Thanks for being a nurse

Douglas Terrell  RN, MSN
© Critical Difference Inc. 2003-2016
Recent Newsletters
Newsletters from 12/9/05, 9/9/05, 6/9/05
Newsletters from 3/9/05, 11/9/04, 7/9/04, 5/29/04
Newsletters from 6/29/09, 3/9/09,12/29/08,
Newsletters from 3/9/10,12/9/09,9/9/09
Newsletters from 10/1/07, 6/24/07, 3/19/07
Newsletters from 12/19/06, 7/9/06, 3/9/06
Newsletters from 12/9/05, 9/9/05, 6/9/05
Newsletters from 3/9/05, 11/9/04, 7/9/04, 5/29/04
Newsletters from 12/21/07, 4/10/08, 6/1/08
Newsletters from 4/2/11,1/2/11,9/25/10
Newsletters from 2013  and 2/14/14

                                                               CRITICAL DIFFERENCE INC®
                                                  PROFESIONAL FREEDOM THROUGH INDEPENDENCE
                                                   7/22/14   Issue LXXVIII 850-477-1234
Making a Difference
GM’s news that people were dying due to faulty ignition switches for years that could be fixed for a couple of bucks, is troubling.  That nobody let the administrative “C” level
staff know about it for 13 years defies imagination.  But, it happens everywhere, once a problem reaches one level above their department it is considered out of their
hands.  The process of identifying a problem and working through the chain of command is the responsibility of each person in the rank and file.  Conversely administration
has to reach down and ask the question of its staff “are we missing something”?  If both processes are not in play, terrible consequences can result.  
In China the new Wenzhou Bullet Train was over budget and behind schedule, corners were cut, some work was never done.  Complaints were made to the level above the
engineers that were in the trench building the system, but were not followed up on.  Power outages were frequent; again the priority of repair was not acted on.  One such
power outage delayed the train long enough for another bullet train to overtake it and plow train loads of people over the river bridge to their deaths 66 feet below.  When
administration is stressed one of the first things they do is stop looking for problems, they have enough already.     
In every hospital in the nation right now system failures are occurring i.e. Code carts are being delivered without essential supplies.  These create workarounds for each of
us, on average of one an hour, which is a lot of operational failures when you consider there is 3 million RNs in the US (Debono, 2013); (Tucker 2009).  Nurses are smart,
committed, compassionate people, how is it that these system failures continue after 25 years of study?  It is because we let it.  When we identify a problem, we take pride
in overcoming the challenge though, we may grumble and might even tell the supervisor but that is where it stops.  We keep our patient from being delayed or slighted and
move on.  This though, is a prescription for the problem to continue and possibly worsen.  Our complaints have to be in writing, period.  Take a moment and identify a
workaround in your area, describe how it impacts your patient, and send it to your supervisor.  She is now responsible for looking into it.  If she can solve it she gets back to
you with the resolution.  If not, she moves the problem to her supervisor and then gets back to you to let you know that the problem has been escalated.  Your job is not
done.  If the problem is not resolved, you need to write her supervisor and copy your supervisor that the problem is ongoing.  That 2nd level supervisor is responsible to
look into it and get back to those involved to let each know of the resolution or the escalation.  This goes on until the chief operating officer is in the loop or the problem is
solved.  Give reasonable time for each step to go through the process.  Each step is in writing, each step is patient centered, all copies are kept and if the next level does not
get back to you in 10 days write asking for a progress update.  GM and China Rail have nothing to be proud of in their record, but health care is losing tens of thousands of
lives a year for 25 years, for the lack of an effective feedback system.  It is time we start that system in our workplace.  You are nurse, the most trusted health care worker
in the United States; you make a difference for your patients every day.  It is time now to pick up a pen and make a difference for the next generation of nurses.
                                                         CRITICAL DIFFERENCE INC®
                                          PROFESSIONAL FREEDOM THROUGH INDEPENDENCE
                                                  12/25/14   Issue LXXX 850-477-1234

Making a Difference
I am struggling through a study on mathematical modeling presented in a psychology paper.  After the second reread, it is evident I am out of my depth and
uncomfortable.  It is clear that I had missed a lot of what the author was trying to show.  How had the author managed to make this so impenetrable?  The use of an
unfamiliar study design, complex math presentations and long complicated paragraphs and little used terms has now led to a third reread. And I am still unsure of the
This may be payback for patients I had failed in the past. Nurses spend a lot of time learning the language of the profession. In turn, shedding those terms when giving
patient instructions comes hard. Our patients need to hear language that is grossly simplified, moving from "take your diuretic" to take your "water pill".  Use words with one
or two syllables, limit the scientific language.  If you use scientific terms, define them for the patient.  Limit words like “not,” “don't” and “unless” and keep sentences short,
fewer than 15 words.  According to C. Dickens (2013) we are looking to provide an explanation a fifth grader could understand.  We have all been taught to ask for a return
demonstration or explanation, yet in one study only 3% actually asked    (J. Schlichting, 2007)!  
Missing the opportunity gives our patients less capacity to manage their chronic disease, yields poor compliance in taking their medications, and increased rates of hospital
readmissions within 30 days of discharge. (D. Berkman, 2011);
(J. Gazmrarian); (S. Mitchell, 2012). If the author of this psychology paper had done any of these things, I might be able to move on. Instead, I will try one more time to
reread and understand the study. Happily my life doesn't depend on it. Wish me luck
Longer Shifts
A study of 22,000 RNs found shifts  longer  than 10 hours "significantly" increased the chance of poor quality of care and decreased safety vs. RNs working 8 hour shifts.
The coauthor Linda Aiken states "long shifts, are popular with nurses, but outcomes aren't very good and there is significantly higher burnout".  

Longer Shifts
A study of 22,000 RNs found shifts  longer  than 10 hours "significantly" increased the chance of poor quality of care and decreased safety vs. RNs working 8 hour shifts.
The coauthor Linda Aiken states "long shifts, are popular with nurses, but outcomes aren't very good and there is significantly higher burnout".  
More Gun Laws
According to study in JAMA (March 6, 2013) states with more gun laws had fewer shooting deaths with the least number of deaths in Hawaii (2.9) and the most in Louisiana
(18) deaths per 100,000 people.  I knew I liked Hawaii six times better.

Death of My Wife of 38 Years
Special thanks to all of you that had held me in your prayers this past month. Mary had a rough go with the ALS, especially in the last week. Up until which she was quick to
indicate she was still happy. After reading hundreds of studies on ALS, Mary taught me something more; it is not enough to outlive the average lifespan; it is about being
alive and happy being there. The frequent visits of her friends and colleagues, definitely made a difference in her life; I am forever in your debt.     
2/22/15  Issue LXXXl 850-477-1234
Making a Difference
By now, you have already started to see a dynamic change in hiring practices here in town and elsewhere.  If you are a nurse with LPN after your name no hospital in town is
even taking applications.  If you are a new grad with RN behind your name to get an interview you will need to have a BSN or better.  Even BSNs with experience are being
told the hospitals are looking for 2 years of experience.  (all the while hiring administrators fresh out of interesting to see what they are getting paid.  
  Already working and you can hear the BSN chant coming.   If you are in charge, expect to have to be working on your MSN any day now.  All that said if you are standing
still educationally you are scripted for replacement.  Preparation for the change is wise especially for the many that have yet to take statistics and some core classes that
frankly are hard. I studied the barriers of RN's returning for a BSN and found that roughly only 18% of ADNs will return to school on their own!  The other 72% list busy
lives, costs and inflexible  work schedules as barriers to stepping back into a class room.  CDI has applied for a patent on a process for resolving just that.  Take some of the
most fear producing course as CEUs.  Complete the entire complement of CEUs and not only can you ask the class be accepted for college credit you will have only paid the
CEU costs (about half of college cost) and completed you license renewal requirement.  In fact to make it a home run getting college credit would probably be reimbursable
with tuition reimbursement from the hospital.  Cheap, completed with small free time blocks you do have, and no risk of having to withdraw from the class of kill you
cumulative average.  
Worst case scenario you learned a bit about statistics and got CEU's for it.
Watch our website as we plan to kick this service off  for you soon.   

Alcohol based sanitizers
Turn out to be better than nothing but is ineffective against noroviruses and Clostridum difficile.  According to Gail Pfeifer (2013) 94% of Clostridum difficile infections are
medically related! While alcohol is better than nothing, soap and water rules.

Lower hospital readmissions     
In Markley (2013) on 30 readmission rates, we find a pretty profound finding: having the ward clerk call for the follow up appt. time on discharge, doubled the number
of doctor follow up visits. Want to impact readmissions, make sure the patient knows when his next doctors visit is.

Higher PaO2 in preterm infants
In a study done looking at use of surfactant in preterm infants an interesting finding surfaced.  Infants on CPAP and a higher O2 sat had a significantly lower death rate.  The
study showed the target O2 Sat should be moved from 89% to 95%.  (Vaucher, 2012)
5/22/15  Issue LXXXlI 850-477-1234
Making A Difference
 In a microsecond, you regret what you just said.  In fact, what was said just made things go downhill fast.  There is not a nurse alive that hasn’t at one time or
another been racing to get to their next patient and been confronted by a patient’s family member, physician, or co-worker and said something they regret.  How is it
we can hone our skills to respond to a code perfectly, but can’t say the right thing in a pinch?  Given a moment, we would have been able to come up with the perfect
answer or response.  Somehow, though, those words are nowhere around when you need them.  What to do?  First, buy yourself some time.  Use your considerable
skills to get a feel for what is going on and then make a response.  If a patient or patient’s family member is upset, you might apologize that there is a problem and go
to the patient’s room to evaluate the situation.  Most of the time, pausing before addressing the complaint will better prepare your response.  Politicians are frequently
cornered by pointed questions.    Reporters, asking questions in a way that no matter what their response will cost him his job, or worse.  Politicians simply answer with
a practiced, prepared response.  Knowing it would be needed eventually, it is neatly packaged, memorized and can be given slowly, buying them a moment to organize
their thoughts.  
 They know the questioner will any second rephrase the question and come at them again.   So, next time someone is bowed up in front of you about a problem, even
if it is one you are familiar with, buy yourself some time. Let him know you are concerned as well and will find out what is going on and get back with him immediately.  
The bottom line is no other profession trusts themselves to say the perfect thing immediately.  We shouldn’t either.  Review situations you are likely to confront on a
daily basis.  Memorize something that will be your response in the face of a flash question, something that shows you care and aren’t blowing them off.  It can be as
simple as asking them to go with you to find the answer. Or ask them something about what they just stated.
 Remember, it is not just what you say, but what your body says.  Smiling inappropriately, rolling your eyes, etc. will negate even the most well thought out response.  
We work in a very tense environment. Our patient’s are totally out of their element, physically un-comfortable and have unmet expectations for staffing and services.
Over 80% of them enter the hospital feeling that you do care about them.  One careless comment, no matter how innocent, can destroy all the work nursing has done
for this patient to date.  Practice your prepared responses.  Purposely buy yourself a moment of time for a real considered response.  Knowing how to respond correctly
will make your life easier, and make a difference to those around you in the process

Study Says
Recent studies have shown that a high number of human trafficking victims are brought into healthcare facilities to treat a variety of physical problems; however, few are
identified and help for their real needs is rarely provided (Lederer & Wetzel, 2014, p. 77). You, as a nurse, have the opportunity, and may provide the only opportunity,
to identify these victims and offer assistance or to educate the victims on the resources to which they have access (Eastern Missouri, Southern Illinois Rescue and
Restore Consortium, 2012, p. 3). This research project is developed by a student in the University of West Florida Nursing Program and Kugelman Honors Program and
is designed to assess the awareness and knowledge Registered Nurses in Northwest Florida have of human trafficking. This research is significant in the nursing field
today because there is a lack of research on the topic of human trafficking, especially research assessing awareness and knowledge nurses have of human trafficking.
You can help further this research by participating in this study by going to the link provided <>. Thank you for
contributing to this important area of research.
                        CRITICAL DIFFERENCE INC®
1/22/15  Issue LXXXIV 850-477-123
Making A Difference
   My Master’s Thesis told me what we all know…even though nurses know we should, we don’t want to
slog our way through a BSN.  We haven’t large hunks of time to spend on it, and even if work paid for the course, we don’t have the interest to miss work (and pay) to go
do it.
   According to a HowWeLearn poll our least favorite subject in college, by an overwhelming majority is math.  According to J. Fullerton and D. Umphery (2001) female’s
most feared course is Statistics.  So when we see a course you need for a BSN is Statistics, you can understand why folks are less than interested in going for the BSN.  Is
the course needed?  Well, yes, but not in the form now being offered.  
   When I wrote my Thesis Proposal my professor was less than kind in ridiculing my proposal’s statistical rigor and asked me where I had taken my statistics course.  Well,
I had taken it at their university and aced it.  So if I didn’t have the skills to do a simple study after completing their statistics course, it was not my fault.  A statistics
course steeped in solving complex math problems, yet neglecting the basic needs of a nurse setting up a study is counterproductive.  
   To solve this problem we need a course that gives us the tools to understand the role statistics has in doing studies and in assessing other’s studies.  The course should
be able to be taken with average math skills.  When a computer spread sheet or calculator can do the number crunching, the course should show us how and encourage the
student to use that route.  The course should be broken up in bites so we can catch our breath between classes.  It should be on line so if more info is needed a couple of
key strokes and info can be Googled.  It should be cheap, (who has a ton of money). Taking the class should be good for CEUs towards your nurse’s license renewal.  
 Well, you and CDI are almost there.  The course is written but to get AACN accreditation we need 10 people to take and critique the first 3 classes (Descriptive Stats,
Standard Deviation and Graphing Data). So, if you are interested in trying, the first 10 Florida or Georgia RNs to take all three classes and pass will get the CEUs free.  Email
me and let me know you are looking to take them and I will send you an evaluation sheet so you can get CEUs .

Why Even do Statistics?
Some really great minds (Kelvin, Kant, di Vinci, Bacon) argued non numerical thought, was small and confused.  They would argue that one should know how correct
ones argument was.  Knowing that 83% of the time the stock market goes up at the end of the year 1.83% would be very helpful. (It does).  Having the foresight to know
how much an investment goes up and how often can make you a fortune.  What if you knew that the stock market goes up in an election year?  It would be good to be able
to calculate what the probability was that it would go up in 2016. (73%).  What if you could calculate what percentage it would go up (8%). (J. Hancock, 2012) Odds are in
your favor if you can calculate the likelihood of an answer.  Equally helpful is to know the odds that you can bet your life or that of a loved one on a new medication.  To look
at a study correctly you have to know the language of statistics, which is why higher education needs you to grasp statistics. To make a difference, you have to know the

 UWF Assembly is March 31 6pm
For those of us familiar with the conference already know the sessions and CEUs are a great value.  You also get a chance to talk to some of the students and get a feel
from them what their UWF experience is like, and with the new time you can even find parking.  So if you can get a break and come please do.  Sign up now with Jill at: