I have spent two shifts in an pediatric emergency department in a major metropolitan city this week and the experience leaves me with a sense of how much reform is needed in health care. Some of the reform that is needed has to do with the structure of the system, but some of the reform we need is within every individual in the system. Each of us needs to look within and change how we interface with the system and our patients. Here are some brief reflections on my experiences:

1. As providers, we must remember that the challenges we face in providing care were not created by our patients. They are trying to have their complex needs met by a system that needs reform.
2. Each time a provider feels compelled to ask why a patient did not do “as they were told” or wonders why a family acts entitled to superior service, they would do better to ask themselves what else they could ask that family in order to address their concerns and equip them with the knowledge and skills they need to cope with the illness.
3. Assumptions and judgments are not part of caring.
4. When we worry about visit times or length of stay, and how many patients we have to see, we will miss opportunities to see the whole person that is the patient in front of us. Just because they are in the Emergency room for a specific problem, doesn’t mean we can narrow our understanding of their health problem.
5. The day will go better if you smile at each and every person, shake their hand, and ask them if there’s anything else they need.
6. If the health care system met their needs, the Emergency Room would not be as crowded.
7. Accept people for who they are and leave blame out of it.

One of my first jobs out of nursing school was in Louisiana in a busy pediatric Emergency Room. We had very few resources and were very busy. For our whole 36-bed unit, we had two monitors and they were at least 42 inches square. They were so old, they did not print rhythm strips. One day I was standing at the bedside of a congenital heart patient and noticed two things: the patient was having PVC’s and periodic oxygen desaturation down to 50%. The monitor never alarmed. There was also no central monitoring station, so if you put a patient on the monitor you had to watch it all the time at the bedside to see what was going on.

We started realizing that they never alarmed. Given how short-staffed we were standing at the bedside watching heart rates and oxygen saturation levels on patients that were not so ill they needed constant care was not feasible. This, along with several other perceived patient safety issues prompted me to organize the nurses. We wrote a letter outlining our concerns for patient safety and requesting a meeting with hospital administrators to present possible solutions. All the nurses signed it, doctors also looked at it and voiced their support. We sent it to the top nursing administrator and copied the CEO, all the Vice presidents, and the president of the Board of Trustees.

Now this was New Orleans, and if you are not familiar with the “laissez le bon temps roulez” culture let me just say that in general, New Orleans is not known for being a culture of progressive change or process improvement. Needless to say, the nurses worked to create ideas for how to improve problems with staffing, suggested purchasing monitors and a central monitoring system, and looking at procedures for triage. We presented to the nursing administration and waited.

Shortly after the presentation, they tried to discipline me for poor clinical judgement for something that was completely bogus. Knowing they didn’t have a leg to stand on given my level of documentation, I asked them to put their concerns in writing so that I could respond appropriately, rather than calling me into meeting where they threatened and questioned my judgment. Needless to say, my documentation saved me and they never substantiated their claims or put anything in writing.

I felt that they were punishing me for organizing the staff, spearheading the letter and the presentation. I was so discouraged since I had tried so hard to make sure everything we did focused on illuminating the problem while providing positive suggestions for nurse-led improvement efforts. The intention of our work had always been about patient safety and I could not understand why they rejected me.

On the up side, 12 new monitors were purchased and the unit was wired for a central monitoring telemetry station. It took 8 months for that to be installed, and in that time, I was so depressed and discouraged that I left New Orleans (about 4 months before Hurricane Katrina).

5 years after those efforts, I ran into a nurse in Georgia from that pediatric E.D. in New Orleans. We talked about the hospital where we work now and how there are so many resources compared to where we worked previously. Where we work now seems posh and luxurious with great staffing ratios, all the best equipment, social work support, child life, etc. I told her that I had been so discouraged by how the treated me there after we did the presentation, but now that I had been away I felt as though we had done much good for the patients we served even without any resources.

She understood and said, “If you hadn’t done that, we never would have gotten any of that equipment, and we’d still be working with two monitors. They would still have nothing, at least we got what we got.” All these years, I felt like I had failed to make a difference there. Now, through her eyes I saw that I had made a difference. I may have paid a price for my actions, but I feel now that a purpose was served and change happened even though it took five years for me to see the result.

On September 17th, 2007 I became a mother. After working as a pediatric nurse for almost 6 years, I had “educated” so many people in the pediatric ER about basic baby care from how to suction a stuffy nose to what to do when fever occurs. I remember being shocked at how little people seemed to know about basic infant care.

Then motherhood happened to me. I forgot everything I had been teaching others and became an insecure, frightened parent when it came to my own child. During those first weeks home I called my pediatrician because my baby had not pooped for 24 hours. If I had triaged that phone call from myself, I knew what I would have said: not something to worry about as long as baby is eating well and having at least 6-8 wet diapers a day. But the new mom in me was terrified that something was wrong. The terrified mommy wins over the rational nurse every time. I remember going to my pediatrician when Molly was 1 month old and asking her not to tell anyone that I was a pediatric nurse.

In my defense I have been doing pediatric hematology oncology for the last three years so even my knowledge of well baby stuff was rusty. But still. I was disgusted with myself and embarrassed at my complete loss of composure over taking care of my own child.

The addition of mommy doubt and anxiety to my life and my new identity as a parent gave me a new understanding of what parents of sick or well children might need from their health care providers.

Parents need to know that we are listening to their concerns first, diagnosing and treating with those anxieties and fears in mind. How often do jaded health care providers dismiss the seemingly overanxious parent and tell them not to worry about something without having actively listened first and then provided basic education. My own experience with this occurred when Molly was 3 months old. She seemed to be sleeping much more than normal. The new mommy in me called my pediatrician and they told me to bring her in. So I did, even though the rational nurse in me knew Molly was OK, anxious mommy alter ego was in the car 5 minutes later. Once there, Molly was fine of course, but I didn’t feel that I had the chance to explain why I was worried. My pediatrician saw the nontoxic looking 3 month old in front of him and we were out the door in 5 minutes. I did not get what I needed because I still did not fully understand why she was acting so differently.

Healthcare providers do not spend enough time providing developmental guidance and assistance with basic childrearing issues. Most pediatric well visits are brief and do not afford parents the chance to really check in with how parenting is going. Most patients will initially say that everything is going well the first time they are asked. But parents need us to provide more support, especially since people are more isolated from each other but are able to Google almost any health topic and educate themselves. There is a great deal of information out there in the internet, but one must be discerning about information. Pediatric healthcare providers have the opportunity to help parents sort through this information.

I have read many books written by medical professionals about pediatric care, but I find the Touchpoints approach by T. Berry Brazelton to be a very holistic and comprehensive approach to how pediatric care providers interact with their patients. http://www.touchpoints.org/

Through my own experiences as a new mother, my ability to serve my patients as a Pediatric Nurse Practitioner has grown significantly. I have a much better understanding of parents. I understood a great deal about the textbook topics of pediatric nursing care, but had never lived the reality of caring for a little human being 24/7.

On the flip side I have to be Molly’s mom first and foremost and let the nurse go take a nap when it comes to my own child. That tired nurse gets some sleep for a change.