Goodbye Missus Chips






Editor’s foreword: I would like to introduce a completely unedited, unadulterated and unsolicited view from the world of a newly graduated Enrolled Nurse. I think horizontal violence within nursing is still far to common place. We can all learn something from the people that inhabit the roles that all funnel in to one key job – building patients back up again. This is a really insightful piece of self-reflection from a Nurse I am proud to call a colleague (Twitter Health Service). Over to you “Stevie”.


It started as an off the cuff comment. I referred to the (much analysed) chip on my shoulder. The (joking) reply was, “isn’t that the prerequisite chip on the shoulder ALL Enrolled Nurses have?” Which led me to thinking, do we really? Or is that just how others see us? What does it even mean? What do I mean when I bring it up? I decided I should ask Google this question, and depending on where you look, you get a few different answers. Urban dictionary tells me it is ‘to be touchy, to be easily provoked, or to harbour a grudge.’ would have me believe it is ‘a perceived grievance or sense of inferiority’, and the free dictionary puts it like this, “to blame other people for something bad which has happened to you and to continue to be angry about it so that it affects the way you behave.”

What jumped out at me was ‘sense of inferiority’. Maybe that’s what’s actually feeding the chip, but to everyone else, the person with the chip comes across as thinking that they are superior, up their own arse, arrogant.

I’m not sure what I mean when I talk about the chip on my shoulder. As someone who is painfully self-aware, I’d like to think that I don’t blame other people for the things in my past & I don’t use what has happened in the past as an excuse for my current behaviours. I am not feeling particularly aggrieved right now either. I would however describe myself as sometimes touchy, somewhat easily provoked and although I am not quite in the league of my Spanish mother, I can indeed hold a grudge.

I don’t think my chip fits those definitions. Maybe mine stems from starting again in a new field at the grand old age of 32 at the bottom of the food chain, having previously been a line manager/trainer/mentor. And yes, let’s mention the food chain/hierarchy. Those who say there isn’t one in healthcare are normally fairly high up it already. I’m bright. I have ‘opinions’. I like to know the ‘why’. I ask questions. I’m confident in my abilities & keen to learn new skills. My tongue is firmly in my cheek & I do a great line in self-deprecating humour. I am cripplingly insecure. Is that my chip? Does it look like that to other people? Is it always there or does it just pop up like an air bag? Is it a defence mechanism?

Do ALL ENs have a chip on their shoulder? Well, a quick poll of 5 ENs (yes I know, tiny numbers, there needs to be more of us on Twitter) revealed no, we don’t think they all do, but we all independently named the same person who we think does. Awks. Not me. Phew.

Being an EN feels tricky. Our scope of practice varies from EN to EN, ward to ward, hospital to hospital, state to state. I never knew how much difference geography would make to scope of practice. In one rural ED Resus I am thinking of, with the appropriate annual training & supervision, an EN can pop in an LMA if required to do so. Down the road in the city as an EN you’d get to scribe & I doubt much else. Woo! It is of course about person not just role, however I think we are capable of more than we are consistently allowed to do.


 I do feel I have something to prove, and I know the best way to do that is to quietly be really damn good at being an EN. But it’s hard to stop comments about ENs such as “your college needs to pull their head out of their backside and stop raising your expectations as an EN”, “you can’t do this in-service, you’re an EN, you won’t understand it”, “what’s the point of you?”, “you’re just the lackey”, “you’re not a real nurse”, feeding your chip. My personal favourite is, “you’re just an EN”. No one is just anything. I know of a ward where they like the ENs to eat their lunches next door with the students. I’d like them to try that with me. Is that my chip popping up again?

So what to do about it? If you think you’ve got a chip on your shoulder, maybe have a think about why it’s there. What makes it deploy? Are you inadvertently feeding it? When people think someone else has a chip on their shoulder, the instinct seems to be to knock it off, put them in their place, or just avoid/ignore them. None of those things seem very nice, and if insecurity is what feeds the chip, ‘taking them down a peg or two’, is probably just going to make things worse. I’ve been told (not in the healthcare facility where I’m employed), to keep students in check, to make sure they didn’t get too big for their boots. Which quite frankly, does not sit well with me at all.

Perhaps, gentle shaping as opposed to being bashed about the head with what someone else wants you to think, is the way forward. What works on my chip, (as lame as it sounds) is a little dollop of kindness. Someone taking the time to really listen to what I was trying to say, being interested, facilitating, encouraging and giving me a voice. Maybe, in a little while, the chip won’t be visible at all. I don’t think I’ll miss her.

‘Condition Haych’ – An Epidemic of Grammatical Proportions

In a recent publication in the Journal of Speaking Properly (Spurr 2014), epidemiologists suggested we are in the midst of an epidemic. Public health officials are relatively confident that the disease known as ‘Condition Haych’ is largely isolated to the Australian population at present (urgent amendment see below for update).

‘Condition Haych’ is a disease characterised by the mispronunciation of the letter ‘H’ – correctly orated as ‘Aych‘ (note the absence of preceding H).

Although the authors were unable to establish a definitive genetic link, the disease process trended toward association with environmental and lifestyle factors. Correlation with other symptoms, such as cognitive inability to distinguish between ‘their‘, ‘there‘, and ‘they’re‘; and ‘your‘ and ‘you’re‘ were statistically significant (p<0.01).

While not a terminal disease, recovery is rare and requires extensive rehabilitation with speech pathology involvement and extreme negative conditioning cognitive behaviour therapy.

I would like to thank my wife for the inspiration to write this review, she is in remission following aggressive therapy for this debilitating illness.

Grammar: the difference between knowing your shit, and knowing you’re shit.

28th June 2014 Urgent Post-publication Update: In the past three days, confirmed cases of Condition Haych have flooded in via Injectable Orange Centre for Disease Control (aka Twitter). There have been widespread reports of Haych-like symptoms in the United Kingdom and a number of verified cases of Condition Haych in Nova-Scotia, Canada thanks to our epidemiologist on the ground @VasospasticRN. I will keep the public updated as information comes to hand.

Resuscitative Fluid Therapy – Get it in quick?

Bolus: a large dose of a substance given by injection for the purpose of rapidly achieving the needed therapeutic concentration in the bloodstream. (Merriam-Webster Dictionary Online)

Watering bike

Get those fluids in STAT

Consider a case. You are called to see a patient.

68 year old lady.

Day one post-operative phase following right total hip replacement.

Documented Operating Room notes as ‘oozy’ operation.

Tachycardiac, hypotensive, dry mucous membranes ECG normal Sinus Tachycardia, normothermic. Moderate haemoserous loss via drain.

Decision made to give 500ml intravenous crystalloid bolus.

500ml is diligently dialled up on the infusion pump to the maximum flow rate (1000ml/hr) and ‘start’ is pressed.

Is this resuscitative fluid therapy? Is it a fluid challenge? Has the goal of therapy been defined?

Are we going to be able to assess for a significant response to these fluids?

As a critical care nurse I am amazed at how frequently in a ward context, compromised, hypotensive and clinically dry patients receive an infusion rather than the requested bolus. I am also equally as surprised that the prescribing medical officer, unless directly asked ‘how fast do you want it in?’ will not specify, yet when prescribing maintenance fluids, will diligently document a precise order of 42ml/hr.

This post is really intended to stimulate some thought about the logistics and human factors that dictate what version of an immensely common therapeutic action our patient receives.

As an in-hospital Medical Emergency Response Nurse, I am routinely employing the probing question of ‘how fast would you like that fluid administered?’ I also attach an addendum – ‘do you want it over half an hour, or would you like to pull it out of the pump so we can give it quicker, evaluate the response and you can work through some other things?’

In terms of practicalities in the delivery (lacking the presence of a medical or nursing student) – a pressure bag will free up a pair of hands from squeezing the IV fluids in by hand. In the absence of this purposefully designed solution, I have often used a manual BP cuff, wrapped firmly around the upper half of the bag and then pumped up.

BP Cuff

BP Cuff = Excellent Pressure Bag

Pressure bag

Actual Pressure Bag

Both of these options are great because you are able to observe the pressure registered by the cuff on inflation and have an estimation as to the amour of force being exerted to the forward flow against the patient’s own BP and tubing resistance. It is important to note, this does not absolve us from monitoring the patient’s response and observing the IV catheter site, but frees up a pair of trained hands to do some more meaningful (even if it is hold the patient’s hand and reassure them, explaining what is happening).

I have attached an list of my favourites for recommended reading/viewing below. These resources have all improved my understanding of the humble fluid bolus.

An elegantly simple description by Haney Mallemat @criticalcarenow

Excellent explanation of the details of a ‘Fluid Challenge’

A great compilation of evidence and FOAM links relating to assessment of fluid responsiveness.

A thought provoking and enigmatic discussion on fluids in sepsis from Paul Marik, nicely moderated by Scott Weingart @emcrit


SMACC Chicago 2015 – Don’t Make Other Plans

I know there are much more high profile websites than injectable orange publicising SMACC 2015. But this conference will be of such epic proportions that it deserves every digital footprint it gets. So… print this poster, make a point of telling your colleagues about this amazing opportunity to learn and build professional friendships. I am also absolutely thrilled that my reflection on SMACC Gold (2014) features on the save the date poster.

Plants in Simulation

The following video presentation is a brief overview of the role of the confederate in simulation. Quite simply, the confederate is one of the best tools I have found in the quest to enhance the fidelity/realism for participants in immersive simulation. I will be presenting soon at the Laerdal SUN Conference – giving a workshop on In Situ Simulation for Patient Safety – ‘Waking Sleeping Giants’ and this video is going to be given as part of a flipped workshop approach in pre-attendance. It’s my first attempt at a screen recording and I learned a great deal (mostly how not to do it next time). I would love for others to share your experiences in simulation or in production of better quality videos than mine. I am really keen to learn.


Sanko et al. 2013 Establishing a convention for acting in healthcare simulation: merging art and science.


What Happens When You Work With Warring Tribes?


My first reaction when asked to write a piece for Injectable Orange was almost embarrassment that someone felt I had something to contribute to this up swell of amazing nursing and medical blogs that have changed the way I think about reflective learning over the last 3 years.  This was quickly followed by an overwhelming feeling of terror – what the hell am I going to say?

After a few weeks of contemplation I decided to take some inspiration from the opening address at the recent SMACCGOLD conference. The incredible Victoria Brazil spoke about the concept of various teams in a hospital being like tribes: the ED tribe, the ICU tribe, the Cardiology tribe, and the various nursing, medical, and allied health tribes. During this presentation a case was laid out detailing perhaps not the best way to navigate through the various tribes of the hospital with their respective cultures and languages to achieve primary coronary angioplasty for a patient presenting with an acute myocardial infarction.

As the laughs and head shaking continued in the audience whilst this case unfolded, in my mind on loop playback was ‘welcome to my daily practice as an ICU Outreach nurse’. I am often asked, ‘what exactly does an ICU Outreach nurse do?’ My response is usually a mixed bag, there is something relating to assessment of the deteriorating patient. I am part of the medical emergency team and to a large degree I am an educator. The one thing I am always sure to explain is that I act as a pivot to ensure the right clinicians are involved in a deteriorating patient’s care to intervene and hopefully change this patient’s clinical course. Another question I am frequently asked in my line of work is ‘how did you manage to get “them” to listen to you when it comes to escalating the care of deteriorating patients?’ This is something I have struggled to answer, but thanks to Victoria’s presentation and a little book called Tribal Leadership, by David Logan, I have come to a better understanding of how I achieve this task. A function which can be so difficult at times. More importantly I have reflected on how I can continue to improve on the vital skill of communicating.


David Logan describes organisations and subsets within these organisations as a tribe. A tribe as a group of 20 to 150 people who know one another well enough that if they saw each other walking down the street, they would stop and say ‘hello’. I thought about this from a ward perspective It’s the nurses, doctors and allied health teams you work with every day, not the ‘tribe’ that works 2 floors down with a different specialty to your own. It’s the nursing staff, whom see their role completely separate to that of the medical staff.

This book then goes on to describe what makes an effective tribe, culture. This culture is a product of the language people use and the behaviours that accompany those words. The nursing staff don’t suggest interventions, the resident dutifully scribes the notes on rounds but lives by the adage ‘been seen and not heard’, the graduate nurse who is worried about her patient’s respiratory rate of 30 but has been told before that is fine on this ward. So what happens when we need something from another tribe? My medical patient needs a surgical review. The in-charge nurse is justifying a 1:1 nurse ratio for an unwell patient and needs medical documentation, but the medical team don’t agree?  In most cases, it is what I like to call war; different tribes, with different cultures and language at the end of a bed. How do you strive for the common goal, when you are from a different culture and speaking a different language? David Logan describes the five stages of tribal cultures that evolve from individual focused behaviours and language. Tribes who strive to be the best against the competition give way eventually to the tribes that can work with almost anyone to achieve the common goal and compete only with what is possible. Sounding like a hospital near you yet?

These five stages of tribalism gave me the insight to understand that I was able to have effective conversations and escalate care because, before having the conversation, I take the time to think about where the other individual was coming from. I pause to consider whether they are an intern that had been sent by the registrar with orders to ‘sort it out’, but whatever you do don’t bring the patient back to ‘my ward’. Are they the ward charge nurse, that has just been pushed to take three patients from the emergency department under the threat of the 4hr Rule and I was asking her to make a bed for the fourth sick patient. I have taken the time during those rare quiet shifts to get to know the tribal chiefs and understand their cultures.

In my role as an ICU Outreach nurse, I realised I had been striving to be a Tribal leader. David Logan describes this as a very personal journey and to get there you must do the “prep work” on yourself first, including:

  • Learn the language and customs of all five cultural stages.
  • Listen for which tribal members speak which language – in essence, who is at what stage?
  • Move yourself forward, start talking a different language and shifting the structure of relationships around you.
  • Take these actions as you upgrade the tribe around you.

There is so much to this concept that lends itself to the way we work as healthcare professionals, the next time you feel like you are going to war, I challenge you to consider the language and culture of the other team, changing yours may just get you to the common goal.

What happens when you work with warring tribes?

I guess I am lucky enough to be bilingual.