Once upon a time in the not-so-distant past, I taught an EMT class for whom I found it difficult to schedule adequate Emergency Department clinical time. In was in late July, and the local ED had a new crop of residents barely able to practice their own craft, much less supervise someone else’s, and there were several classes of nursing students doing their clinical rotations as well.
My solution was to send all my students to the local nursing homes instead. It was perfect — each student would assess roughly 40 patients of the type they’d be most likely to encounter in the field.
Each patient had multiple chronic disease processes, and most had some level of cognitive impairment or difficulty communicating. My students even saw their fair share of acute conditions, and their nursing preceptors sent more than a few patients to the hospital based upon my students’ assessment findings.
There was also an unexpected benefit to my improvised solution: my students gained a healthy appreciation for how hard it is to be a nurse in a convalescent home. It’s a far more difficult job than we may appreciate.
Yes, you heard me correctly. I’m indeed defending that most maligned of creatures: the nursing home nurse.
My mother was a nurse who worked in one of those homes, and she was good at it. She could have chosen any field, but during one nursing clinical rotation, she said that the statue of Jesus outside the nursing home told her that this was the place she belonged.
Yes, I know. We rolled our eyes at the time, too, but there was no denying her dedication to her job. She loved elderly people, and it showed in the quality of care she provided. At the time, I thought all nursing home nurses worked that way. It wasn’t until I became a paramedic that I discovered otherwise.
Still, in watching my mother work, I gained an appreciation for the difficulty of the daily tasks she faced, and it’s something I try to pass on to all my partners and students. It is an odd quirk of EMTs that were are often disdainful of the non-emergency aspects of health care, as if resuscitations and rapid transport is all that is meaningful.
We should know better.
Consider that we are usually asked to care for only one patient at a time. Nursing home nurses may care for as many as forty. The care those patients require may not be acute, but it is important nonetheless.
Ever worked for an absentee medical director who wrote absurdly restrictive protocols that left you feeling as if your hands were tied behind your back? Well, every nursing home is that way, and those nurses feel the same way about having to call the doctor for the slightest change in treatment orders.
We are openly scornful when we arrive at bedside, only to find the patient struggling to breathe through a face mask at two liters per minute. But do you realize how much a licensed practical nurse is taught about oxygen therapy? Precious little, even in comparison to an EMT-B.
On a typical 3-11 shift, the nurse will pass medications twice. Each of those medication passes may take several hours to complete, and regulations forbid setting up the medication cart in advance. So the nurse makes two med passes, doing what assessments she can as she goes, and still has to chart and give report to the oncoming shift. In those eight hours, she has been able to lay eyes on each patient twice, for a grand total of perhaps ten minutes.
So is it any wonder that sometimes an acute change in the patient’s condition is missed, or that a nurse errs on the side of caution and sends a patient to the hospital at the first hint that something is wrong? Or that the nurse is sometimes fuzzy about the patient’s medical history?
When you work a wreck scene, do you openly disparage the first responders and the care they provided, limited as it may be? So why are some of us blatantly disrespectful of the nursing home nurse? At least those first responders are trained somewhat in emergency care procedures. Most nursing home nurses are not.
There are a few tips I’ve learned over the years that may make those dreaded nursing home calls flow a little more smoothly:
- Treat the aides as the patient’s family members, and as your primary source of information. They may have little more than a high school education and often a limited command of the English language, but they spend more face-to-face time with the patients than the nurse ever will. They’re the ones to ask when this condition started, and what is or is not normal behavior for the patient.
- Thank them for calling you, and don’t start your conversation with a laundry list of questions about what they haven’t done, and why not? You’re the emergency care professional, not them. That’s why they called you. We’re supposed to be the pros from Dover, and the pros don’t start out by mocking the people who called for help.
- Don’t start off by asking why the nurse isn’t in the room, or demanding the chart. Question the aides first, and start your assessment. When the nurse arrives with the chart, use it to fill in the blanks. Do you really need that information before you can initiate stabilizing treatment? And if the patient doesn’t need stabilizing treatment, what does it matter if you get the paperwork now, or five minutes from now?
- When you spot a mistake being made — one that can adversely affect patient care — treat it as a teachable moment, not an opportunity to flaunt your superior knowledge and skills. Use the Golden Rule — treat people as you’d like to be treated yourself.
The next time you find yourself rolling your eyes and questioning the intelligence of a nursing home nurse, first try walking a mile in their shoes first.
You may find it a more difficult walk than you’d imagined.
