By: Dr. Maryanne Giuliante, DNP, RN, GNP, ANP-C
This is the second post in series of 2 posts from one of NYU Nursing’s program managers and nurse practitioners Maryanne Giuliante.
When working in teams is mandated, many offer a big “grunt”. I remember, as a doctoral student, we were encouraged (more like forced) to work in a team for one of our initial assignments. As new doctoral students, we were in the throws of trying strike the right balance between working, being a student, and possibly many other “hats” many of us wore. Many begged the professor to reconsider, and offered many solid excuses as to why it would be better for each of us to work alone. Our schedules, family obligations, living far from each other, and many other (creative and valid) arguments were proposed. We thought we were making rather nice progress in our discussion. Our professor listened to our plight, and even seemed to waver a bit at certain times. In the end, it was clear that it was not meant to be. She made us forge ahead with the initial plan to work together. Grunt!
Looking back on that exercise, I appreciate the value of the assignment. Though the actual task at hand was easily forgotten, the lesson regarding teamwork and what can be accomplished was priceless. Though each of us were nurses and thought that nobody was going to bring anything particularly unique to the table, we soon discovered quite the opposite! We learned the value of personal attributes and skills sets can transform a mediocre product into one with depth, character, and uniqueness. We discovered the need to become introspective and honest with our abilities, and to embrace both our strengths and weaknesses.
Though it seemed daunting, all of us were able to overcome the aforementioned logistical challenges and put important things like family, work, and other obligations aside. In doing so, we learned to be malleable and respectful of other’s priorities, and in turn, this exercise churned out overt mutual respect for one another. Yes, the assignment was tough, but the lessons learned continues to pay me back in ways that cannot be calculated.
Please share some personal experiences about teamwork. What have you discovered on your journey that has helped you to become a better teammate? What kind of challenges have you encountered? What techniques have you leveraged to enhance the outcome?
BY: Dr. Maryanne Giuliante, DNP, RN, GNP, ANP-C
This is the first post in series of 2 posts from one of NYU Nursing’s program managers and nurse practitioners Maryanne Giuliante.
As the manager of an inter-professional collaborative community-based initiative here at the Hartford Institute for Geriatric Nursing at New York University, I am very interested in the “recipe for success” as it relates to a “good” inter-professional collaborative practice team. I believe all answers stem from communication. Understanding the meaning of messages that we send to our colleagues from a complimentary profession is often underrated. By their nature, other professions may not truly understand the message we deliver, as they do not see the patient through the same “lens” as we do. As such, open, honest, complete, accurate, and respectful communication cannot be underestimated. The manner in which these messages are delivered can completely and directly impact the quality of the outcome. Please share your thoughts and experiences with inter-professional collaborative practice teams and how your experiences may have impacted your model of care delivery. Specific examples welcome!
By Niamh Marie Daly
This is a chapter of a Student Perspective Series, from the NYU College of Nursing Geriatric Special Interest Group
My experience in geriatrics began in high school when I started working as a caregiver at an assisted living facility serving those with memory impairments. I was immediately drawn to the personal interaction with residents and continued to work as a caregiver in college and after graduation. I decided to pursue a second degree in nursing largely to improve my ability to care for individuals living with Alzheimer’s and dementia. In the first few weeks of class our instructors have addressed ‘The Graying of America’ or the increase in the percentage of older adults living in the United States. Similarly, as the number of Americans age 65 and older increases so will the prevalence of dementia.
Health care professionals have an obligation to embrace the change of demographics with improved methods of care that address quality of life for individuals with dementia. The Eden Alternative is an incredible approach to improving well being for those with dementia. It is a global initiative dedicated to promoting person- directed care that takes into consideration how unique and different every individual is. As I began to research The Eden Alternative I was reminded of a resident at the facility I used to work for. This woman became extraordinarily anxious every afternoon and the medication used to treat her anxiety provided little to no relief. As we got to know our new resident we discovered how much she enjoyed a cup of tea and talking about one of three things: her sons, her cat and her career as a nurse. Eventually we began making her a cup of tea at the first sign of anxiety and a caregiver would sit and discuss her favorite subjects with her. Almost immediately her anxiety and worry would disappear. After understanding who she was as a person and establishing a relationship with her we were able to appropriately address her problem. A cup of tea and a conversation was the cure for this woman but the Eden Alternative reminds us that what works for one person may not work for another.
Providing the highest level of care requires getting to know the individual in question. My challenge as a nurse will be looking at each patient as a unique human being and providing care based on their individual needs. As I do this I will keep one principle of the Eden Alternative in mind, “Medical treatment should be the servant of genuine human caring, never its master.”
Niamh Marie Daly is a member of the NYU College of Nursing Geriatric special interest group and has just entered her first semester in the accelerated nursing program at NYU and is interested in geriatric nursing.
By: Alexandra Moy
As a Chinese-American, geriatric nursing is not just about caring for the elderly. Geriatric nursing speaks to me on a personal level, because of my cultural background. Caring for the elderly makes sense to me because it ties in a value from my culture that is very important – respect for elders.
As a child, I always taught to respect my elders. The oldest members of our family were also the most respected and honored. My parents were working long hours, so my retired grandpa was the one who walked me to and from school, made me lunch and dinner, and tucked me into bed. I was grateful for his care and I always admired how he seemed to have endless amounts of knowledge and wise words. As he progressed into the later years of his life, it was only natural that I would reciprocate as his caretaker.
This mentality has transitioned into my adult life, and now whenever I meet patients at my hospital clinical, I always treat them with respect. In contrast, we now live in a world that is obsessed with preventing aging. The prospect of aging, both cosmetically and functionally scares everyone. On top of that, elders are not treated with the same kind of respect. As a society, we look down on aging. We see aging as a loss of importance, as something that is negative. With all this negativity around them, older adults start to believe that they are a burden to those around them, and start to resent the inevitable aging process. However, I hope that I can share my view on aging with patients through my care. I treat older adults with respect because in my culture, they have given to society and it is my turn to reciprocate by caring and respecting them. I hope I can carry these values into my practice as a registered nurse and deliver excellent geriatric care.
About the Author: Alexandra Moy is her first semester of the accelerated baccalaureate program at New York University College of Nursing. She plans to start her career in oncology nursing and eventually become a family nurse practitioner. She is an e-board member of the Geriatric Student Interest Group.
This is part of a Student Perspective Series, from the NYU College of Nursing Geriatric Special Interest Group
Since I was a young girl people have always expressed to me how social and skillful I am at talking and listening to people. It’s something that has always come very easy to me. I can pretty much engage with anyone, from any background, at any age and from any educational level. I believe I acquired this technique from my mother. Having this skillful characteristic is important, especially in the role of nursing. According to Chitty and Black, communication skills “are vital to effective nursing care” (Chitty and Black, 2010, p. 200-201).
My clinical experience last week was very meaningful. The patient was post-op day one and had a high level of pain in the morning when I arrived. As I used therapeutic communication to actively listen to the patient describe her surgery and pain, I was also able to use my past surgical experience to empathize with the patient. When the nurse reappeared in the room, I was able to give her feedback about the patient’s pain level.
Just then the nurse went to check on pain medication for the patient and I chose to remain in the room and keep the patient occupied by talking and getting to know her. She was an older adult and reminded me so much of my Nana, my grandmother on my mother’s side. Working with older adults is always a joy and brings me a lot of happiness. About ten minutes went by and I reassessed her pain level. It was then that the patient informed me that she disregarded the pain in her leg because the conversation distracted her and kept her from focusing on her discomfort. This comment made me so happy because just ten minutes earlier her facial expressions conveyed discomfort and agony. It’s essential to remember that when delivering care to older adults, the nurse needs to preserve their optimal mental function, and sometimes an effortless conversation will provide this. Through this experience I realized just how important a simple exchange of words could be, especially with regards to the relationship of the nurse and patient.
After lunchtime I stopped and took a second to look around my floor. Most of the staff looked busy, moving from task to task. The nurses went in and out of rooms, patients undergoing physical therapy were walking with staff and many others remained in their rooms. It was then I wanted to make a mental note. I want to always remember the importance of developing a meaningful relationship with the patient because “the nursing process can begin only after the nurse and patient establish their therapeutic nurse-patient relationship” (Chitty and Black, 2010, p. 193).
It takes just a few minutes to bond with someone; however, it’s all too easy to become too busy to consider the importance of these simple interactions. Building a relationship through communication is such an easy thing to do and I believe it’s vital for nurses to take the time to really connect with their patients. I know firsthand how quickly it is to become too busy or sidetracked by the amount of stress or responsibility on one’s plate. For example, living in New York has made me realize just how precious time is, and how quickly it can be wasted. That phone call you were going to make to catch up with a friend can go from days to weeks and turn into months before it is made.
My lecture classes so far have stressed just how significant it is for the nurse to always keep the patient as the focus. I’ve decided I will achieve this by keeping the relationship with the patient at the top of my priority list. It will be my responsibility as a new nurse to develop that one-to-one relationship with the patient so all other team members can help to provide the best patient care.
Chitty, K. K. and Black, B. P. (2010). Professional Nursing: Concepts & Challenges, 6th Ed. Saunders, Maryland Heights, Mo.
About the Author: Heather Anne Fryer is an accelerated nursing student at New York University College of Nursing in her last sequence. She plans on graduating this May 2014 and would like to specialize in either Critical Care or Geriatric Nursing. Heather Anne Fryer is also a member Geriatric Student Interest Group and HIGN Blog Writer. On her free time she enjoys running, traveling and fitness.
This is a chapter of a Student Perspective Series, from the NYU College of Nursing Geriatric Special Interest Group
By: Ana Cheung
I never considered specializing in geriatric nursing before my academic career at New York University mainly because I have had limited interactions with the elderly. My maternal grandparents died while trying to escape the Vietnam War and my paternal grandparents lived out in the Midwest so I rarely saw them. It wasn’t until last summer that I was able to connect to geriatrics on a more personal level.
At the tail end of summer 2013, I volunteered with the medical relief organization, Floating Doctors, which provides healthcare and medical treatment to isolated coastal communities in Panama. They also worked locally with a live-in geriatric facility, the asilo, by providing regular visits to conduct check-ups and physical assessments, administer medications as well as offer companionship to the residents. For the most part, the residents were in good health and mentally present. However, open sores, scabies, dementia, and debilitation were common afflictions.
Half of my time was spent at the asilo and it was a memorable experience. Most of the residents only spoke Spanish, and even though I didn’t know any, I was able to communicate with them through smiles, laughs, touch and basic greetings. I knew all their names and they affectionately called me “China,” which would become my nickname during my stay. A handful of residents did speak English and I often spent my afternoons chatting with them. As a group, we took walks to the park, danced (especially those in wheelchairs), played cards and when it wasn’t raining, I would sit with one or two of my new friends in the backyard, watching the sun set across the ocean, as we listened to the rhythmic lapping of the waves.
This idyllic picture of beauty did not discount the daily reality that some of the residents faced— of being in pain, confused, unable to walk, tired, depressed and/or agitated. The true beauty of this picture lay in their ability to grin, joke, and relish the bright moments of their days. Rolando* would follow our senior volunteer supervisor around and playfully tell everyone they were brothers. His eyes always twinkled mischievously and he seemed like the kind of grandfather who would help his grandkids play pranks on each other. Sylvia*was constantly confused but she was saccharine sweet and had a smile that would light up the room.
The human spirit is amazing, especially when it is resilient. What I learned most from my volunteer experiences with the elderly and NYU clinical rotations is humility. Humility from being humbled by my patients’ life stories, humility from being inspired by their strength, humility from their kindness to let me see them at their weakest and to assist them. Humility as in we are all human and vulnerable—and it is our humanity which binds us together. By helping others, we respond to our innate humanity to nurture, be compassionate, to listen and to learn. I have a lot to learn and a long way to go but I am so thankful to have patients from all walks of life and backgrounds to guide and teach me the skills and traits I will need on my journey to becoming a successful geriatric nurse.
About the Author: Ana Cheung is a nursing student in the last semester of her accelerated baccalaureate program at New York University College of Nursing. Specialties in which she is interested in pursing are geriatric, hospice/palliative care, and community/public health nursing. As a former Peace Corps Volunteer, she is also drawn to working as a nurse internationally. Within the NYU community, she is a board member of the Geriatric Student Interest Group and Nursing Students for Global Health.
When Mrs. P’s husband was dying he asked a good friend of the family, and long-term business partner of his spouse, Mr. C, to watch after her. What did that entail, he thought? What did Mr. C agree to?
As we care for older adults, those who have assumed that role across the lifespan and others who are suddenly thrust in the role, the range of emotions that one experiences after such an announcement can vary. At first blush, one is honored to be asked. After all one doesn’t typically delegate important decisions to people they can’t trust and who they believe is incapable of making sound decisions, right? Albeit, Mr. C did not volunteer to take care of Mrs. P, he did accept the responsibility and was honored in knowing that Mr. and Mrs. P trusted him to do the right thing, and to act in her “best interest.” The honor of being asked and the reality of what that meant were not clear until years later. Mrs. P, an African American female, age 89, lived alone, was functionally independent, and didn’t suffer from any chronic conditions. She was able to engage in activities of daily living and enjoyed reminiscing about the early years of being in business. Three months prior to suffering a fall, which resulted in a hip fracture, Mrs. P had a sudden weight loss. Mr. C took Mrs. P to see her primary care provider who was concerned about the weight loss but upon completing labs did not subject Mrs. P to further diagnostics. As the weeks progressed, Mrs. P was taken back to see her primary care provider and even made one trip to the Emergency Room complaining of not feeling well yet unable to articulate a chief complaint. Approximately 6 weeks later Mr. C found Mrs. P on the kitchen floor, a bit clouded, and an ambulance was called.
When Mrs. P arrived at the hospital, accompanied by Mr. C, she was evaluated and a hip fracture was confirmed. Mr. C, in his role as health care agent, began to question the plan of care for Mrs. P. He understood that hip fractures increase exponentially with age and that people 85 and older are 10 to 15 times more likely to sustain hip fractures than are those age 60 to 65; and that one out of five hip fracture patients dies within a year of their injury. With this in mind, it was reassuring to Mr. C when the ER physician said that a meeting would take place to discuss next steps. Imagine then Mr. C’s surprise when he returned hours later to learn that Mrs. P was taken to the Operating Room (“OR”). She is in the OR the nurse explained when he asked for her whereabouts. Why wasn’t I called? Who consented her for surgery, he asked? He nurse replied, “I don’t have the chart it is with the patient.” Mr. C became angry that he wasn’t notified given that he is health care agent and sole family member. In the midst of this, he began to anticipate the outcome of the surgery and the overall impact of the fall, as well as what it meant to be asked to watch.
After a three (3) day admission, Mrs. P was discharged to a nursing home for rehabilitation. She was alert and orientated and upon admission signed a DNR order and Medical Orders for Life-Sustaining Treatment (MOLST) form. One week post admission she developed pneumonia as confirmed by chest x-ray and it also found a “dark area” in the lung. The chest x-ray was repeated 7 days later and because Mrs. P wasn’t eating, Mr. C was being asked to consent to a PEG-tube. When Mr. C questioned the PEG-tube, and whether it was life-sustaining treatment, coupled with the fact that the status of the ‘dark area’ was unknown, he requested a team meeting.
At the team meeting Mr. C expressed concerns about the plan to insert a PEG without knowledge of the suspicious area while the team argued in support of the tube. “We must feed her; we have tried everything and she won’t eat.” Mr. C was aware of the eating issue because he too brought in favorite foods and tried to encourage her to eat. Mrs. P was discharged to hospital to further evaluate the suspicious area and to have PEG inserted if indicated. A cat-scan revealed lung and esophageal cancer and metastasis to kidney. Hospice was called immediately for consultation and Mrs. P returned to nursing home for comfort care where she died 3 days later.
As Mr. C worked to honor Mrs. P’s wishes, he continued to ask himself, did I do the right thing? Should I have taken her to the hospital? Should I have left her bedside to allow someone to ask for her consent for surgery? What was the conversation like when the doctor obtained consent for surgery? Was it, “do you want to walk again? If you do, then you must have surgery?” Did she understand that ‘walking again’ and returning to her home was unlikely? How did the hospital miss the ‘dark area’ if in fact a chest x-ray was done before surgery? Why was her health care agent, her next of kin, not notified before the hip repair was done? Did the doctors see Mrs. P as an old lady without family and they could just take her to the OR, knowing the likely outcome, without any consequence? Would they have taken someone of a different ethnic and/or racial background to the OR without family and/or health care agent’s knowledge? These questions became more central as the bills came in. The hip repair, hospital bill alone, was $50,000. Providers, transportation, nursing home rehabilitation center etcetera were all additional costs. Thirty-eight (38) days later, with her new hip, and the trauma of surgery, she passed away. Was the hospital motivated to perform the surgery? Did they stop to think was this the best thing for her or was that only Mr. C’s concern?
Advance care planning today. When we think about health care in America, and the need for advance care planning, studies show that only 20-30% of American’s complete directives and that number is far less for racial and ethnic minorities. Some studies found that African Americans don’t complete advance directives. Here Mrs. P had completed the Durable Power of Attorney for Health Care, a Do Not Resuscitate Order, and the newly adopted Medical Orders for Life-Sustaining Treatment (MOLST). Mrs. P was not interested in having extraordinary measures taken given her age and her view of a good life. The very thing she thought she provided for, and what her late husband sought to establish, was at risk. She did as health care professionals advocate, she made her wishes and preferences known, and shared them with her health care agent. Mr. C struggled as to whether the right decision was being made and knew if he didn’t take a position a PEG-tube would be inserted and it would be far harder to withdraw treatment than never starting it. Mr. C drew comfort in knowing the status of the ‘dark area,’ the cancer, and that it caused the patient to lose weight, have a loss of appetite, and to be unable to eat. The decision to not insert the PEG-tube was clear and comfort measures would be the final treatment.
Having a health care agent who is willing to assume the role is important. Like Mr. C one doesn’t always know just what their role will entail. However, being willing to speak up; to separate ones values as agent from those of the patient; knows the patient well and know what is important to them; and you are someone that they trust are all necessary if you are asked. Honoring the request when the time comes, albeit years later, is a gift and may you, if asked, pass this gift along. I/we did!
Gloria Ramsey, JD, RN, FAAN
Graduate School of Nursing
Director, Community Research Engagement
Center for Health Disparities
Uniformed Services University of the Health Sciences