'Sister Nurse' Responds to Critics

Nursing

I'm a nursin student in Michigan, and generally an optomist. Now I wasn't there that night so I couldn't say who was right or wrong, but I know that if I had a sick child I would do whatever I thought was necessary to see them through. So congratulations for you determination and resolve.

That said, the only way to "fix" the problem or concern that you raise, is by instituting smile, and term of endearment quotas. Rediculous. Can you name one profession where everyone can be trusted to do their best every time? All we can really do is police our own actions and attitudes, hope that it encourages others to do the same, and maybe point out the outstanding contributions when you see them. Did I mention that I'm also a realist.

Nursing

As a nurse of 27 years, I am in complete agreement with you on most of your points in your article, Ms Madsen. And what your comments are is a policing our own actions and attitudes as nurses in Nursing. If writing a column about your experience highlights the need for some remedial education, then so be it. I would have also followed up by writing a letter to the Nursing Director along with names and specific examples. I would have cc'd her/his management also, along with the Directors of the ER and the Floors. I, too, would have included names and specific examples of outstanding performance ON the spot to upper management. You mention in the article that you were not acting as a "nurse" but as a "mother". Mother's aren't always calm, cool, and collected when it comes to their children. I can't fault you for that. However, I recognize within myself to have to 'govenor' my own tendencies to overreact in a demanding and caustic way when I have been in a similar situation. That being said, it's very difficult to do when one is under stress and feeling guilty about missing the symptoms delaying care.

Karen Madsen

I too would like to add to the discussion on Karen Madsen's encounter in the ER. I have been in healthcare for my entire professional career, and I have experienced the same dilemmas that Karen mentions.

A nurse in any hospital situation with a family member/loved one is in a precarious position: he/she knows what should be done etc., but is not the ‘nurse’ at this point but ‘a knowledgeable consumer’. To speak or not to speak: I say speak.

I agree that nurses need to have discussion about what really is broken in the health care system and the nurse's role. The first step in making anything better is to address it and label the behaviors so that they can be talked about. Nurses do need to stand up and talk about these issues. Thanks Karen for bringing up these issues.

Nurses always need to present themselves as professionals. Yes, I agree that nurses also need to be able to blow off steam - but in private please!

I would also suggest that nurses need to re-examine why they joined the profession. Ask the hard questions of yourselves: have I lost my way? Am I more concerned about me and less about the people I am entrusted in serving? Has my spirit been deflated? Do I need to find another job?

There are plenty of materials to help nurses with the difficulties they encounter each day in their work. The HcPro 'Stressed Out" series is one vehicle to help nurses with common areas of concern. There are others.

We need to use the resources available to us and not just throw around rhetoric and play the blame game. In some cases we need to turn around and face the enemy and find out that the enemy is us.

Nursing

My issue with your article lies completely in the fact that nurses are forefront in your attack on the system.

Maybe the doctors were on break, making your daughter wait for attention in the ER. You can't get medication until you are evaluated and it is ordered. You know that, but America does not.

Maybe your state is closing hospitals, like mine causing wait times to explode-due to lack of funding and reimbursement for charity (emtala) and reduced medicare/medicaid reimbursement. Waiting times for all have increased.

Perhaps, you have a uninsured, underinsured, or illegal immigrants using your services as a primary care office. NJ doctors turn away Medicaid, and good luck if you have no insurance. Receptionists don't let you in the door.

Maybe its because Americans and their access to quality healthcare is down the toilet causing an increase of sicker people with higher admissions rates-BUT THERE IS NO ROOM AT THE INN-so they are boarded in the ER. Less beds for an emergency.

These are all valid reasons why care is not what you think it should be, and were not even touched upon. They would be the first ones I would be pondering, as I know they are causing an "emergency" in my neck of the woods. Let America know the truth.....this is the basis of/or lack thereof medical treatment in hospitals. Stressed out nurses who are overburdened and rushed are a side effect.

You seem to think you have opened a dialogue for nurses, it hasn't been a positive one. Your comments have tainted us, and I don't like it! How do you think those former students may have felt? I am surprised your college has allowed articles like this without review. Your article and so many others, leave me asking what is wrong with nursing professors and nursing academics? Where are you all coming from and what do you hope to accomplish through articles like this? Passive-Agressive, don't like it at all!

The only positive thought I can send your way is that, I am glad your daughter is recovering from her surgery. I truly hope her the remainder is swift and she is 100% quickly. I also hope that in the future, your articles if negative will include ALL personnel involved-keep it fair.

Nursing

I'm glad to see Ms. Madsen address what has been a very hot topic on Allnurses.com. However Ms Madsen has failed yet again to actually try to address the problems, only complain about the symptoms. Anyone with any common sense knows that there are good and bad employees at any place of work. However most people's opinion on what makes a "good" nurse vary greatly. I could care less if a nurse "fluffed" my pillow if he/she got my IV on the first stick or administered my pain med right at the two hour mark.

As for the your treatment in the ER, as usual the truth probably lies closer to the middle. You, Ms Madsen, have no way of knowing what kind of patients were in front of your daughter in the ER. It is also pretty safe to assume the triage nurses HAD done all they could for your daughter. Sadly nurses are the most visible spokes in the wheel of health care, how pedestrian of you to attack them. Hospital policies determine who is triaged first, and Doctor's write the morphine orders, not the nurse. That should be common sense to most, and you should have addressed the SYSTEM in your piece and not the cogs.

Finally, I find it interesting that you continue to take such pride in being the "demanding parent" and brag about your actions for what was "best" for your daughter. Ms. Madsen all of us that have children love and care for them. We all want to protect our children from suffering and pain. However, acting with dignity and maturity in a stressful situation can set a tremendous example for a child. We all want to scream and throw fits from time to time, but we are adults so we try to act in an appropriate manner.

In addition, you have no way of knowing what any nurse has on his/her plate during their shift and I can promise you that the floor nurses working with your daughter knew who you were and the consequences of not keeping you pacified. This means that more than likely they took time away from THEIR OTHER PATIENTS NEEDS to ensure that you don't make a scene or even worse, write a scathing article about them on the internet.

I like everyone else following this story is sincerely happy that your daughter is o.k. I wish you the best and hope that you will use this as an opportunity to evaluate your teaching, how you evaluate your collueges, and yourself.

What bothered me (and many other nurses) the most about your original article was the emphasis it placed on compassion over skill and ability. This is something many nurses have come to expect (and accept) from the public, but coming from a fellow nurse, is a bit tough to take.

That isn't to say that compassion isn't important in nursing; but in some situations, it certainly takes a back-seat to skill and talent.

Doing a job "quickly and efficiently" is the mark of a good, experienced triage nurse.

When the ER is busy (as it sounds like it was the night you took your daughter in), triage is not the time to be overly kind, compassionate, and chatty.

Friendliness encourages people to be chatty and long-winded.

I realize that sounds just awful, and before I worked as a triage nurse, I might have agreed.

However, the reality is that it is the job of the nurse in triage to "cut through the crap." We have to wade through an often long story, redirect people to get the important information (frequently interrupting them), do a quick/accurate/focused-yet-thorough-enough assessment, and make a very important decision as to where the patient needs to go next, all within about 5 minutes.

At the same time, the entire waiting room is mad at us because they are still waiting -- either to be called to the back, or to be called to triage, and it is all our fault.

We are often lied to, yelled at, threatened, and assaulted. (People also try very hard to manipulate us, though it usually doesn't work very well with an experienced triage nurse.)

And people complain that we arn't friendly enough. It is no wonder triage can be the hardest position in the ER to fill. It takes skill, knowledge, quickness, efficiency, and a decent tolerance for abuse.

I came in to work one Sunday night, and found myself in triage, following the type of triage nurse that you would likely appreciate.

She was sweet, friendly, kind, compassionate, loveable. She was also backed up to the tune of about 30 patients waiting to be triaged, with another 20 or so waiting to be seen.

I grabbed a good, experienced tech and together we got through those 30 patients (including ekgs, IVs and labs where appropriate per our protocols) in about 90 minutes. We got the appropriate patients seen in fast track before it closed, and we were able to then re-check VS and assessments on the patients waiting to be seen by a doctor in the back.

I wasn't particularly friendly that night. I wasn't mean or rude (though some may have felt I was), but I got my job done and got people worked up and seen.

Does that make me a bad nurse? According to your comments, it does.

That is really unfortunate.

Yes, there are bad nurses out there. There are lazy nurses out there. Since I wasn't there, I'm not going to judge the triage nurse your daughter had. I really wish you wouldn' judge hert, either. You say that the nurse didn't care about your daughter's pain, or about the other two patients you mentioned.

How do you know this? You don't know what the triage nurse told the charge nurse in the back, or what else she may have done to get your daughter seen ahead of someone else.

Please also realize that your recollection of events is colored by your emotions that night. Memories aren't as accurate as we'd like them to be, especially when we are upset.

I agree that ideally, her VS would have been reassessed. However, I would only get to reassess VS once everyone who had checked in had been triaged. Up until that point, I was just eyeballing them when I called someone else back.

I've looked at your CV online at Cox College, Mrs. Madsen. After going over your detailed experience, I see that you have never worked in the ER. So you really wouldn't know what it's like in the ER, would you? You wouldn't know the process for triaging patients or sending them directly in the back to see the doctor, would you?

I think not.

You could have done more with your article had you addressed the real problems with the healthcare system, not just blaming the nurses and then come back with the most passive-aggressive reply.

I may not smile enough, Mrs. Madsen. But I tell you, that I put all my heart and soul into the lives that I save. Sometimes I'm just too busy saving a patient in septic shock whose SBP is in the 60s and tachycardic and getting intubated, from dying to stop and smile.

Accurate Appraisal?

I also am a full-time nursing instructor with a Master's degree (like the author) and I teach in a BSN program. I also work part-time in a local community hospital (mostly in the ER) to keep my skills current. It also helps me to avoid "Ivory Tower" syndrome. I want to continuously have my fingers on the pulse of the "real world" of nursing, not just academia.

One of the first things taught in nursing school is the NURSING PROCESS, which begins with ASSESSMENT. A thorough assessment always precedes NAMING THE PROBLEM (or diagnosis). I do not think the author adequately assessed the situation in the ER that night. Instead, her understandably raw emotions colored her perspective in her "knee-jerk" tirade against the nurses. For instance, does Ms. Madsen really know what was going on behind the scenes in the ER that night? How many traumas? How many pediatric emergencies? How many MI's or CVA's? How adequately staffed was the ER? Why did she not interview the nurses to obtain their perspectives before firing off this judgmental article?

All this misguided article (and its sequela) accomplishes is yet another "slap in the face" to the profession of nursing. And this, by another nurse, a member of academia. We nurses need to support one another - the brave souls out in the trenches certainly need encouragement and appreciation for all they do.

"Seek first to understand." - Stephen Covey'''

RE: Compassion in nursing

Ms. Madsen complains about the perceived lack of compassion in the nurse who triaged her daughter. As a father and a registered nurse, my sympathies are entirely with Ms. Madsen and her suffering daughter. However, I do not think that Ms. Madsen and I completely agree about how compassion in nursing is best defined. Yes, nurses, at their best, are kind, considerate, and supportive of their frightened patients, and I share Ms. Madsen's high valuation of those traits. However, those things are easily feigned, even by incompetent individuals, so they are not valid measures for compassion (much less competence).

Here is a better one: After taking care of your family all day, report to an overcrowded, understaffed, poorly managed emergency department. Be lied to, spit on, threatened (sometimes physically - yes, this happens to nurses rather frequently), yelled at, and cursed. Provide skillful, knowledgeable, scientifically based care to each of these individuals, serenaded by their complaints and more threats. Have a child die under your hands while their terrified parent watches in muted horror. Skip your break because, well, who has time for breaks when the bay has to be cleared of the child's corpse to make room for the next patient (whom you silently pray you will be able to help)? Go home. Cry yourself to sleep, and then, when the alarm clock rings, GET UP, PULL ON YOUR SCRUBS, AND DO IT AGAIN knowing that it will not be any better, but that it is what you do, it needs to be done, and you care enough that you are willin to pay the crushing emotional price that doing it exacts.

That, and not smiles on nurse's faces, is how I define compassion. How about you?

Point of View

Ms. Masden,

As a registered nurse, I am appalled by the article you wrote. The article addressed personal feelings of a mother in a stressful situation but you have misdirected the public by placing your credentials after your name and writing as an "authority" in a venue in which you lack experience. This is the sole reason that you have found nurses in general to have responded negatively to your tirade. It is unprofessional and emotionally charged.

As a nursing professor who holds the keys to training new nurses, you should be the shining beacon of unbiased professionalism that leads others to good habits and excellence. This outburst should have been addressed at the hospital through the complaints system or on a personal blog instead of being offered up as truth and fact for the public.

The general public would have been better served if you had written a well researched article on the state of healthcare from a nursing point of view and addressing your personal experience as the catalyst.

What is the role of the nurse?

Ms Madsen, you state " It is the human elements of touching and kindness and caring that set nurses apart from any other profession."

This child-like view of nursing should be abolished once and for all. The public (and apparently, still some nurse educators) have held this ton of guilt over our heads long enough and it evokes images of the handmaiden/prostitute. It has been a contributing factor to the physical and verbal assaults that the public feels so freely to spew out to nurses.

Why on earth do you believe touching, kindness and caring sets nursing apart from other members of the healthcare team? Is it because it's been our history? If so, that's not a good enough answer.

Please re-examine your views towards nursing and what exactly it is you wanted from the nurse in the ER while you waited.

(from a 30 year veteran nurse)

Misguided anger

"If anyone seriously thinks that an over-four-hour wait with an acute abdomen is acceptable, then I think that "acceptable" needs to be redefined."

Three issues here:

First, it took the mother over 24 hours.

Second, the mother is under the wrong impression that the ER nurse comes from a position of authority or has the resources to change the 4 hour wait time.

Third, the mother should have known the above to be true, yet still directed her wrath towards the nurse.

Karen Madsen

I work in the very same ER that Ms. Madsen is throwing under the bus, so to speak.

No, our doctors were not taking breaks and making the patients wait-- Our doctors, like us, often get NO break, or try to choke something down at the desk in between all of the technical procedures and tasks that are required of ER nurses-- Also, I would just like to comment-- Many nurses at triage are not as "warm fuzzy" as they would like to be because they have a constant barrage of trying to sort the true lifethreatening emergencies from the moderate emergencies to the minor emergencies (hence, the word Triage) -- in our daily roles as triage nurses is common fair for Nurses to verbally, physically and mentally abused sometimes to many times in one 12 hour shift, that you give up count. Sometimes when you don't get the emotional reaction from a triage nurse that you wish to get, it's because they know they have a job to get done, and they are trying to remain professional, as the patient and family members at the desk continue to curse, call names, threaten, "I'm gonna sue", "You're a bitch, my daughter is sick, I'll take her back myself and find a bed" (Yes, I've had this said to me-- and I allowed them to walk to the back and look for themselves-- guess what-- even HE didn't find a bed for his sick daughter, his sole mission) As Trauma and Triage nurses we often have to reign in our emotion and focus on what it is that needs to be done because we know the wait isn't getting shorter and the line is getting longer--- and EVERYONE is sick-- they all are. I think if Ms. Madsen, in all her knowledge, can explain to us exactly how we are to produce non-existent beds from our derrieres, we would welcome the help. To be quite frank, I would say the majority of the nurses in the ED AND our physicians are parents-- and we KNOW that feeling when you can't always get things to be done the way you want to-- but as health care professionals, all we can often do is cope in the best way we can--- I think what has really offended the nursing population is how Ms. Madsen has pinpointed TRIAGE nurses as uncaring and cold, and ER nurses as soulless zombies (gotta add a little humor there) -- If Ms. Madsen has worked in the ED or in a Trauma unit or in an ICU, she will also have to concede that we as people are a different kind of horse to begin with-- we often have different sense of humor, different sense of urgency, and to us, it doesn't matter how warm the "fuzzy" feeling is, if our patient is on the downhill slide-- I don't see many accountants smiling and joyous during tax season-- and our season in the ED never ends-- we get no reprieve-- and the majority of is LOVE our jobs and what we do, or we would not continue to come back day after day and be "blamed" for the wait in the ED -- I agree completely that compassion and caring are the hallmarks of our profession-- however, you underestimate the underlying strength and focus of the group of people that you are criticizing-- We work long hours, we go through continuous extensive training, we have STRINGENT guidelines, BUDGET limits, and at the bottom of the pile of all the problems in the healthcare system, are the people that keep it running-- the gatekeepers that protect those that come through our doors the best we can-- The majority of the people in the ER have a calling, it is in their blood, they wouldn't do anything else-- a career in a profession such as nursing has its ups and downs-- and right now our entire country is going through a "down" with the nursing shortage, the stretched hospital budgets, the long hours-- and the last thing we need is one of our own publicly criticizing.

Ms. Madsen-- I think you should have privately taken your concerns to the appropriate people- as a nurse, and especially as an instructor, you KNOW the chain of command-- I feel it was very inappropriate, and really undermines your integrity in the way that you addressed your concerns.

I personally have worked in the ED that Ms. Madsen is criticizing-- and I can honestly say I have never seen her in the ED as an instructor or otherwise-- that could just be a mere coincidence- but I would think that someone that is going to point fingers might be more familiar and address it more appropriately-- the worst thing you can do is make your coworkers look bad -

Oh, by the way-- I also don't think you should criticize anyone laughing and then in the same breath say that no one smile and no one cared-- we care, we are human, and we have our days as well-- apparently you were having a bad day at the same time.

There are many more points I could dispute with your little rant, but honestly, I don't think that you understand the magnitude of what people are trying to convey to you-- so I don't think it would do much good-- I also have been a patient in our ER, and I received nothing but the best of care while I was there.

Thanks for all the positive input and encouragement from all the other posters-- All of us nurses in the ED at Cox do our best on a daily basis-- I can't speak for everyone, but I know we love what we do- sorry if we don't smile like robots, but we are thinking of your health and our patients are our priority. We have awesome doctors in our ED, we have some really great nurses, and even our techs and medics go out of their way to give their best.

So, please don't judge unless you know the exact situation that is going on-- it's unprofessional and judgemental, and part of our profession is to NOT judge- but to provide care and make our patients confident that they are getting the best care they can receive.