspiration.

Intermittent endotracheal cuff inflation required some complex additional equipment and lengthening the inflation tubing  increased dead space and exacerbated the  potential for  leaks. There was also the ever present risk of aspiration when the cuff was deflated. This overly complicated  modality was usually abandoned with much haste as it just didn't work very well.

There is that old joke about anesthetists passing gas, but in reality, they are passing gases. Fiddling around with the inspired mix of gases was second nature when novice anesthesia folks began overseeing ventilator therapy. Traces of helium mixed with the FiO2 were thought to aid in alveolar dispersion, but in the long run seemed to make little difference. 

Life on a ventilator was unpleasant at best. Before propofol came along, anesthetists would sometimes  "trace an agent," or install an in line vaporizer to sneak in a whiff of halothane to settle things like "bucking" down. Progress in IV sedation put a halt to anesthesia  vaporizers on ventilators except, of course, in the OR.

Ventilators are an unforgiving entity and that ominous click...hiss...pause  always overshadowed the cheerful cacophony of melodious alarm tones, quickly becoming  the dominant noxious noise in the ICU. Ventilators really strummed a different sort of tune that frequently foreshadowed impending doom.

In the rapidly gathering storm leading up to intubation and subsequent ventilation, impending consequences were often conveniently overlooked. Rendering someone mute with an endotracheal tube and lashing them to a machine forcefully converting air into breathe has all the grace of getting clobbered by a linebacker on steroids.

Late at night, numbed by fatigue induced hopelessness, strange thoughts percolated through my mind when caring for a poor soul on a ventilator. We all want a nice linear, progressive, and predictable path from illness to health. Sometimes, though, ventilator patients are too far along on their journey to the other side. If  I'm ever in this predicament, I hope my caregivers reconsider my path and don't interfere with my final journey.

When I'm on that peaceful river journey to the other side, I better not come across a ventilator masquerading as a life boat!

Diploma Nursing Students Learned Procedures the Hard Way

 

Needles could turn a smile into a grimace, lickety split

Procedures were the alpha and omega of diploma nursing programs and the ultimate way of measuring a student's progress. Like just about any other trade school, academic accomplishment took a back seat to providing a free source of  hospital labor. Procedures performed without concern for remuneration on unsuspecting patients were the currency used to pay for  "free" books, housing, uniforms, and food. There was no such thing as a free lunch.

Student nurses' mindsets were carefully groomed  to maintain a calm, confident, omniscient  bedside demeanor despite the fact that this was our virginal attempt at thrusting a 2 inch Imferon needle into a fellow human's vulnerable flesh. We were acutely aware that the procedure was likely inhumane and excruciatingly painful. Student nurses also carried the burdensome  knowledge that any flaw in their Z tract injection technique would be visibly advertised by that ugly, dark brown Imferon staining the surrounding subcutaneous tissue. An ear beating public  dress down from my favorite instructor, Miss Bruiser was sure to follow. I found it ironic that her name reflected the very nature of the Imferon staining complication, a big old brown contusion that looked a mess.

As a general rule of thumb, any procedure performed above the waist line, was done to a fellow student, affectionately known as a procedure pals. This relationship always reminded me of a cat vs. groundhog fight, one minute the cat is chasing the ground hog and the next minute the rodent is baring his formidable front teeth at the feline. The nurse and the victim patient in subsititutus  had to be very wary when dealing with  one another, she who injects and skedaddles  might live to inject another day, or the next minute, become the hapless recipient. Like so many other aspects of nursing, a classic no win situation.

 Performing painful treatments on each other was thought to be a vital component of nursing education, a real boon to developing empathy and the proper "attitude," what ever that was. Thank heaven we were not studying neuro surgery.  I shudder to think about the mess a bunch of first time amateur  craniotomies would look like.

When it came to performing uncomfortable downright painful procedures there were two student nurse  personality types involved. The most dangerous, in my humble opinion, was the eager beaver, overly enthusiastic student who would stop at nothing to be the first one administering the tormenting treatment. 

These were the novice nurses who thought the blood dripping from their fingers after a botched venipuncture was a badge of honor or that  it was appropriate to celebrate doing post mortem care for the first time. Miss Bruiser usually was able to take the wind out of their sails by insisting the eager students "volunteer" for her to insert a NG tube down their dainty little porboscus. Her ram rodding technique combined with her "demonstration" of a sulcus at the base of the tongue would humble anyone. The manipulation of the tube at the level of the epiglottis was guaranteed to provoke a hacking, gagging fit that would turn one's stomach while simultaneously bring tears flowing like a fire hydrant. A memorable experience that was sure to temper the gusto of the most aggressive eager beaver.

At the other end of the student nurse spectrum were the reluctant, overly sensitive types who were preoccupied with the uncomfortable nature of their ministrations. I was, without a doubt, a member of this tribe and frequently found myself biting my cheek when it came time to do just about anything associated with inflicting pain.

Mrs. Viotto was the kindly, grandmotherly nurse that was assigned to us who were not so eager beavers when learning painful procedures. Her constant reassuring smile resembled the exaggerated expression a pantomimist would use. Her typical discourse followed the theme  that we were there to help patients recover and in order to accomplish the end goal we would sometimes have to do things that were "uncomfortable." Pain was not part of her vocabulary. Everything from dressing changes on burn patients to bicillin injections were just "uncomfortable."

There was a reassuring smoothness in the way Mrs. Viotto conducted herself when demonstrating procedures. Rather than the stabbing and jabbing of the over eager student nurse clan, she stressed gliding a needle into position or threading a catheter in place. I learned more from her than any other instructor.

There was a very short window of opportunity for student nurses to master procedures and if by junior year a deficit was identified big trouble ensued. That dreaded yellow dismissal form with the dream shattering message, "unsuited for the practice of nursing," would soon find it's way to your mail box

. It was like an amputation in the days before anesthesia; painful and irreversible. Although, sometimes, the students who persevered envied the one's who left, especially when the ex-students would return to nursing school for a visit with tales of menial jobs paying more than a nurse could ever  hope to earn.

Not on My Mayo Stand!

 One of my most popular posts from the  past was about items I never, ever want to see on my OR back table. https://oldfoolrn.blogspot.com/2017/01/not-on-my-back-table.html. Scrub nurses work  at ( or least  they did 50 years ago) from two horizontal surfaces. A large  back table at the foot of the patient which is loaded with just about anything and everything  needed for the surgery and the Mayo stand placed over the patient just below site of the surgery. This stand  is solely for the instruments in immediate use. I've seen some illustrations of Mayo stands that really flustercate my fragile foolish faculties, so here are some thoughts about the care and feeding of Mayo stands from a perspective of many moons ago. (I had to put that disclaimer in because some folks compare my ramblings to contemporary standards and I get harshly critical emails.)

Side hanging  instruments as shown in this illustration desecrate one of the most basic of  OR commandments - Thou shall not let any instrument dangle over the edges of your Mayo stand. The outer ridge of the stand acts like a fulcrum sending your instrument flying if you inadvertently drop an elbow during a critical moment. Flying instruments, depending on where they land, are never a good thing in an OR. A nasty surgeon once lobbed  a Haney clamp at me and then in a Karma driven moment, dropped a weighted speculum on his foot. Yes...there is a flying instrument god in every OR.

I started this post out thinking that maybe I should do the ten commandments of Mayo stands, but that sounds cliched and besides, what happens if I can't think of ten? Maybe it's better if I just ramble  on in in my typical foolish manner.

When in use, Mayo stands should always be at the scrub nurse's waist. A uniform height helps establish muscle memory so that when you go to grab something, your hand goes to the intended spot without thinking. Many nurses need some altitude enhancement to reach the correct height and I went out of my way to construct elaborate altitude enhancing arrangements.  oldfoolrn: Scrub Nurses Flying High

Yikes! When it comes to just about any sort of tubing or cable, be it suction line or Bovie, it's much neater to keep them on the back table until needed. Think of your Mayo stand as fly-over country and pass the long  tubing or wiring directly from the back table to the surgeon. This Mayo also has a towel clip and a Metz scissors hanging over the edge of the Mayo waiting to be dropped or take flight. I do like the way the scrub nurse lined the top of the Mayo stand with a couple of honest to goodness cloth towels. Disposable paper Mayo stand covers and towels generate that raucous rustling noise that really grated on my nerves. It reminded me of opening presents on Christmas morning when I was often stuck in the OR.

Old scrub nurses were real sticklers when it came to keeping all your instruments on one level while they were reposing on your Mayo stand. The only high-rise object tolerated was a stack of 4X4 sponges because when it comes to anything bleeding you can't be too careful. I vividly recall the dressing down a new resident received from Dr. Slambow when he took a loaded sponge stick and  swiped instead of a dabbed at a small bleeder. "You meathead!@#&, you are wiping the clots away." The good surgeon did not tolerate fools well, except for me. 

 

This Mayo stand illustration should be captioned double trouble. A scrub nurse is like a mama bear protecting her cubs when it comes to guarding and maintaining the sanctity of her Mayo stand. Here we see more than one set of lunch  hooks...oops I mean mitts on a Mayo stand. Fifty years ago a stunt like that would merit a knuckle smack with the business end of a scrub stick, especially if my nemesis, Alice, was standing behind that Mayo stand. Alice was an equal opportunity knuckle buster, surgeon or nurse, it didn't much matter. The other faux pas  here involved a specimen jar filled with a likely toxic solution like formalin. Mayo stands are restricted from any liquid that could be toxic. Methylene blue and lidocaine are just fine, but biopsy fixatives are a big no...no. 

Noah was right, everything is better in pairs. When bringing up ratcheted instruments from the back table always grab two at a time. There should be an even number of hemostats, needle drivers, kochers, mixters and babcocks. I never did like the way grabbing a babcock. registered in my ear  when spoken.  Picking up a pair of babcocks always sounded more civil, so don't grab a babcock, pick up a pair. Avoiding odd numbers of instruments on your Mayo stand  helps avert that dreaded foreign body mishap. Thank heaven  this never happened to me (I pray.) .Avoiding some mishaps is  a matter of luck as much as skill. Surgery is a high wire act with lots of distractions and bad things do happen. It was well known that any nurse involved in a foreign body incident would be fired on the spot. We were scared straight.

Some nurses delighted in adding artsy fartsy touches to their Mayo stands and I'm not sure if this is a good thing or not. I'm not very artistic so maybe I have a dog in the manger attitude when it comes to fanciful touches to Mayo stands, especially when the artist is a much more accomplished scrub nurse than me. My friend, Janess, liked to craft lovely designs in her  wax paper sharps bag by cutting designs along the top border of the container. She was an artist with a straight Mayo scissors and I think her flower designs were the very best.

Elite scrub nurses were a very special breed that certainly excluded me with my size 9, hubcap sized hands. Fleet of foot with nimble fingers and a fast firing central nervous system, always totally relaxed, but ready to strike at a moments notice. Probably the ultimate paradox was their narcissism coupled with unyielding selflessness. You have to love yourself if you are going to  do just about anything for another with such blatant disregard of your own needs. 

I'll always remember my favorite scrub nurse mentor, Alice, harping about some Mayo stand minutiae and when it came time for self-evaluation her only fault was having to deal with low motivated sloppy dolts like me. Old OR nurses like Alice were different from the rest of us.