Nursing/Caregiver Stress

Laurl at ONS

Welcome to the ONS Hot Topic Chats! Today’s expert is Dawn Camp-Sorrell , who will be talking with us about Nursing/Caregiver Stress. Welcome Dawn!

dcamp-sorrell

Welcome! Do you have any questions or concerns you want to start out with?

dcamp-sorrell

How 'bout any suggestions on how to decrease the burden of caregivers?

oncnurse

I'm looking for information about ways to help adult children caring for a sick parent.

dcamp-sorrell

This is so hard when so often these adults have family responsibilities and are working.

dcamp-sorrell

We are fortunate that we actually have an elderly day care…

dcamp-sorrell

We also have several churches in the area that will provide respite care for the elderly

dcamp-sorrell

This gives the adult children time to regroup.

oncnurse

How can you better support the adult child who has a parent with whom they may not agree with the treatment decisions, but as the nurse your responsibility/advocacy should be for the patient?

dcamp-sorrell

This is difficult. So often you can't just tell them your thoughts, but I think there are ways to communicate other treatment decisions.

dcamp-sorrell

Often times, I will suggest to look at some other written material or go to a certain web site. This will at least give the family something to think about.

oncnurse

What about when they want treatment  (or not) and the patient doesn't (or does) and you are caught in the middle?

dcamp-sorrell

It’s hard when you as the nurse feel like you are in the middle of the patient and the family.

dcamp-sorrell

It is so important to be the advocate for the patient.

dcamp-sorrell

Any thoughts Lorna or pavila?

dcamp-sorrell

Again, I feel as if as the nurse we should be on the patient's side. To empower and encourage the patient to go for the treatment or procedure they want

dcamp-sorrell

Often times, the family just wants to be in control of the situation and basically they are not.

oncnurse

Right, in control in all other aspects of their lives except this.

dcamp-sorrell

You are so right oncnurse. Hostile family members are not easy to deal with.

dcamp-sorrell

It’s difficult when family members are hostile and you are trying to be the advocate.

dcamp-sorrell

Patients can become hostile as well.

dcamp-sorrell

In those situations, the best think to do is to listen, be patient, stay calm and reflect everything the hostile person is saying.

pavila

I think it is important to help the family give input in to things that they can, but ultimately we are the voice of the patient and we have to provide the education so that we know our patients are making an informed decision.

dcamp-sorrell

Yes, you are so right pavila.

dcamp-sorrell

I think that is why nursing is so different from any other profession. We wear so many different hats.

dcamp-sorrell

Being an advocate is hard work and it can be draining at times

pavila

I would be interested to know what oncology units/cancer centers are doing to boost the morale of the nurses, as our nurses are so drained.

dcamp-sorrell

What a great question!!!

dcamp-sorrell

What I've been hearing is so much depends on the manager and the culture of the unit

oncnurse

Very hard - the culture is so important- one of supportiveness and not just come and do your work and leave.

dcamp-sorrell

I've had several to suggest that there places of employment offer exercise programs.

dcamp-sorrell

You are so right Pavia, many managers don't give the necessary support.

pavila

Don't you find that hard with the multi-generations? I’m seeing that with our new nurses versus the veterans on the unit.

oncnurse

Pavila, which group of nurses has the most difficulty on your unit?

pavila

I would say it is the older nurses, seeing the younger/new nurses being able just to clock in and out and not really "connect" with their patients.

dcamp-sorrell

I have found that the older nurses tend to be burning out. I know that I often have a difficult time catching on to new technology compared to my younger counterparts ie charting on the computer. I always feel as though I'm leaving something out.

dcamp-sorrell

Wow! That’s hard pavila!

dcamp-sorrell

I just can't imagine working with oncology and not connecting.

dcamp-sorrell

The older nurses have got to mentor to the young. To see what they are missing.

Lorna Baker

I also believe, as the nurse, I should be the patient's advocate, as long as I know the patient understands the decisions he/she is making.

dcamp-sorrell

Unfortunately it goes back to the manager or the culture. If the older nurses are burned out, they can't do it.

dcamp-sorrell

Lorna, you are so right. As the advocate we must ensure that the patient understands the treatment.

dcamp-sorrell

Lorna, if we know that the pt has been informed then we can stand by their decision.

pavila

So what do we do to preserve our older nurses or those that have entered nursing as a second profession? Or how do we mentor our nurse managers as we see that field turning over as well?

dcamp-sorrell

All good questions!

dcamp-sorrell

I think it is all about relationships.

dcamp-sorrell

Not just with patients and families, but with each other.

dcamp-sorrell

Nurses are terrible to "eat their young".

dcamp-sorrell

Again, I think you need a strong manager to ensure healthy relationships.

dcamp-sorrell

However, wonder if you don't have that nurturing manager, then what?

dcamp-sorrell

Well, I think it comes to the individual nurse. I think attending a leadership conference that ONS has is a great way to empower the individual nurse.

dcamp-sorrell

You would not believe what you as an individual can do to begin the change of the culture on the unit.

dcamp-sorrell

I believe that positive will produce positive.

dcamp-sorrell

You can do things that don't involve a lot of time or energy and impact the patient's care.

Laurl at ONS

The leadership conference Dawn is mentioning is the Leadership Development Institute...info about it on ONS website at www.ons.org- CNE Central.

Lorna Baker

During nursing week, we had a guest speaker talk about parenting (as opposed to nurturing) staff, and how this may foster the staff nurse to then act like a child instead of a professional. Have you seen staff nurses acting out?

dcamp-sorrell

Just the other day, one of our nurses brought a mason jar full of daisies to the conference room for all of us to enjoy. May sound silly, but it sure did change the environment for the day.

dcamp-sorrell

Lorna, what a great idea!! I think we have all seen nurses act out.

dcamp-sorrell

We should have the expectation that older nurse should foster the younger ones.

dcamp-sorrell

I know it can be hard at times when life is so busy on the unit or outpt area.

dcamp-sorrell

But this needs to happen to make sure the younger ones know how to communicate.

pavila

I agree, but it is with the foundational understanding of novice to expert. They can't be seasoned oncology nurses at the end of an orientation period.

oncnurse

I just keep wondering who will take care of us when we are old- these nurses who just clock in and clock out and don't connect with us? That's why up to the older nurses to show younger nurses the value in connecting with patients.

dcamp-sorrell

Pavila, you are so right. It will take probably years to get there.

dcamp-sorrell

It’s a difficult process with lots of growing pains for the unit.

dcamp-sorrell

The mentoring has to be there.

Lorna Baker

We were talking about that at lunch today. One of my colleagues said our parent's generation has us to care for them, but who will we have?

dcamp-sorrell

Yes, Lorna!

Lorna Baker

I think it is hard to mentor compassion.

dcamp-sorrell

I find the younger generation does more communication with Ipods and computers than with actual folks.

dcamp-sorrell

We have got to get back to the basics on how to communicate. Our younger folks grew up with this technology.

dcamp-sorrell

As the older nurse, we have to demonstrate the how-to…

dcamp-sorrell

Lorna, you could be right about mentoring compassion.

pavila

With today's communication being more hands-off, I find the younger RNs have more difficulty with death and how to process it, whereas the older RNs grieve together.

dcamp-sorrell

Yet, just the other day a younger nurse watched me talk with a family member about the patient dying. She commented that she liked the way I did that.

vandaesme

I came in late, so I am trying to catch up w/the conversation. We are discussing caregiver stress, right? Just nurses or family caregivers?

Laurl at ONS

Any and all kinds of stress!

dcamp-sorrell

I agree pavila.

Laurl at ONS

Right now just discussing how nurses not supporting one another optimally can create nursing stress...

dcamp-sorrell

We have been there from the beginning of the communication process. So often the younger nurses haven't had these opportunities yet.

dcamp-sorrell

I firmly believe that with time they will have these skills especially if they have some one as a role model.

dcamp-sorrell

I just find it hard for nurses young or old to stay in patient care if they can't communicate.

dcamp-sorrell

I will say, it is hard when you feel as though you are the only one that can do this communicating with the patient.

dcamp-sorrell

I've often found myself following up after someone has gone in to talk with the patient about treatment or follow up care and just could not get across the right words.

oncnurse

Has anyone tried a formal matching of older and younger nurses to try to develop that mentoring/teaching of the compassion/caring side of nursing?

dcamp-sorrell

It seems that the start must be in the school of nursing. I have students once a week and will actually do role playing.

Lorna Baker

I agree. I recently had someone start in unit orientation. I found out at the end of the week she and her preceptor did not communicate well, so I spoke with them both and then changed the assignment. She told me things were better with the new preceptor, and then several days later sent an e-mail saying she wanted out of the programme. That left the new preceptor and myself wondering what else we could have done.

dcamp-sorrell

Unfortunate! Sounds as if you tried to meet their needs.

oncnurse

Interesting that the student tells you by email.

dcamp-sorrell

It doesn't surprise me that this communication was done by email!

oncnurse

I think that that in itself may tell you something about the communication issues between them.

vandaesme

Sounds like perhaps the student was the actual source of the poor communication

dcamp-sorrell

This day and time we are getting further away from actual communication.

dcamp-sorrell

Where does each of you work? And Lorna are you from the US?

oncnurse

This is a way nursing could actually distinguish itself more - by keeping to the traditions of one-on-one and compassionate care- even in the face of all of the technology.

Lorna Baker

I work in Tampa. I am originally from Jamaica, WI

dcamp-sorrell

Good point oncnurse! The key is ensuring this is done in school of nursing, during orientation, and with follow up in the work setting

dcamp-sorrell

Just wondering Lorna by the way you spelled program. Cool.

oncnurse

How about recommendations for resolution of conflict with doctors? Especially when the patient may want something other than they do?

dcamp-sorrell

Conflicts with physicians can be tricky considering most folks side with MD not the nurse.

dcamp-sorrell

I find the best approach is direct. To gently confront them regarding the conflict.

pavila

I always let patients know that I encourage second opinions that their health is more important than buying cars, and they don't think twice about visiting a second car lot.

dcamp-sorrell

I usually give the MD verbatim what the patient has requested.

oncnurse

That's a good analogy pavila.

Lorna Baker

Oncnurse, I was just thinking about that. Do most of your institutions have ethics committees that allows for nursing to initiate a consult?

dcamp-sorrell

Good point pavila!!!

oncnurse

I wonder what the ramifications would be of going to the ethics committee- I think of some nurses I know who would definitely NOT do that if they thought it might mean troubled relationships with that doctor down the line - or with their manager for the "trouble" they are causing.

dcamp-sorrell

What is difficult is when you finally confront the MD about what the patient wants and then go in to the patient's room to find the MD has changed their minds again!

dcamp-sorrell

Good point oncnurse!! Fear can be a huge stumbling block!

oncnurse

Have you ever taken something to the ethics committee like that Lorna?

pavila

Do you have any counseling staff? We have counselors specific for our Cancer Center and getting them involved has eased situations many a times.

Lorna Baker

That brings us back to the role of patient advocate.

dcamp-sorrell

Wow Pavila!

dcamp-sorrell

What a great asset to the cancer center. We don't have counselors on staff.

dcamp-sorrell

We do have folks that we can refer to.

Lorna Baker

We have nursing rounds and have recommended on occasion that an issue be brought to the ethics committee. As you say, there are times when the physician changes his/her mind before it gets to the meeting.

dcamp-sorrell

Lorna that is so true!

oncnurse

It's nice you have that avenue Lorna and it is well-established that this is an "ok" thing to do.

dcamp-sorrell

It never ceases to amaze me that I will put my neck out there with the MD with what the pt wants and then the pt changes their mind and feel pretty stupid.

dcamp-sorrell

We have to find ways to support our managers no matter how thick their skin may be.

dcamp-sorrell

I leave peppermints and a funny note in my manager's chair in her office.

dcamp-sorrell

I just want her to know how much I appreciate her going to bat for me.

Lorna Baker

That is a nice idea.

vandaesme

Regarding pts changing their minds, I think it's important to remember they are under stress too dealing w/their diagnosis & therefore can be easily swayed regarding their decisions.

oncnurse

If the management group can be supportive of one another, then your manager can get the support she needs outside of trying to get it from the staff, and can instead give.

dcamp-sorrell

Absolutely!! Another reason for our advocacy and clear heads when with advocate.

vandaesme

Also, in dealing w/end of life issues, statements such as "do you want everything done" aren't really effective.

dcamp-sorrell

Yes you are so right vandaseme

dcamp-sorrell

I've heard that statement so many times, I've be awaken in a dream with it!!!

vandaesme

And who is going to answer "no, I don't want everything done"

dcamp-sorrell

Right vandesme

Lorna Baker

So true!

dcamp-sorrell

You’ve got to have those discussions one on one with the patient and again with the family separately. Occasionally this can happen together.

dcamp-sorrell

Also think we need to ensure our own family members have thought about this.

pavila

JAMA 2008 had a great article on end of life discussions that we used for our journal club. The author was Wright. It opened the eyes of many of our nurses in how important these discussions are.

dcamp-sorrell

Perhaps at the Christmas dinner table isn't appropriate, but at least you have the info there.

vandaesme

I also find that the timing of those conversations is extremely important. It's probably better to speak w/the pt in times of wellness/remission, not when they are being transported down to the ICU.

dcamp-sorrell

Ha Ha! So right

pavila

We also have to pull in the physicians as they can delay the process as well.

dcamp-sorrell

Yes, I've heard many of conversations in the elevator on the way!

dcamp-sorrell

Yes Pavila!

dcamp-sorrell

MDs I do have to say, are the worse. I still think they view death as failure.

vandaesme

MD's are trained differently than RN's.

dcamp-sorrell

Oh. That is such a good point. Needs to be during the well periods and not during the stressful times.

dcamp-sorrell

So true vandaesme.

dcamp-sorrell

We view the patient holistically.

vandaesme

Exactly

pavila

As well as the quality of life and the quality of a respectful death.

dcamp-sorrell

So true!!

Lorna Baker

A lot of people have Advance Directives 'at home', and the family is afraid to say/do the wrong thing, so no decision gets made.

dcamp-sorrell

It amazes me that we are not in charge of the world as nurses!

oncnurse

The world would be a lot more human if we were.

dcamp-sorrell

Lorna, that is true. We have to ensure that we are carrying out the directions of the patient.

dcamp-sorrell

Well folks just a couple of minutes left, any other great thoughts? this has been a very lively chat

Laurl at ONS

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Lorna Baker

Thanks for organizing this.

Laurl at ONS

We are so happy that you enjoyed this chat!

Laurl at ONS

Please be sure to check out the transcripts of this and past chats at the ONS Hot Topic Website.

dcamp-sorrell

I just had a little lightening

Laurl at ONS

Future chats coming up soon - the next one is on Complimentary and Alternative Medicine!

dcamp-sorrell

Thanks for coming today. I enjoyed our chat.

Laurl at ONS

Thank you all for attending!

Laurl at ONS

Have a good day!

pavila

Great discussion. Thank you!

vandaesme

Thanks