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I went to my first nursing research a couple of weeks ago. It was fascinating…and somewhat discouraging. The speakers kept talking about the need for leaders in nursing, advocates for best nursing practice. And I kept wanting to raise my hand and say “Haven’t you people heard of the Clinical Nurse Leader?” I came away from the conference knowing that we still have a ways to go in educating in our own colleagues about our role. Sometimes being on the front lines is exhausting.

But I was also left with an intriguing thought. One speaker in particular introduced the idea that when we aren’t using best practices, we are committing nursing malpractice. A bold statement to be sure, but something that also gave me pause.

Last week I questioned the levels of evidence we painstakingly learned in statistics and research classes. I touted the place of qualitative research. I even proposed that the placebo effect wasn’t always such a bad thing.

But when it comes to our practice as nurses, when it comes to the direct care we provide, are we not obligated to investigate what the research does say about the work we are doing? Are we not ethically and professionally responsible for knowing that the care we provide is indeed the best care? The conference speaker said the most important question we can keep asking is “Why?” Why do we do things the way we do them?

Malpractice is a strong, scary word. But if we’re not practicing to the fullest extent of our license and our nursing knowledge, I think the argument could be made.

What do you think? Is this opening a legal can of worms or do you think it’s a valid point?

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I recently came across this post by Dr. Simpson, a plastic surgeon/medical blogger who had some choice words about complementary and alternative medicine (CAM). I will admit that there may have been steam coming out of my ears by the end, but here is the gist: Complementary and alternative modalities as a whole are bad/unethical medicine and should not be utilized by medical providers nor sanctioned by state boards. 

As you can probably predict, I object. Vehemently.

It is true that many CAM options don’t have high levels of scientific evidence to back them up. But perhaps we need a new way of looking at evidence. RCTs may be the “gold standard” of science, but many CAM modalities logistically can’t be tested using these methods. The reason is that many CAM practices rely on a give and take between provider and patient, a deep therapeutic relationship without which these practices indeed may not be as effective. When I climbed onto the table at my energy healer’s practice, my participation in the process was required. Were I to be randomized in a study to a “sham” energy medicine group, chances are I would feel and experience nothing. Does that mean my experience wasn’t valid? It sure as hell was to me. When I see my acupuncturist once a month to help me with stress management, can I prove that the needles provoked a physiological response that in turn directly caused me to relax? Probably not. But does the experience help me relax in ways that no other experience has? Yes, yes it does.

Which brings me to my main point. Perhaps we will never be able to prove the scientific efficacy of certain practices. But so what? If they help us heal in a holistic sense, do they need to be “proven”? If our bodies feel refreshed and our minds are renewed when we leave our provider’s office, is this “placebo effect” such a problem? If the danger is negligible and the potential for healing unlimited, what’s the big deal?

I understand the role of evidence in recommending health care decisions. I’m going to be a Clinical Nurse Leader, for crying out loud. CNLs are all about evidence-based practice. I also recognize that nurses need to embrace research and encourage best practices. If you want science, go check out the National Center for Complementary and Alternative Medicine. You’ll get more evidence than you could ever want. Some of it might surprise you.

There is also something to be said for qualitative research. There is something to be said for creating theoretical frameworks and interviewing patients about their experiences with CAM in order to explore themes that may come in handy when designing person-centered interventions. There is something to be said for the psychosocial and physical wellbeing that can and does result from interactions with holistic health care.

RCTs and systematic reviews certainly have their place in advancing the science behind Western medicine. But there are equally valuable research methods and equally important priorities when we are talking about helping our patients heal. We don’t just need to know which blood pressure medication is going to be most effective. We also need to know what brings a person’s blood pressure up, and how we can help them lower it through learning to deep breathe. Will it be effective with every single patient? No. But neither will a drug. Is it beneficial to teach sustainable, person-centered, non-pharmaceutical methods of self-care? You bet.

As health care providers, we need to broaden our minds about the definitions of “health” and “healing”. In the mind of Dr. Simpson, “healing” means freeing oneself of illness. But I think we all know better than that. I think we are all on a journey. Some people with illness might even say they are healthy (gasp!), because they can get up every morning and do what they need/want to do each day.

If biomedical providers are this close-minded to holistic options, it’s no wonder their patients don’t tell them when they want to try acupuncture, or see a chiropractor. It’s the lack of conversation between and among providers of all types that leads to dangerous outcomes. Don’t blame the homeopath for prescribing those herbs. Blame the silence that wedges “us” versus “them”, that makes patients reluctant to reveal whom they’re seeing, and why. Blame the superiority complex that we in Western medicine claim over modalities that have been around for thousands of years.

We should be talking to each other. It’s for the good of our patients.

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Thank you for sharing more about you (and if you missed it, feel free to go back and do so).

Now it’s time to hear about your use of this blog. What brought you to The Makings of a Nurse? How often do you visit? What kind of content do you prefer? This will help me in choosing new post topics and creating new content series.

Click here to leave your feedback. And thank you for your time!

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One of the most exciting aspects of researching this series is discovering the innovative work being done across the country. Who knew a major health system in the Pacific Northwest had an integrative medicine program?

Our amazing guest today is Dr. Ken Weizer, N.D. Dr. Weizer specializes in naturopathic cancer care for the Providence Integrative Medicine Program in Portland, Oregon. After learning about him, I want to work for him as the program’s integrative health CNL. Dr. Weizer is himself a cancer survivor and after you read about his practice in his own words, I’m sure I’d have to fight for that job. 

In addition to direct patient care, Dr. Weizer offers presentations and workshops to local support groups, as well as health care professionals. His “Laughter Is the Best Medicine” program has received high praise from participants.

I have a special affinity for his work, since my PCP is also a naturopath. To me, this practice epitomizes what health care is supposed to be about.

But don’t take my word for it. Here’s a closer look, brought to you by a resident expert…

What is Naturopathy, compared/contrasted with “conventional” biomedicine?

Naturopathy is the medicine that was practiced before the advent of drugs in the last 50 years. I focus treatment on lifestyle changes – exercise, diet, stress reduction. Most of my patients use both naturopathic and drug-based doctors.

What got you specifically interested in cancer care? 

My own cancer in 1989. A life changing experience. I wanted to see if there was a new and better way to treat people with cancer.

What are the benefits of working for an integrated clinic as part of a large health system? What are the drawbacks?

Benefits: Truly working with a team of doctors that know, trust, and work with each other…Seeing all the doctors in one location… Having the assurance that the naturopaths are trained and skilled in treating cancer, and conservative in their approach.

Drawbacks: Having to go to the hospital to see the naturopath…Our approach is conservative. Many people with cancer are scared and quite frankly – panicked – and think that doing more is better and using any and all methods is the way to go. For those people, we may not be the best fit, as we are going to use only evidence-based and/or rational therapies.

How do you usually get referrals?

Medical oncologists, radiation oncologists, nurses, physical therapists, social workers, counselors, other patients.

What kind of recommendations you might make beyond a pharmaceutical prescription?

I try to present the client with a comprehensive, but simple and appropriate plan. This will generally include: nutritional supplements, dietary advice, stress reduction techniques, and an exercise plan. I often refer patients to oncologists, physical therapists, massage therapists, and acupuncturists.

What kind of educational process did you go through to become a naturopath? How can people recognize a credible provider?

Naturopathy requires a 4-year doctoral program. Credible providers have a doctoral degree in naturopathic medicine.

How much do your visits cost? Does insurance cover your care?

The first visit lasts an hour and usually costs $195 out-of-pocket. Follow-up visits are usually $65. About half of the patients are covered by insurance.

How/when do you collaborate with oncologists and other medical providers who see your patients?

We are in constant collaboration. We are on the same computer system, we send each other notes, we talk with each other, we attend weekly tumor board conferences together.

Have you ever seen a patient whose needs were outside your scope? What did you do about it?

Yes. I refer them to the proper facility and physician.

What kind of evidence is available to support the efficacy of naturopathy?

A growing body of integrative care data is emerging. Perhaps it is the trend of the future. (See NCCAM’s page on Naturopathy for a list of current randomized controlled trials, systematic reviews and meta-analyses regarding the efficacy of this practice).

How did you get involved in making presentations about laughter as good medicine? 

A patient gave me a red nose after watching the film Patch Adams. Then I heard Patch speak, and I was inspired to bring the light of laughter into the darkness of cancer. Providence has been very supportive of this.

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Sorry for the relative silence this week. I’ve been a little distracted…

My Precious

Yes, that’s right. I took the plunge.

My MacBook has done me right for the past five years. But lately the affectionately-termed “rainbow wheel of death” has been making appearances with increased frequency. It was clearly becoming time for a change.

Not to mention this semester is my last chance (for now) to utilize a student discount.

So I upgraded.

And I’m in love.

Yes, I’m a Mac geek. But I love the interface, the trackpad, the high speeds. I love the fact that with a couple clicks of a mouse and a little patience, I could turn on Migration Assistant and my new computer looked just like my old one, except with more bells and whistles and updated apps. It required 20-some hours of patience while everything moved over. But it would have taken a longer time cumulatively to do it myself.

So I’ll be drooling for a bit. And blogging with a little more spring in my type.

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My name is Nurse Teeny and I am an education addict.

There, I said it.

On the heels of promising to get over myself and live in the present, I stumbled across information about a local DNP program that offers certification as a Clinical Nurse Specialist-Gerontology. Or a Ph.D. in nursing education, focused on Community Health Nursing. Don’t even get me started on which one to choose (or how to do both, for that matter). Which all brings me to an important question…

Just how many letters do I really need after my last name?

Not that it’s really the credentials I’m seeking. It’s the learning. The thirst to know more, to be better, to offer more to my clients.

I full acknowledge that it’s also professional and personal restlessness. I know this. It’s part of the whole being “wound up tight” thing.

But if this tells you anything, the most important room in S and my dream home is the library (well, for S it’s probably a tie between the kitchen and library). Walls and walls of books. And big comfy chairs to read them in. And a big front porch for writing.

I thirst to know. It’s who I am.

I still pledge to stay put. For now. I’ve filed away the advanced practice program brochures for a rainy day. For the sake of my sanity and my family, I know I need a break.

But in a sick, twisted way, it feels good to know I can always go back.

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One of my goals for the new year is finding out more about you. Where are you from? What brought you to this blog? What keeps you coming back? What do you want to get out of reading The Makings of a Nurse?

I want to know what makes you tick, so that I can tailor the content to encourage participation and feedback. What better way than to do a couple surveys and analyze the findings? How very evidence-based of us.

So here’s the first one. This one is all about you – where you come from, what you do, where you work.

Talk to me…

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If there is one thing I have realized after two years as an RN, it is the importance of communication to patient safety. On my very first Med-Surg rotation, I remember my clinical instructor telling me to over-communicate. And that has stuck with me. I’m sure it makes me a pest to some, but so be it. We work in a field where we are responsible for the health and safety of people for a limited time period and then someone else takes over. It is critical that when we hand off care, we do so effectively.

So when it came time to decide on a final quality improvement project at my clinical site, communication gaps jumped out at me left and right. And the more I broached the topic with the staff, the more positive feedback I got that this was a need. Not to mention my preceptor was over the moon about this.

One of the lovely things about the VA is that it provides a built-in infrastructure, replete with offices of patient safety and tools. Lots and lots of tools. So in designing this project, I didn’t have to reinvent the wheel.

We settled on utilizing clinical crew resource management (CRM). This is a patient safety model based on principles developed by the aviation industry. It emphasizes checklists, focus during critical events such as take off and landing (or in our case, clinical handoffs), and above all, communication, communication, communication.

So we’re taking these concepts and running with them. I’ll reflect on the experience over the new few months, but here are a my first few tips for implementing change at the microsystem level:

1. Start planning early. There will be delays. I promise.
2. Find a champion on your unit. Someone who will not only be an early adopter, but who will also help you implement from the ground up. You need buy-in from a local respected figure.
3. Listen to the staff. If you are set in your ways and don’t actively seek out input, nothing you suggest will be well-received.
4. Be present. Before, during and after you make a change. Before so that you can get to know everyone and establish a positive relationship. During so that you can be available and show enthusiasm. After so that you can keep getting feedback and show that you are still open to adjusting the process.
5. Observe, observe, observe. Learn before you do. Understand what is already working. Find out where gaps exist. Don’t rush into a new microsystem, guns blazing, and expect to receive anything besides return fire.

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I have resisted publicly commenting on the Amanda Trujillo case for a few days.

My rationale? I didn’t know the whole story.

I still don’t know the whole story. But I realized that my rationale is BS. A cop-out.

I don’t need to know the whole story to know that a colleague, another professional, stood up for a patient and paid dearly for it. Whatever the context, whatever additional details Banner Health may be holding onto, the fact remains that a fellow nurse acted within her own scope of practice and was fired for it.

The fact remains that a patient didn’t have complete information before he gave consent to surgery. Which means he didn’t give informed consent. When Amanda realized this and educated her patient, advocated for her patient – hell, practiced as a nurse – she lost her livelihood.

The physician failed the patient. The hospital failed the patient. Amanda didn’t fail the patient. And yet she’s the one fighting for her license with the Arizona State Board of Nursing. She’s the one facing a psychiatric evaluation for fighting back. I kid you not.

The nursing Code of Ethics Provision 2 says this:

The nurse’s primary commitment is to the patient. 

Apparently fulfilling our professional ethical obligations can jeopardize our jobs. And our licenses.

How ironic, that practicing as a nurse can end our nursing careers.

For background on Amanda Trujillo’s story, see here and here or listen here. For details about how to support Amanda, see the Nerdy Nurse’s post here. And for an incredible post about how Amanda’s struggle is our struggle, see Joyce Harrell’s blog post.

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Photo by Andrea Hubbell Photography

Today’s Holistic Nurse words of wisdom come from Kath Younger, a registered dietitian (RD) and popular food blogger at Kath Eats Real Food. Fun fact: Kath and I are both part of a large Davidson College family – we graduated two years apart! Today she lives in Charlottesville, Virginia where she owns Great Harvest Bread Co. with her husband Matt Monson. I asked Kath to share her thoughts on the relationship between health and nutrition and she graciously took time out of her very busy holiday schedule to contribute. Thank you Kath!

What does it mean to be healthy, in your professional (and personal) opinion?

To mean healthy means that decisions that impact your health in a good way out number decisions that might be detrimental to your health. I think it’s more about effort than a number on a scale and more about what you put in your body than what you don’t. Health to me means choosing to be educated on which food, exercise, environmental, stress, sleep, etc. factors make you feel good and lead to a long happy life.

What inspired you to become an RD?

After graduating from college, I lost 30 pounds through calorie counting, exercise and a focus on eating real food. To be honest, the weight melted off of me. Once I set my mind to it, losing weight was so easy. I reached my goals in about 15 months and learned so much about myself and healthy living along the way. Despite how easy I found weight loss, so many people struggle with their weight. So many yo-yo diet and starve on sugary granola bars and iceberg lettuce. When I set out to become an RD, my goal was to someday open a business where I could show people how easy weight loss can be – and how delicious real food is. Little did I know then that my practice wouldn’t take shape in a office building, but online through creative photography and cooking!

What kind of educational process did you go through to become RD? What kind of continuing education do you need?

Although I had a bachelor’s degree, which was good, I had nothing else needed for the RD requirements, so I had to start from scratch in my program. This mean taking Chemistry 101 – the periodic table, acids and bases – all the boring stuff I learned in high school. But at the same time, I started on my nutrition track and loved the curriculum so much that the sciences were less painful. My 2 years of studies went by SO fast (including a whole summer of summer school). I really enjoyed being a student again, although I’ll admit I had it easier than a few of my classmates who had children or full-time jobs. My internship was most definitely the most challenging part of my degree. It was 6 months, full-time with no vacation days. It was extremely intense, especially since at this point I knew when I finished I would be working for myself as a blogger and opening a bakery with my husband in a different state. But I charged through and am very glad I completed the internship and passed the RD exam!

How can the foods we put in our body affect our health? 

Nutrition is such a young science. Scientists have only touched the tip of the iceberg of all there is to know about the relationship between food and health. There are many epidemiological studies that link whole foods to good health (I did an entire research project on real food while in school!). Yet scientists have trouble isolating nutrients and getting the same effect. I believe that there are hundreds – maybe millions – of nutrients that we have yet to discover, and moreover, processes and interactions between them that work in magical ways. Since we don’t have the answers yet, the best thing we can do for our health is to eat food in the state nature grew it.

What are your short- and long-term goals as an RD?

In the short term I’m hoping to continue writing my blog, which serves as an example of how I fit healthy eating into a busy life and provides recipes made with real food. I’ve written a few science-based articles on nutrition since becoming an RD, and I’d love to find ways to do more of that. Long term, I’m dreaming big with a TV show on healthy living – perhaps a collaborative effort with some of my co-bloggers dedicated to fitness and food. And maybe one day if the blog dries up I’ll open that brick and mortar private practice – or open up on online weight loss consulting business. As of now, though, the blog and bakery eat up most of my time.

Where can people get more information about becoming an RD or about the relationship between food and health? 

Other than Katheats.com you mean!? I actually do have a whole post dedicated to becoming an RD and it includes a list of a bunch of other RDs online at the bottom. Eatright.org is the American Dietetics Association’s (soon to be renamed the Academy of Nutrition and Dietetics! ) main site and there a lot of information hidden inside. From Q&As about becoming an RD to research blurbs and position statements on topics, you can find a lot of information inside.