2017 Thoughts for the New Year

I did not see the ball drop over Times Square at the stroke of midnight. I was visiting friends next door and they were on a media blackout… so tired of bad news…wars in foreign lands…terrorist attacks…contested election results…international relationships showing signs of wear… fear about our preexisting medical conditions, ect. So we drank an Irish whiskey called “Writer’s Tears” and ate way too much dark chocolate. By 1210 a.m. on January 1, 2017, I was home watching television and revisiting the dropping of the ball over Times Square.

Why? Well I could say because the primary alkaloid in dark chocolate is theobromine with an average biological half-life of 7.1 hours. But more than that…much more than that …was a driving need to look optimistically toward the New Year. No New Year resolutions…just a recommitment to my life spent as a nurse, to know and tell the truth, to advocate for those who do not have the power to advocate for themselves. On December 7, 2016, the Gallup Poll released its annual ranking of professionals on honesty and ethics. Healthcare professionals and police officers filled the top spots. Once again nurses ranked #1. This tells me that the public needs to feel safe in times of great risk around the world. Sadly, the lowest ranked profession was U.S. congress member.

http://www.gallup.com/poll/1654/Honesty-Ethics-Professions.aspx

Healthcare providers are the gatekeepers and the safe-keepers and need to hold that responsibility as a foundational duty. Health policy makers in the U. S. Congress need the guidance and wisdom of those who actually must delivery health care. As 20 million more Americans have health insurance under the ACA then prior to ACA, the world in 2017 may become even riskier without wise decision-making regarding access to healthcare. Activism and compromise are needed if we are to maintain the public trust.

We at Pacific Perinatal Group pledge to serve our perinatal colleagues in their efforts to improve maternal, fetal, and neonatal health outcomes. As a Benefits Company in 2017, we re-dedicate ourselves to the emotional, professional, and spiritual resuscitation of perinatal healthcare providers everywhere. Let’s look for safety in each other’s hands.

Happy New Year! … From the Partners and Staff at PPG.

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Let's Dream, Support and Do Things

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 I always wonder why I get inspired at the most inconvenient times.....like 11:30 pm the night before my 12 hour shift at the hospital.  I saw this quote and it completely resonated with me.  People ask me all the time about PPG, what we are about, what we are doing and where we are headed.  This quote summarizes our PPG  philosophy and how we want to motivate others. Let me explain....

A few years back, I began contemplating my career and what I wanted to be when I grow up and honestly was feeling a bit uninspired in my career.  During this time, I was given an amazing opportunity to partner with three other women and form a new kind of nursing business that ultimately became known as Pacific Perinatal Group (PPG).

We wanted to develop a nursing education and consultation business that was different than anything we’d ever seen. We wanted to “do things.” We were tired of the status quo of educational conferences in run down locations, covering watered down topics and leaving nurses feelings scared and uncertain about their practice.  We dreamed and envisioned a company that would invigorate nurses again and bring them back to the passion they have for their calling.  We envisioned bringing cutting edge topics that would challenge our way of thinking and would change our practice.  We imagined a myriad of specialties coming together to conferences to enhance rich discussion and collaboration. And…we wanted to be supportive to all of our colleagues. Not judgement or exclusivity but appreciating each for their individuality and contributions. 

Right before our eyes, these dreams and visions are becoming reality.  PPG IS about support, inspiration, inclusiveness, education, excellence….and Passion.  In today's high tech, high-risk, demanding, draining perinatal world, this is such a need. 

Perinatal friends...would love to hear your thoughts. Have you attended one of our events? How we can support you better?  With much admiration~Darla

Patient Safety, Perception of Risk and Healing Presence

You cannot open a medical or nursing journal, go to a staff meeting, or attend a professional conference without hearing about patient safety and the many strategies designed to improve outcomes and decrease liability. Patient safety and associated legal risks will be among the threads discussed during PPG’s Spring 2017 Conference (Save the Date - April 21, 2017), as we look at the impact of perinatal healthcare changes over the past decade.

Patient safety and the “Culture of Safety” have driven organizational focus since the Institute of Medicine (IOM) released the groundbreaking report: To Err is Human in (1999).  Why? Because the report brought a shocking realization that we were perhaps seeing just the tip of the iceberg of preventable patient injury and death while in modern complex healthcare delivery systems. The World Health Organization and other national healthcare systems around the world were identifying similar errors. To Err is Human took great care to explain that flaws in the system of healthcare were to blame for many of the poor outcomes. Intensive effort has been expended by patient safety experts (Leappe, 2015). Still, it was just last month that the professional literature was full of critiques of a report in the British Medical Journal (BMJ). The study arguably found medical error to be the third most frequent cause of death in US hospitals (Makary & Daniel, 2016) and we are reminded that there is much work to be done in healthcare delivery.

Attention to risk reduction and promotion of optimal outcomes is very important. We support evidence-based practice because it gives power to changing practices that are not in the best interest of the patient, like excessive oxytocin use. But, ask yourself what motivates you as a perinatal care provider? What led to your entry into practice? Was it patient safety? There are of course many reasons, but a common denominator appears to be the desire to help people. There is usually a measurable degree of this, and to birth babies, and teach new parents to care for their babies, and importantly to decrease suffering. But few of us get up in to morning and say, “Today I am going to keep my patients free from harm.” However, if we manage to not harm our patients – are we fulfilling our duty to them? I would argue that patient safety is merely the bear-bones bottom line of clinical practice - a stripped down version of what healing is all about. Revisit the Hippocratic Oath (“first, do no harm”), the Nightingale Pledge (I will do all in my power to maintain and elevate the standard of my profession”), or the ANA Code of Ethics and you will find a multitude of duties for which we are responsible. It is a lot to do, truncating time for important provider-patient relationships, and sabotaging a sense of satisfaction with our chosen profession. Let me explain….

In facing the risk of medical error, we begin to lose confidence in our ability to independently protect the patient from falling through one of the many cracks in a complex healthcare delivery system.  Anxiety – when trying to stay on top of patient’s needs on a busy day, or when working with an exhausted team, or the challenges of managing mothers with co-morbidities, or just getting charting done – anxiety is understandable. There is a growing body of knowledge that recognizes hypervigilance and anxiety as a symptom of trauma. According to Wikipedia (2016): 

Hypervigilance is an enhanced state of sensory sensitivity accompanied by an exaggerated intensity of behaviors whose purpose is to detect threats. Hypervigilance is also accompanied by a state of increased anxiety, which can cause exhaustion…. In hypervigilance, there is a perpetual scanning of the environment to search for sights, sounds, people, behaviors, smells, or anything else that is reminiscent of threat or trauma.” 

 Does any of this sound familiar?

 I recently received an email from an old colleague who I had not heard from in a long time. She told me that she had not worked for several years and was being treated for PTSD. Apparently, somewhere in her 40-year career in nursing between Vietnam and working with an especially difficult team member, anxiety got the best of her and she had to take a break. Now, I am not suggesting that perinatal providers are all suffering from PTSD. But many of us do feel anxiety when we cannot be in two places at one time, like when technology is increasing risk to our patients and we must closely monitor it, instead of interacting meaningfully with the patient. We feel anxiety when our ability to sit down and really know the patient is replaced by the demands to be doing something else. Carper (1978) wrote about ‘the therapeutic use of self, which has been defined as the ability of a caregiver to use his or her personality "consciously and in full awareness in an attempt to establish relatedness and to structure nursing interventions" (NursingPlanet.com). Constant “scanning of the environment” as noted above for threat to patient safety, if not hypervigilance, certainly distracts the provider from connecting at that level with the patient.  If over time we do not have signs and symptoms of PTSD, we certainly know exhaustion and perhaps waning job satisfaction.

Eric Cassell MD, in his 1991 classic, The Nature of Suffering and the Goals of Medicine stressed the importance of knowing the person, as well as the science of that patient’s disease or condition. The more a physician (or healthcare provider) knows his or her patient as a person, the greater the effectiveness of the relationship. This he stated is the basis of the doctor-patient relationship, in effect a collective collaborative relationship necessary for healing to occur. He cautions against patient stereotyping as this makes that patient two-dimensional and fails to recognize the evolving continuum of that patient’s experience.

So what is the solution to this modern day situation? There are strategies. A potentially under-appreciated strategy in healthcare systems for promotion of patient safety is to promote provider-patient relationships as primary, much the way we honor the chaplain-patient visit. One very low-tech strategy is to sit down for five minutes and meet the patient, the family, and the significant others. To maximize the therapeutic use of self, the healthcare provider must be quick to relate and prioritize the primary relationship of provider and patient, while providing care that also focuses on protection from harm. I believe that entering into a therapeutic relationship with the patient who may be for at least the time being, frustrated, angry, frightened, painful, or suffering is engaging and very challenging. But, seeing the stabilizing effect of therapeutic use of self is the reward of being a healthcare provider. Assisting with the passage of a new life into the world is of course the ultimate reward….  And as is human nature, we are more protective of those with whom we have relationships.

Meaningful healing relationships heal providers as well. Healthcare providers, while carrying a mega-dose of altruism, also need to be fed with the belief and understanding that we do good work – that we are in fact good people. It is a two-way interaction greater than the sum of its parts. We can then get up in the morning and say, “Today I am going to connect with the person who is my patient, even if just for the moment. And if necessary, I will protect her and baby too”. Our work has never been more important.

References

Carper, B (1978). The fundamental patterns of knowing in nursing. Advances in Nursing Science, 1. 1, 113-117.

Cassell, E. (1991). The Nature of Suffering and the Goals of Medicine. New York, NY: Oxford University Press.

Institute of Medicine (1999). To Error is Human: Building a Safer Health System. Washington, DC: National Academy Press.

Leappe, L. (2015). Patient safety in an era of healthcare reform. Symposium: Patient Safety: Collaboration, Communication, and Physician Leadership, 473:5, 1568-1573.

Makary, M & Daniel, M (2016). Medical error—the third leading cause of death in the US. BMJ, 353, i2139.

Wikipedia (2016).  Hypervigilance. Downloaded from https://en.wikipedia.org/wiki/Hypervigilance on July 29, 2016.

    

 

Microbiome Revisited

We are 3 months out from our Spring Conference and I’m still riding the wave! Every speaker and topic ignited my imagination and drive to delve further.  Take Dr. Steve Frese’s presentation on the infant microbiome.  As I listened to him speak, my mind went back to my college days. Microbiology with Dr. Alexander. On the last day of class we were discussing the famous quote “the microbes will have the last word” attributed to Louis Pasteur.  Of course, Pasteur was French so it was probably more like “les microbes aront le dernier mot”.  At the time, I was a Biology major trying to decide between nursing and medicine, so my paradigm was framed by a “bacteria equals disease” mentality.  This quote was chilling to me.  I saw bacteria as the enemy.

Medical science has been in a 100-year war against bacteria. Always present in the news are reports of antibiotic resistant “super-bugs” and stories of how modern medicine has run out of novel antibiotics.  Truly, it seems like we are on the cusp and microbes are about to get the last word.  But emerging science is now telling us that we had it all wrong.  In eradicating as many bacteria as we could, it seems that instead of keeping ourselves healthy, we have attacked one of humans most important allies.  You know all those times we look back at some crazy thing that we used to do a hundred years ago and think “how could they have been so stupid?”…well, um, hehe, yeah…..

If you missed the conference, or just want a refresher on what the microbiome is, the following video from NPR is a good place to start. The animation, clearly, is fictional, but gets the point across.

Here is another video of Dr. Robynne Chutkan, which describes the research surrounding diet and the effect on the microbiome

For the super nerds out there, a great book called “I Contain Multitudes” by Ed Yong will be available August 18, 2016.  It’s available for pre-order on Amazon.

The Amazing Role of Being a Labor Nurse

February is the month that we all think about love and life, of hearts and relationships….but do you ever really think about what we do for a living?  I am amazed at what we are gifted to be a part of, the difference we can and do make in someone’s life forever.  As nurses we bring that feeling of February to everything we do—at work, at home, at school—it’s who we are! 

This plaque is on the wall in my boss’s office, the author is unknown, but he/she had a good handle on what we really do as labor nurses—as nurses in any field.

I Am Your Labor Nurse…

While everyone else in this hospital strives to make their patients feel better, I will work my butt off to put you into more pain.  I can give you enough pain meds to knock down an NFL lineman, but first I will stick you with a crazy huge IV needle, because 22’s are for wussies!!

I will let you hold my hand, I will tell you to keep calm and BREATH, and I will poke your child in the head several times before you ever get to touch him yourself.

I will see you at your most vulnerable and your most exposed, and I will also help you to be your most strong, courageous, and amazing.

I will tell you that you can do things that you, yourself, don’t believe you are capable of….but you will find I am right.

I will help you through this.  I will end up with a twisted back, tired feet, and fluids on my scrubs—and I won’t even notice because it’s all part of the privilege of helping you bring a life into this world.

I am your labor nurse, and this is the grossest, most amazing, most terrifying, most gratifying job in the world.  Please don’t punch me…that’s what your husband it for.

Again, I do not know who the author is (does anyone else?—would LOVE to know), but they did a beautiful job at depicting our work world—the craziness, the beauty, the honesty, and the humor of it all!!  Thank-you whoever you are!!

Enjoy who you are and what you bring into others’ lives—you are loved and very appreciated!!  

 

 

Trust is a Loaded Word

Trust is a word that circulates a lot in the nursing profession.  We want patients to trust us, nurses want to trust the nurses and doctors who are on shift with us, and we all want to have trust in the system in which we give and receive care.  Trust is a loaded word.  Do we know what it means? Are we using it accurately?  For the uninitiated, Brene Brown is a qualitative researcher and professor at the University of Houston Graduate School of Social Work and an incredibly prolific writer and speaker on the concepts of vulnerability, shame, trust…you know, the BIG stuff.

As you watch, its easy to apply to our friendships or our marriages or other important relationships, but I think the anatomy of trust and the individual components of trust can be uniquely applied to how we interact with one another and with our patients. 

 Here’s a link to a talk she gave on trust at UC Berkeley:

A New Year's Resolution

As I gave thanks to some dental work for interrupting my holiday food binging, I reflected on the abundance I experience. As a nurse making a fair living, I cannot remember the last time I was hungry. But that is not the case for many in our country and around the world. A pause was needed to consider first, had I shared enough, and secondly, prospectively what impact does hunger and inadequate nutrition have on our pregnant patients, the fetus, the neonate, the family.  A cursory Google search quickly produced something that I had learned many years ago in graduate school (but had forgotten) about the Dutch Hunger Winter.

The “Dutch Hunger Winter” occurred towards the end of WWII in The Netherlands from October 1944 to May 1945, as a result of the German blockade.  Food stocks in the cities in the western Netherlands rapidly ran out. The adult rations in cities such as Amsterdam dropped to below 1000 kilocalories a day by the end of November 1944 and to 580 kilocalories in the west by the end of February 1945. Starvation occurred and in those women carrying pregnancies, there was a high incidence of pregnancy lost, preterm labor, and small for gestation age birth weight. The Dutch Famine Birth Cohort Study (Stein, et al.1975) found that the children of the women who were pregnant during the famine were smaller, as could be expected. However, surprisingly, when these children grew up and had children, those children were also smaller than average. These data suggested that the famine experienced by the mothers caused some kind of epigenetic changes that were passed on to the next generation.

Findings from ongoing follow-up research on these starvation pregnancies (two generations out) show associated diabetes, heart disease, obesity, and schizophrenia in those offspring AND their offspring (Haij, 2014). Epigenetics has been defined as the study of the mechanisms controlling gene activity during development of “complex organisms" (Holiday, 1990). An area of research called developmental origins of health and disease (DOHAD) has been exploring for some time possible epigenetic changes related to the fetal intrauterine environment.

So where does all this leave us?  Well, we know that famine is bad for anyone. But we do not understand how obesity in subsequent generations is genetically hard-wired. We do not fully understand the impact of micronutrient deficiency on fetal genetics.  What is clear is that nutrition in pregnancy may be one of if not the most fundamental components of prenatal care.

Pacific Perinatal Group will explore this topic further at our spring 2016 conference: Mamatoto: Integrating Maternal, Fetal, & Neonatal Care. For further information go to: http://www.pacificperinatalgroup.com/events/spring16. As we ready ourselves for another year of caring for childbearing women and their babies, it is helpful to consider this early 18th century proverbial saying: “As the twig is bent, so is the tree inclined.”  Early influences can have a permanent effect.

My New Year resolution is this: to do what I can to protect, nourish, nurture, and educate childbearing women as our best hope for future population health. Happy New Year from Pacific Perinatal Group!

References

Hajj, N, Schneider, E, Lehnen, H., & Haaf, T. (2014). Epigenetics and long term consequences. Reproduction, 14 pp. 111–R120

Holliday, R. (1990). DNA Methylation and Epigenetic Inheritance. Philosophical Transactions of the Royal Society of London. Series B,  Biological Sciences. 326 (1235), pp. 329–338.

Stein, Z., Susser M., & Saenger, G, et al. (1975). Famine and Human Development: The Dutch Hunger Winter of 1944–1945. New York: Oxford University Press.

 

Mamatoto-In Memorium

MAMATOTO  

In Memorium

I have been working on the March Blog this week, inspired by newborn lambs frolicking in the greening pastures of Oregon’s many rich fields and agricultural valleys. This is an ancient and recurring rebirth that we witness every spring, filling us with the hope of survival. Our spirits are lifted. We make plans for the future. We trust that rebirth will happen again and again, as it has for all time. The pattern of renewal can be counted on.

While pondering springtime and rebirth, the sad news came to us at PPG that our beloved friend and partner Darla had suddenly and unexpectedly lost her mother. I was painfully reminded that the wonder of life comes and goes on the terms of a higher power. We are honored as healthcare providers, sons and daughters, husbands and wives, friends and neighbors to witness the miracle of life as it slips through the veil into this world and out again.

Mothers are amazing. They give birth to us. In Spanish giving birth is expressed as “dar la luz” or to give light. If we are lucky they stay to feed us, protect us, grow us, give us our culture and faith. If we are fortunate, as we become adults, mothers befriend us. And just when we are ready to give back to them because we are strong and can, they leave us with a legacy to remember. We are all on some level (even if DNA is the only evidence) – we are all our mother’s child and always will be.

Perinatal providers have the privilege of ushering new lives into this existence - often several times a day. We place the newborn skin-to-skin with Mom and watch the bond of a lifetime become irreversibly complete. Mamatoto, a Swahili word meaning mother baby, reminds us of this oneness. There is nothing like baby lambs in springtime to remind us that we can trust in birth as part of an eternal cycle. We are all part of the miracle. We are humbled to witness life’s renewal.

In memory of Darla’s Mom

Oxytocin-The Love Hormone

Because many of us celebrate St. Valentine’s Day on February 14th, we thought how better to celebrate than to talk about “Oxytocin - the Love Hormone”. Now like all great loves, we know that it can be a love-hate relationship. As Perinatal Nurses know all too well, nurses who carefully titrate this drug in labor (and often go to the mat to protect laboring women from overuse of oxytocin), the love hormone can be too much of a good thing in the wrong hands.

Kerstin Uvnas Mobergin in her book “ Oxytocin, the Love Hormone” discusses how oxytocin helps mothers bond with babies, and sometimes with the adults in their lives. Oxytocin’s impact on successful breastfeeding is also well known. Nutritional supplement and pharmaceutical companies have bottled this elusive hormone for home use as a nasal spray in what some believe to be the answer to stimulating human attachment behavior.

So as we celebrate February 14th, the day set aside for recognizing those we love, it is important to remember to use the love hormone judiciously when it comes to laboring women. As we become better stewards of patient safety related to oxytocin, remember that childbearing women are hardwired to produce and uptake oxytocin as needed and a little goes a long way. Further, ongoing research about oxytocin suggests that oxytocin may be related to broader emotions and may not be all about love. The following Ted Talk suggests that oxytocin may be important for a multitude of emotions.

Hopefully we can all feel the love. So hug somebody today. It will release oxytocin and make you and yours feel good. Happy St. Valentine’s Day from the partners at PPG to Moms and their loved ones everywhere!

Nurse POWER (pose)

Nurse POWER!

My sister sent me the link to this TED talk just before a job interview. Thank goodness! I arrived with enough time to find a restroom, go into a stall, set the timer on my phone for 2 minutes and pose. Power pose that is. I chose the wonder woman version, because, well, it seemed to fit the occasion. I can truly say I felt comfortable and dynamic.  I knew I had been able to portray the exact image of myself that I had wanted. My best self had come across.

In the video, Amy Cuddy, a social psychologist describes her research on how certain body positions can increase testosterone and decrease cortisol, which allows a person to be more calm. This same combination is found in leaders and more assertive-type people. This made me think about nurses and the nursing profession. How many of us are not able to assert ourselves, be leaders and take a role in the decision-making of our units and organizations because of our perceived lack of power? And although you can’t stop for a power pose break in the middle of, say, a hemorrhage, could a regular practice of this help in those stressful, emergent situations? Let us know what you think in the comments section. Is this silly? Funny? Useful?

Nurses Make a Difference

This video is a beautiful homage to nurses, from the perspective of TV news commenter Lawrence O’Donnell. He left his stay at a New York City hospital with a deep respect and affection for the nurses who cared for him and for the nursing profession. It’s always nice to hear the revelations of non-health care professionals about how nurses care for their patients. Although I was quite surprised that he thought tipping nurses was appropriate and inadvertently compared us to housekeepers at a hotel, I appreciated some of the larger aspects of the nursing life that he was able to touch on. Sometimes, jokingly, I’ll bid my husband farewell in the morning with an “off to save some lives" instead of the usual “off to work." But that is exactly what we do. And most of us don’t think that’s particularly remarkable. But as Lawrence put it, don’t you think that is more newsworthy than what some congressman said? Despite all the bad news we hear and see, I hope we as nurses can remember that a lot more things go right in our country and in our hospitals, every day, and that we get to do work that is meaningful and important. We at Pacific Perinatal Group have a deep, abiding respect for nurses and the nursing profession. Please return back to this blog often, as we try to keep positive, respectful and thought-provoking issues at the forefront for discussion.

Please leave comments below. What did you think of this video? What is the sweetest/funniest way a patient has tries to show appreciation? Any perceptions or misperceptions of nurses that you encounter?