Of Sacred Cows and Evidence-Based Practice

I wrote this for my synthesis paper in one of our PhD subjects

                Ever since the ancient times, people have realized and accepted the fact that there is nothing permanent in this world but change. One of the ancient philosophers, Heraclitus (500BC; Graham, Summer 2011) compared existing things into the flow of the river: ”Into the same rivers we step and do not step, we are and are not."  This illustrated how change happens constantly. Man, being part of this world, is also affected by change. “All good men desire to change.  He longs to develop and to perfect himself” (Von Hildebrand, 1990). Under this line of thinking, nurses try to improve their Nursing practice. And since Nursing is a science, Nursing Practice should be based on science, wherein research is used to answer questions, establish protocols, and promote critical thinking and decision making at the bedside (Rauen, Chulay, Bridges, Vollman, & Arbour, 2008).

            Many new ways of practice had been introduced based on evidence – that is, research findings that are relevant and applicable to clinical situations with the aim of better outcomes for the patients. This is referred to as Evidence-Based Practice. The Institute of Medicine defines evidence-based practice (EBP) as “the integration of best research, clinical expertise, and patient values in making decisions about the care of individualized patients (Rauen, Chulay, Bridges, Vollman, & Arbour, 2008). More accurate measurement of blood pressure (Rauen et al, 2008), less- restricted visiting policies (Makic, VonRueden, Rauen, & Chadwick, 2011), unit guidelines for urinary catheterization (AACN Bold Voices, 2012) and the development of the seven domains and associated quality indicators for End-of-Life (EoL) care in critical care  (Efstathiou & Clifford, 2011) are among the results of the nurses’ efforts to discover better and safer ways of doing things.

            However, one irony about change, although constant and good people desire it, is that people also tend to resist it.  Change requires willingness and ability to change practices, regardless of the tradition and commonly held beliefs (Rauen et al 2008). Sometimes, though, it is not easy to leave tradition and one’s “security blanket” that were referred to by Rauen et al as sacred cows. John Maxwell (2011) describes this process   as the “pain of change”. It is painful to break the habit of doing things. It can be tiring and toilsome work, requiring persistence and resourcefulness (Sanborn, 2008). It is especially difficult if one's opinion or beliefs very much differ from the new evidence being presented. Several studies support positive outcomes for on-duty napping (Fallis, MacMillan, & Edwards, 2011). The authors noted that in nurses working either 8-or 12-hour night shifts, sleep deprivation increases the risk for patient errors, near misses, and personal injuries on shift and while driving home. Furthermore, the authors also concluded that sleep deprivation, sleep disturbance, and fatigue are also significant contributing factors to impaired personal health. They thus broached into the idea of restorative naps within work to address these problems. This proposal may be a welcome practice to many night duty nurses, but one can meet resistance among the traditionalists.

            More resistance can be expected to Daly’s (2008) proposal to withhold cardiopulmonary resuscitation unless there is prior order from the physician. She recommended  “to restrict use of CPR to those patients who provide adequately informed consent and for whom CPR has a reasonable chance of success” (Daly, 2008). This revolutionary idea based on research may not have many takers but this and the other new discoveries (too revolutionary or not), give growth and development to nursing science and consequently, to practice. Because of EBP’s, more specific and clear guidelines are present, that can signal to the staff the orientation of the goals of care and the interventions to be provided (Ells, 2010).

            EBP can further grow if there is a unified research agenda among muti-disciplines in health that are based on the assessed needs of a particular place. The effort to do this was shown by the multisociety task force for critical care who came up with a comprehensive agenda for critical care research using input from a broad range of stakeholders to serve as a blueprint for future initiatives (Deutschman, Ahrens, Cairns, Sessler, & Parsons, 2012).

            In summary, evidence-based practice has shown many ways of having a deeper knowledge about the patients, families and about the processes followed by the health team so that there is improved efficiency and safety in practice that would bring about better outcomes of care. Although resistance to change due to traditonal beliefs and practices may be encountered, these traditionalists who resist “putting their sacred cows out to pasture” will eventually be convinced if better outcomes are consistently manifested. With a concerted effort from the members of the different health disciplines who pulls the cart together in one direction based on one research agenda, we can expect greener pastures ahead. 

Holy Week

Holy Week

    
           It has been more than a decade (17 years to be exact) that I have attended the Holy Week services in my hometown, Passi. But I can still recall and appreciate those childhood memories wherein everyone tries to come home and be with their families during this time of the year. Life is a lot simpler then but I didn't find it boring at all. Holy Week begins today, Palm Sunday.  Radio stations, TV Networks (we only had Channels 4, 8, 10 and 12 then) and everywhere you go remind you that it's Holy Week. Bombo Radyo had Holy Week specials. You don't hear the usual "Sin-o ang May Sala" radyo drama. Instead, they're replaced by the Seven Last Words and other inspirational dramas. I also remembered crying over the characters portrayed by Tito, Vic and Joey and their entire Eat Bulaga troop. They don't do game shows on those days. Instead, they play serious characters and teach lessons of forgiveness, love, etc.

    But the highlight is the Easter Triduum - Holy Thursday, Good Friday and Easter.  Having studied and learned more about our  Christian faith, I am amazed at how great a teacher our mother the Holy Catholic Church is. The Bible characters come to life during those days and the entire town participates.  The 12 Apostles come from the different parts of the town. They also went by pairs to the houses, in their costume and sash to identify which Apostle they play. Oh, and they carried a coin purse too. When they come to your house, just like in the Gospels, after locating where the Sacred Heart image is, they start praying for peace and blessing for the entire family. We were welcoming, I think, so we didn't witness any of them brushing dust off their feet and getting back their prayers for peace. The 14 stations of the Cross is spread all over town that during the procession, you will have walked around the entire town to complete the 14 stations. The walk was quite tiring that I remembered cheating when I was a little younger. Our house is located towards the end, so instead of completing, we stayed at the street corner and just watched people and images pass. When I became a teenager, I was distracted with people watching. During the procession, you will see who is courting who or who is officially together. I also remembered watching out for my crushes  and wondered when I will ever be noticed.  But the procession and the Way of the Cross, I now realized, is a great catechism. Through the images, we get to know more the characters in the Gospels. Below are my considerations on these images:

     My Lola Esther's family is in charge of Mary Magdalene. Her image had nice curls and long lashes and rich clothes and she always carried a bottle of perfume. As a child, it was explained to me that she's quite vain that's why she's represented that way. But as you check out her character in the Gospels, you will realize that she's that lady whom Jesus expelled 7 devils. She lived a sinful life but after being forgiven, she learned how to love greatly and be most generous. She was that lady who didn't skimp on an expensive perfume (a whole year's laborer's wage worth) by breaking the bottle so all gets poured to anoint Our Lord's head before his Passion. 

     One image I didn't quite like was Martha's. She wore a very simple dress and carried a walis tingting. Why did she earn a place in the procession? Well, this lady taught us the value of domestic work. If Mary taught contemplative life, Martha teaches us the importance of taking care of the work of the home. It is such an important but unrecognized job. Without a lady taking care of a home, it will just be a house. But the home is where life and values are first learned. The love and care of a mother and wife will produce happy and contented and inspired husband and children.

      St. John. This young man became an Apostle when he was a teenager. He was the only unmarried among the Apostles. His life teaches us that chastity and total self-giving is possible and noble. Who was that apostle who kept reminding the early Christians to love one another even at old age?  It was John. Why was he able to speak about Love? Because his total self-giving taught him Love. 

      St. Peter with a cock. "Before the cock crows twice, you have disowned me three times" Jesus told Peter. Peter had a lot of faults but he said sorry and rectified. This impulsive guy truly loved Our Lord. That is why despite his weaknesses, he was made the "Rock" where Christ built his Church. He became the first head of the Church and he died a martyr trying to spread the Christian faith. He felt not worthy to die the way Jesus did so he asked that he be crucified upside down. 

      Jesus' agony in the garden with an angel holding a chalice. "Father, if you will, remove this cup...But not my will but yours be done". Suffering is never inviting. Even Jesus, in his human body, did not want it. But that suffering was our Redemption. So, in the end, Jesus followed The Father's will. We too should embrace our little and big crosses. The hurt are like the chips under the jeweller's hand.  Without being cut, we won't shine as the diamonds that we are meant to become. 

      There are a lot more images to consider and events in the Easter Triduum to comment on but it is time to end so I'll end... You may add your thoughts on the Last Supper, the Visits to the Monumentos, the kissing of the cross, the Easter vigil with the blessing of the seed of the farmers, the 7 Dolorosas, the meeting of Jesus and Mary at Easter morning...

Tulong sa CDO at Iligan 2012

Around Christmastime, I found myself signing up for a Medical Mission/De-briefing for the Typhoon Sendong Victims in Cagayan de Oro (CDO) and Iligan City. For a segurista type of person like me, I was surprised with myself. I know that by mid-January (the scheduled trip for the project), I will still be hectic at work. And I will still have backlogs from my other previous little assignments and commitments. Normally, I’ll be having second thoughts of making my already complicated life be more complicated. But there, the team leader has told the others that I'm joining and they're buying our tickets soon. Since there seem to be no backing out, I started helping in the fundraising. That part is where I started getting my inspiration to continue with what I’ve found myself into. Thank you for responding to my call for help. Thank you for your encouragements and for the prayers you’ve said for our safety and for the good effects of the activity. Thank you too to those who sent financial assistance to the project. We were a total of 15 volunteers – 5 MDs, 8 RNs, a dentist and a pharmacist. This group was started by the staff of Mapua Institute of Technology Health Services. The rest of us were friends of theirs who got invited because of our past experiences to these types of projects. Because of your help, we were able to go to CDO and Iligan to extend quality help to a percentage of those affected by Sendong. We conducted free medical consultations with free full dose medicines including antibiotics, distributed relief goods (Thanks to the place called Divisoria, there was multiplication of bath towels, blankets, toothbrush and detergent bars. Thanks to generous donors, our food items were not limited to sardines and noodles and rice) and had de-briefing with those billeted at Camaman-an Evacuation Center in CDO and Tambo Shelter Box (Tent City) in Iligan City. There were 89 families in Camaman-an and 123 families in Tambo. We also left boxes of necessary medicines to the Parish Church of Camaman-an. There were at least 30 families sheltered in the parish social hall. Unfortunately, we couldn’t find time to service them like the other two centers so we decided to give them our excess medicines which was timely because they’ve ran out of supplies.

Faith, hope and love were very tangible in every step of this adventure. These and other insights from the project, I’d like to share to all of you.

Not to be ashamed to ask. Somehow, it’s in our human nature to feel it not so easy to beg. There’s that fear of being rejected, ignored or insulted. But I realized that asking people to help is giving them opportunity to be generous. Asking my friends for help is giving them opportunity to show how much they care and support me. I don’t measure help by money alone. Since you are my friends, somehow I also know your capacity. A like to my post, a line of encouragement and a promise of prayers weighed as much too. It’s amazing to witness how generosity can be infectious. Because people saw that we’ve gone out of our way to render service, they were encouraged to help us too. Our van driver didn’t charge us for van rental for our trip to the airport going back to Manila because he saw our work when he serviced us the day before. We asked permission from the Philippine Army rescue group in Tambo to be allowed to use their dining table for our lunch. Not only were we allowed to use their table, each of us was also served a bottle of ice cold drinking water.

Faith in God. So much for religion being opium of the people. I rather believe that being need, being at a loss leads people to the Omnipotent. Because of faith, many of these people are coping well enough from the trauma of having to flee from the raging waters of the flood and from the losses that they had. For example: There’s Fe who, because of the logs that hit her while in the floods, lost consciousness and as a consequence lost her child whom she was holding that time. She didn’t blame anyone for the loss of her child. She mourns for the loss, yes. But because of her faith, she’s able to accept what happened and comforts herself by looking at the picture of her child whenever she misses her. Another lady said she lost a comfortable home they’ve invested and sweated out for, for years. Because of faith, instead of mulling over the loss, she and her family are planning how to start all over again. Another lady was so grateful to St. Joseph. She salvaged his image among the junk several years back. Because of her devotion to the saint, she attributes their survival. She kept on speaking to the saint during their ordeal. She said their house was not as sturdy as that of the others, but it did not collapse during the floods and they were all saved.

Personally, the experience also widened my understanding of faith. Before the actual trip to CDO/Iligan, I had several little and big requests from our Lord. A friend was teasing me because my little prayers were unanswered. In fact, my little fears started to become real. There were several inconveniences that happened before and on the first day of our trip.  But I was in awe with the answer to by big requests. I was bracing myself for the de-briefing assignment. Knowing my tendency to fall into melancholy and despite that, I hoped to achieve the aims for the participants of the de-briefing activities -- that they be able to tell their story, that I be able to detect unhealthy coping and make the necessary referrals, that I be able to synthesize what I’ve heard, that I be able to identify coping mechanisms so that the participants be able to find direction. I asked that I don’t get emotional, that my forgetfulness don’t attack, and that I be able to say the right words – the therapeutic technique in the nurse-patient interaction. I was able to achieve that. My gift for synthesis was at its best and I did not have to worry about how to respond! And my group mates where just great!

Hope. The people’s faith is helping them get up from the devastation of the recent calamity. I had to correct myself in how to refer to them. They are survivors, not victims of Sendong. You can feel their hope of being able to rebuild their lives again. Meanwhile, they need to be guided; they need more assistance in their little steps towards independence. For instance, they need new homes. Since acquiring a new house is not going to be soon, they need shelter boxes (tents) where they can have more privacy and security while the head of the family starts going back to work again.

Love. It’s so wonderful to confirm that, really, love conquers all! There’s a young couple in CDO who was expecting their first child last December. When the waters started to rise, the pregnant lady was awakened by mild contractions. She awakened her husband and they both discovered that water has started to enter the house they’re renting. The man called at a neighbour who’s a tricycle driver and instructed him bring his wife to the hospital while he put their belongings to a higher part of the house. But the waters were rising fast. The man eventually decided to leave the house to save himself, leaving behind the baby clothes and the money they’ve saved up for his wife’s hospitalization and everything they own. While he worried about whether his wife was able to make it to the hospital, his wife feared that she might soon be widowed because she saw how ravaging the floods were. I love happy endings and this one is.  The following day, the couple saw each other in the hospital. It was a few more days before their baby came. At the time that I met them, they are just awaiting the right time to start going back to work again. I didn’t notice any trace of trauma on the couple during our conversation. They shyly told me they’re celebrating their first wedding anniversary last January 22.

A fourteen year old girl’s story also caught my attention. She told me that during the floods, her father had to fish her out from the waters knowing that she cannot swim. Recalling the near death experience made her cry but it strengthened her trust on her father and was grateful to realize how much her father can do - endangering himself - for love of her.