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Jeanette Ives Erickson

We must not compound one tragedy with another...

—by Jeanette Ives Erickson, RN, MS senior vice president for Patient Care and chief nurse

By now, we are all too aware of the horrific events that only last week shook our nation and touched the lives of every American and every thinking, caring individual in the world. This is a profoundly sad time, and I first want to extend my condolences to the many members of the MGH community who lost family members and loved ones in this tragedy. Know that the thoughts and prayers of your colleagues are with you. I hope you will be brave in your grief and come forward to let us help you.

It’s hard to know where to begin, how to recover, how to heal after an event of this magnitude. But heal we must. If we are to move forward from our feelings of loss, and anger, and helplessness, we must do it together. Already, in the aftermath of September 11, 2001, we have witnessed moments of great courage, kindness and sacrifice.

Each of these moments makes us stronger. Each of these moments fills us with pride as strangers reach out to help one another. Each of these moments reminds us that we are all connected.

My message to you today is one of unity. I ask that as we emerge from the shock of these terrible events, we use the tools of understanding we have gained from our work around diversity and culturally competent care to stay focused on our mission as caregivers; to respect the rights, beliefs and differences of all who are in our care and in our midst.

Violence and acts of terrorism are to be condemned. But we cannot compound one tragedy with another by allowing ourselves to stray from our own values. We have worked hard and come far. We must continue to lead by example and proceed with compassion and empathy.

I cannot state this strongly enough: The entire international community is affected by these events. This was not just an attack against America, it was an attack against humanity. Blame cannot be assigned to any country, people or nationality. Blame rests with the individuals who committed these terrorist acts, and we cannot let our sadness or anger cloud our understanding of that.

The best thing we can do now is what we always do—care for each other and our patients.

I remind you that our Chaplaincy (6-2220), the Employee Assistance Program (6-6976), and our department of Social Services (6-2640) are available for support and guidance.

May peace be with you... and with us all.

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Recognition and Excellence

—by Trish Gibbons, RN, associate chief nurse The Center for Clinical & Professional Development

On June 21, 2001, Trish Gibbons, RN, associate chief nurse for The Center for Clinical & Professional Development, presented, "Recognition and Excellence" at the summer 2001 Macaluso Awards ceremony. Excerpts of her presentation appeared in the July 5th issue of Caring Headlines. Below is the expanded version of her talk.

As a new member of the MGH community, I am honored to say a few words at today’s celebration. Soon after I arrived, I heard about the Stephanie Macaluso Award. As I spent time on various clinical units, getting to know staff and learning about the practice at MGH, recipients of this prestigious award were often introduced to me with mention of this honor. During committee meetings people say, "He or She is a Macaluso recipient." It is a way of distinguishing people. It is an honor bestowed. And so perhaps one place to begin is to ask, why are recognition and celebration important to us? Why do so many of us take pride in celebrating the accomplishments of our fellow clinicians?

I believe that when we recognize the best within our professions we make expert care visible. Through the stories of these clinicians we understand the impact of care and caring practices on patients and families.

The actions of expert clinicians remind us that caring requires connection and involvement as well as knowledge and skill. Doctor Patricia Benner, RN, who has written extensively about clinical wisdom, tells us that attentiveness and engagement are hallmarks of good practice.

Psychologist, Carol Gilligan, identifies caring and connectedness as central to a feminist model of ethics. She observes that, "The ideal of care is thus an activity of relationship, of seeing and responding to need, taking care of the world by sustaining the web of connection so that no one is left alone."

As we learn about the work of exceptional clinicians, we appreciate more fully the power of their expert knowledge and clinical wisdom. Benner, when referring to the clinician-patient relationship says, "...this relationship is not a uniform professionalized blueprint, but rather a kaleidoscope of intimacy and distance in some of the most dramatic, poignant and mundane moments of life."

As we see in action the exquisite skill necessary to do this work, we understand that it is complex. Experts might make it seem effortless but as members of the professional community we know better.

And we identify with these clinicians. We understand the power of these relationships; the privilege of sharing in the lives of patients and families; the intimacy that arises from concern and connectedness; the impact of partnering with a patient to assist him in accomplishing a goal.

And so perhaps another question is, what do the voices of our patients tell us about our care? Are there lessons in their stories to further add to this conversation?

One woman writes on behalf of her husband, "You always made him feel like he was your most important patient. As I watched you care for other patients, I could see that this was the attitude toward each. You made our families’ difficulties much easier to cope with while trying to give the impression that you weren’t doing anything special. Thank-you."

A daughter writes of her mother’s care, "An endless number of health professionals cared for my mother over the past four months. I can’t tell you how comforting and vital it is to have the staff respect the family.

Thank-you for caring for my mother and for caring about her family."

And finally a wife writes, "When someone you love is ill and in the hospital, you always worry that no one can care for them or know their needs quite the same way you do. When I experienced the way you cared for my husband my fears left me. I think you treated him as you would your own family member. I will always be grateful."

Making a difference in the lives of individuals and families is fundamentally our common bond as healthcare professionals. The Stephanie Macaluso Award is given to direct care providers whose practice is caring, innovative, guided by knowledge, built on a spirit of inquiry, and based on a foundation of leadership and entrepreneurial teamwork.

So perhaps we have an answer to why recognition and celebration are important to us.

When we recognize the "best in our professions," we make the work visible for all to see. We celebrate the practice of clinical experts because it is scholarly and wise. They are the ones whom Benner calls "authoritative knowledge workers," and we respect them for what they have achieved. They are the role models. They embody the gold standard, the ‘good’ inherent in what we do. Their practice represents what we try to achieve every day in our own work.

And so when we honor these caregivers, we celebrate the gift of clinical practice. We re-affirm our deepest values and our own commitment to excellence. We share in the excitement because we, too, are dedicated to making a difference every day.

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Fielding the issues

Parking, parking, parking

The Fielding the Issues section of Caring Headlines is an adjunct to Jeanette Ives Erickson’s regular column. This section gives the senior vice president for Patient Care a forum in which to address current issues, questions, or concerns presented by staff at various meetings and venues throughout the hospital.

Question: There is already a shortage of parking, and I just heard that the Nashua Street Brown lot is closing. Is this true, and if so, where are we going to park?

Jeanette: Parking at MGH is a resource that is in increasingly short supply. Over the past several years the Big Dig has taken hundreds of MGH spaces while the demand for parking for patients, visitors and staff has increased. Unfortunately, we have been informed that the Nashua Street Brown lot and the adjacent Red lot are closing. They will be converted into a waterfront park as part of the central artery project.

The Brown lot has been the primary parking location for evening staff. Parking and Commuter Services is working to develop a creative solution to address the loss of these parking spaces. The approach we use to re-allocate the remaining Nashua Street Orange lot spaces will proceed with an emphasis on employee safety. The plan is to use these spaces for evening staff and voluntarily move day-shift Nashua Street parkers to the Fleet Center. A new card system is being installed in the Orange lot, which will allow Fleet Center parkers to park in the Orange lot on days they are unable to exit the Fleet Center by 6:00pm. We have also contracted a number of spaces in the Lomasney Garage. More details on this option will be available in the next few weeks.

Question: If I work the night shift and am asked to fill in some time during the day, where would I park if I don’t have a weekday parking permit?

Jeanette: I appreciate your willingness to be available to support patient care beyond your regular work schedule. The Staff Nurse Advisory Committee has also raised this question, and we are working with Parking and Commuter Services to address the issue. A new program is being implemented to provide parking to staff who’ve been asked to work a shift that is not supported by their existing parking arrangement. The plan is to utilize the Fleet Center Garage on weekdays and the front MGH garages for nights and weekends. This program is expected to be rolled out this fall; more details to follow.

Question: Earlier this summer I had difficulty finding a parking space in the front garages because spaces were filled with people going to the Hatch Shell. Shouldn’t staff parking be a priority?Jeanette: Our garages and parking lots are intended for use by patients, visitors, and staff. But during the weekend of July 14th, a combination of ongoing construction in the front garages and a large number of cars using our parking facilities to attend a concert at the Hatch Shell created an unusual shortfall of parking spaces. As a result, Parking and Commuter Services has revised its procedure to close the garages to the public earlier on days when there are nearby events. When the Parking office is experiencing high weekend volume, the Parkman Street Garage will close to the public and the upper levels will be reserved for employees. Please remember to go to the upper levels of the garages if the lower levels are full.

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The Cancer Center

Fun, supportive and educational materials help make ‘Family Connections’

Thanks to the generosity of the Friends of the MGH Cancer Center, a Magic 106 fund-raiser, and other supporters both within and outside of MGH, the MGH Cancer Center will be able to dole out backpackfuls of materials to parents facing a cancer diagnosis and their children.

With the creation of a new program called, "Family Connections," the Center is embarking on an initiative to provide meaningful, age-specific information and activities to every member of the family when a parent is diagnosed with cancer. Backpacks, or tote bags, depending on the age group, are filled with age-appropriate educational pamphlets, expressive outlets (such as coloring books or journals), a stuffed animal or cuddly toy for emotional comfort, a pocket-sized photo album, and an array of toys, games or activities that can be used alone or with others, at home or in the hospital.

The goal of the program is to create an open and supportive atmosphere while providing important information and resources to families.

Says oncology social worker, Kathy Clair-Hayes, LICSW, who spearheaded the project, "The number one question I hear in my work with patients is, ‘How do I talk to my children about cancer?’ What I tell them is what I’ve learned from other families who’ve gone through similar experiences. In that way, it really is families helping families. And hopefully, this program will help patients open up to us even more, tell us what they need, so we’re better able to support them."

Clair-Hayes reports great enthusiasm and collaboration among those who worked on the project. Social workers, nurses, child life specialists, child psychologists, and others all had ideas about what should be included in the bags.

Says Clair-Hayes, "I was thrilled that so many people got involved. And it’s been very rewarding hearing the feedback from clinicians who’ve seen the bags. They’ve all commented on how meaningful the contents are, what a great resource they’ll be for our patients and families."

Parent packs will be available to MGH Cancer Center patients who are parents of children 18 years old or younger. Kids’ packs will be available by age group: 13–18 years old; 7–12 years old; pre-school and kindergarteners (3–6 years old); and toddlers and infants (under 3 years old). Parents are encouraged to preview the contents of the bags to ensure they’re appropriate for their children.

A ‘Family Connections’ newsletter is included in each bag, again tailored to the age of the family member who will receive it. The newsletter offers information about hospital and community resources, advice on how to talk to children about a parent’s cancer diagnosis, ideas for fun things to do in Boston, and much more.

The Family Connections Backpack Program is scheduled to begin October 1, 2001. For more information, contact the Cancer Resource Room at 4-1822.

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Recognition

Korpi receives NICU’s Ben Corrao Clanon Award

It doesn’t get any less poignant as the years go by. The memory of Ben Corrao Clanon and his all-too-short stay in the NICU are recalled each year as Ben’s parent’s, Regina Corrao and Jeff Clanon, return to MGH to present the annual award they established in his name. This year, on Tuesday, August 28, 2001, the honor went to NICU night nurse, Kerstin Korpi, RN.

Nurse manager, Margaret Settle, RN, introduced Korpi at the small ceremony and reception in the NICU conference room. Said Settle, "Selecting a candidate was very challenging this year; we really wanted our choice to reflect the excellence in primary-care nursing that the Corrao Clanons have nurtured and encouraged over the years. We were thrilled to nominate Kerstin as she continues to embrace the many changes and advances that impact our practice. She provides care in a way that truly empowers families. With Kerstin as a permanent night nurse, we know the exceptional care delivered in the NICU every day, is going to be the standard throughout the night as well."

Interim associate chief nurse for Women and Children’s Services, Judy Newell, RN, observed, "It’s because of nurses like Kerstin that I sleep better at night—knowing that level of expertise, compassion and skill is right there. I’d like to thank Jeff and Regina for their continuing support of primary nursing in the NICU over the years. You are helping to make a difference. Thank-you."

An emotional Corrao presented the award to Korpi, saying, "When you leave a hospital with memories instead of your baby, those memories become all the more cherished. And that’s what I have, wonderful memories of all the gestures, all the little things Ben’s nurses did that made his life here so special. It’s those memories that are a comfort still today."

Ben would be 15 years old this year.

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Exemplar

New nurse experiences dynamic nature of nursing

My name is Erin Sullivan and when I wrote this narrative, I was a new nurse on Ellison 18, the adolescent pediatric inpatient unit. This is my first job since graduating last May. Not knowing what to expect, I spent the better part of the summer completely overwhelmed, totally exhausted, and frequently asking myself how I would survive the next day. But I have definitely learned a lot about nursing. Emotionally, the job brings me to the highest highs and the lowest lows. I find that I laugh and cry a lot more now. Despite seeing so many incredibly sad situations and painful moments, I’ve learned how important laughter and happiness are in life. I have learned to take the smallest improvement, the smallest step forward, and make them into happy moments. Even the saddest situations, such as the impending death of a young child, can in some way bring peace to a distraught family. Even in my very brief nursing career, there are moments when I feel overwhelmed by the power of nursing. Listening to patients and their families, and being with them during acute and stressful times, you can’t help but feel the power of nursing "presence."

I distinctly recall my fist shift alone—it was a 12- hour night shift, and I was very tired and very scared. After report, I started checking on my patients and I reached into my back pocket. That’s where I kept my "good luck charm," a Celtic cross I’d had for many years. After my first shift on Ellison 18, I knew I needed something to help me along, and this little keepsake had been with me for many milestones and big events in my life from the nursing licensing exam to the Boston Marathon!

One of my patients that night was Steven, a 16-year-old, who was well known on the unit. He had been diagnosed with multiple meningiomas that were first discovered when he was five years old. Steven was a very medically complex patient, and I was slightly hesitant to take care of him. As I checked his IVs, tubes, and took his vital signs, I think his mom could sense that I was ill at ease. She immediately started cracking jokes, and she wanted to know all about me. The whole time we were talking, country music was blaring; it was Steven’s favorite. Steven was non-verbal, and it was often difficult to understand his needs, but he did love his country music. Steven’s mom told me a lot about her son, and I spent the better part of that night just listening. When the night passed and the sun rose, everything had gone rather smoothly. On my way out the door that morning, I reached into my back pocket again and felt for the cross. It was there, and I was so happy I’d made it through my first shift as an RN. There was hope for me after all.

Over the next several weeks, I took care of Steven many times. I got to know him and his family quite well. By now they had spent the better part of their summer in the hospital, and the future remained uncertain. I know it was difficult to see Steven so completely dependent as they spent every day and night at his bedside. The hardest part was the uncertainty, not knowing what the future would bring. I recall one day going in to see Steven and a very sad country song was playing. Steven’s mom was singing it to him, and she was crying. It was a very sad moment, and I really didn’t know what to say. I could tell she was at the end of her rope, frustrated by the lack of progress over the past several weeks.

Later in the day, Steven’s mom brought out some old family photos and shared them with me. As the end of my shift was nearing, I learned that plans were being made to transfer Steven to a rehab hospital. I knew this would be a very difficult transition for this family to make. The road ahead would be long and uncertain for Steven. After a while, a thought crossed my mind. I reached into my back pocket and found the cross. It was there as it had been every day for the last four months. I thought for a moment about how far I had come in those four short months, what an immense transition I had undergone.

I walked into Steven’s room and gave the cross to Steven’s mom. I told her about how it had been my "good luck charm" and how it had helped me through some difficult times over the years. While it was hard to part with such a meaningful keepsake, I knew this family needed it more that I did. I told her the cross represented hope; hope for a new and better tomorrow. I shared how it had given me hope since starting as a new nurse. No matter how bad the day was, no matter how overwhelmed or distraught I felt, it was always there to remind me that I would get through it somehow. I wanted her to have the cross to "watch over" Steven in his upcoming journey. She was surprised and happy when I gave it to her. She didn’t know what to say. I think it was one of those moments when there really is nothing that can be said. But I knew that moment represented a turning point for me as a nurse. It was one of the most memorable moments in my short nursing career.

Steven’s mom put the cross on the bulletin board surrounded by pictures of family members and country singers. She told me she’d keep it with him forever, and it stayed tacked to the bulletin board until Steven left for the rehab facility weeks later.

Seeing that cross on the board made me feel like I had made a difference. Before leaving, Steven’s mom met me in the hall. After spending months in the hospital with her son, it was difficult for her to find some sort of closure. She told me she had something to give me. I followed her into the room and she gave me a beautiful gold bracelet with the Irish Claddaugh on it. It was her gift back to me, she said, for the care I had given Steven over the past several months. As she put it on my wrist, I felt honored to have become so close to this family at such a difficult time in their lives.

I wear the bracelet all the time, and it will always remind me of Steven, and of my own personal nursing journey. It also reminds me to maintain hope, even when faced with difficult challenges and setbacks. The thing that amazes me most about these special nursing moments is that even as they occur, the chaos all around you goes on—the alarms, the phone calls and pagers—and time itself goes on. Often after a long night shift I’ll walk outside squinting in the bright sunlight; feel the cold air on my face, and marvel at the dynamic and powerful nature of nursing.

Comments by Jeanette Ives Erickson, RN, MS, senior vice president for Patient Care and chief nurse

Those who have never shouldered the responsibility may underestimate the courage it takes for a new nurse to walk into a patient’s room and say, "Hi, I’m going to be taking care of you today." I think when Erin met Steven and his mom, she saw some of that courage in them, and it drew her to them. Erin may think that her treasured gold cross was her only gift to them, but I think it was her skill, her presence, and her compassion that they will long remember.

Erin may be a new nurse, but if this narrative is any indication, she’s going to be a good one! Thank-you, Erin.

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Clinical Nurse Specialist

As patient needs expand, so does the role of the CNS

My name is Mimi O’Donnell and I am one of the clinical nurse specialists for Cardiac Surgery. As a CNS, I have many roles and responsibilities, such as patient educator, ventricular assist device nursing coordinator, Valve and Coronary Artery Bypass Graft (CABG) pathway manager, and liaison between the cardiac surgeons and referring doctors in the community (to name just a few).

Being the ventricular assist coordinator is a new role for me. We have had patients on ventricular assist devices (VADs) for several years, but this past November was the first time we discharged a patient with an assist device in place. This turned out to be one of the most challenging as well as satisfying experiences of my professional career.

There are several types of ventricular assist devices used at MGH, however the device I will be talking about in this article is the Heartmate Vented Electric Left Ventricular Assist System. This system can be run on batteries as well as an electrical power source. Patients use batteries during the day, allowing them to be more functionally independent. At night they use the electrical power source, which also recharges the batteries.

Mr. S is a 65-year-old man with a past medical history of coronary artery disease, several MIs, coronary artery bypass grafting, and placement of an automatic internal cardioverter defibrillator (AICD). In early August, 2000, he presented with worsening heart failure, renal failure and some liver failure despite maximal medical therapy. Mr. S had a Heartmate Vented Electric Left Ventricular Assist device inserted. From a medical standpoint, Mr. S made good progress following his surgery, but from a nursing standpoint he presented many challenges. Our goal was to prepare Mr. S and his family in an efficient, timely and organized manner for discharge home. This turned out to be more challenging than anticipated. Mr. S was an extremely bright man who, prior to his illness, had run several companies. Unfortunately, he experienced some cognitive loss secondary to his (pre-device) low cardiac output. This made it difficult for Mr. S to focus as staff and I attempted to teach him about the device. A second factor that slowed our progress was that Mr. S was an engineer, and he was more focused on designing a better device than learning about the one he had. But his family was a big help; they were there every step of the way, encouraging him when he became frustrated and reinforcing the information and techniques we were teaching him.

Before we could discharge Mr. S home he and his family needed to be able to:

• describe the system components
• explain how the system worked
• demonstrate how to operate the system
• identify an emergency situation and what his response would be

Working with his primary nurses, his associate nurses, and occupational and physical therapists, we came up with several teaching plans. Our first priority was to make Mr. S comfortable with the device, so we reviewed the components of the system every day. Once he was comfortable with that, we moved on to an explanation of how the system worked. Then we moved on to making and breaking connections, going from electrical power to batteries, and from batteries back to the electrical power unit. At this point, it became apparent that we needed to slow down and revise our teaching plan. We could only cover one concept at a time, and we needed to have a uniformed approach. I became Mr. S’s primary teacher, working closely with his primary nurses to ensure that we were all on the same page and that we were uniformly demonstrating techniques.

While I and his primary nurses worked out a system, the occupational therapist wrote up detailed step-by-step instructions for Mr. S to follow. We had him read the instructions and then perform the function. When his family was present, we had him go over the instructions with them to help reinforce the information. Each day we had him read the instructions several times, tell us what he was going to do, and then complete the task. With this approach, we became much more successful, and over time Mr. S was able to independently go from the electrical unit to batteries and back again.

Our next step was to teach Mr. S about the system controller, which is the brain of the unit and integral to the electrical operation of the VAD. Each morning he needed to test the system controller to ensure that all the alarms were functional. Each day we would cover an alarm code and review previously learned alarms. We also needed to teach him how to change the controller if there was a problem. This took a lot of time and practice, as he needed to set up a parallel system, but with the help of very concise directions from occupational therapy we succeeded.

Our last major task was to teach Mr. S how to use the hand pump. The hand pump provides manual back-up for the Heartmate system. If, for some reason, the pump cannot pump an adequate amount of blood, Mr. S would need to disconnect himself from the power source, attach the hand pump, and pump at a rate of 60 beats per minute until help arrives. There are several steps involved in priming the hand pump and we spent about two weeks perfecting the technique.

Soon, a discharge date was established for Mr. S. He was to leave our unit in ten days. During that time, three important activities needed to happen. First Mr. S would have an initial four-hour, supervised home visit. I would accompany him home to do a safety check of his environment, verify that the electrical power unit would be housed in an appropriate place, and that it would have its own dedicated outlet. Mr. S’s visit went very well but it was a very emotional day for him. He walked from room to room, touching favorite objects, showing me the wall unit he built in his den, pictures from their vacations, three dimensional pictures his wife had made. He admitted that during his hospitalization there were days he didn’t think he would ever see his home again. When he returned to the hospital he was very happy but quite exhausted.

The next day we began planning his unsupervised 8-hour home visit. Before this could occur, we needed Mr. S to demonstrate his mastery of the hand pump. We needed to be sure he could not only walk us through the process, but actually do it. Mr. S found this very frightening but understood why it was necessary. His supervised home visit had been on a Thursday, so we planned his unsupervised visit for the following Tuesday.

On Monday afternoon Mr. S would have to successfully demonstrate his usage of the hand pump. When patients come off the power source, they need to begin pumping within two minutes or clots may begin to form in the device. To Mr. S, two minutes seemed like a very short time and he focused on that aspect of the procedure. He was very nervous and spent all Monday morning practicing hand-pumping. At about 4:00pm, he said there was no time like the present—he was ready. Mr. S’s primary nurse and I gave him a quick pep talk and then he flawlessly preformed the procedure. It only took him 17 seconds to come off power and start pumping, and 15 seconds to re-connect to power. Once he was finished he realized how long two minutes really was. And he noted that he wasn’t the only nervous person in the room. Looking directly at me, he laughed and said, "Your hives had hives." And he was right, it was the first time I’d had a patient hand pump himself, and I was nervous!

The following day Mr. S had a successful 8-hour home visit. Both he and his wife agreed that home was where he should be, and on the following Tuesday their wish came true. Mr. S has done very well at home. He and his wife have resumed as many of their normal activities as possible. They go out almost every day, but they’ve learned that when they go to the movies they have to go in the afternoon and sit off to the side, because the device makes a ‘swooshing’ sound and can be distracting to other people.

Recently, Mr. S celebrated the first anniversary of the insertion of his ventricular assist device. His continued progress has been very gratifying for everyone who cared for him.

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