The Nightingale Protocol.

A Handbook of Hope and Encouragement for Nurses and Caregivers

Angela Posey-Arnold RN BSN

1272 County Road 296

Hillsboro, Alabama 35643

256-974-2807

Gracenotes1@bellsouth.net

www.angelaposeyarnold.com

Angela Posey-Arnold RN BSN began her career in nursing in 1988, practicing in pediatrics, diabetic metabolic unit, home health care and finally in long term skilled care and rehab. In 1994 she was hired as Director of Nursing in 103 bed skilled nursing facility and found the nurse inside that she had been searching for in a very unlikely place. These are her stories, shared from her heart.

Flying By the Seat of My Scrub Pants

By Angela Posey-Arnold RN BSN

Anxious anticipation filled me as I arrived early for my interview. Working for years as an RN in Quality Assurance in Home Health Care, I rarely saw a patient. I missed the hands on nursing. The expectation of possibilities of the interview was exciting. It was an Assistant Director of Nursing position in a Long Term Care facility.

I never thought I would like working in a nursing home because of the horror stories I  heard. I took the job because I thought it would be a stepping stone to a job with the state. I knew I would want to change the world if I worked in Long Term Care. I got the job and I got my chance.

I was hired at ten o’clock a.m. on January 4^th, 1994. I remember the exact time because I had gone home to eat lunch only to get a call at one o’clock p.m. from the administrator asking me if I could go ahead and start work that same day.

I thought to myself, “This is a little odd. Why would he want me to work today, I haven’t even started orientation.”

I put on my scrubs and went back to the facility. The administrator seemed extremely nervous and told me all I had to do was to be present in the facility for 4 hours. So, I did. He asked me to make rounds and get to know the staff and residents. Then he left. Little did I realize I was actually in charge. I was flying by the seat of my scrub pants. Oh, how green I was. If I knew then what I know now, I would have had the sense to be terrified. As it was, I didn’t know enough to be scared.

The facility had just lost every administrative RN they had from DON to Nursing Supervisor. They were all gone. I was the only RN they had. I know I should have probably run for the hills, but somehow I knew this is where I was supposed to be. I went back the next day and began to learn what was really going on. Weeks before the Director of Nursing had walked out with the Nursing Supervisors and MDS coordinator in tow. All due to an ongoing conflict with the administrator in regards to poor quality of care.

There was overwhelming evidence that the nursing department was hopeless. The administrator spent all his time in his office with the door closed and his phone on “Do Not Disturb”. At the same time they hired me they also hired Elizabeth as the director of nursing. She was scared to death and had no idea what to do. She couldn’t teach me what she didn’t know herself.

Staffing was terrible, nursing care was worse. Many of the residents were in restraints; there was a horrible number of cases of weight loss, pressure sores, medication errors, odors, residents being neglected. It was a nightmare for two weeks.

I went home everyday exhausted; all I could do was pray. Because of my faith in God I knew that He didn’t like the way his children were being treated. He wanted change too. I also knew that I could only make changes with His help.

The staff walked around in a state of despair. They were so unhappy. Some of the nurses were just bad nurses, lazy and mean. They did not want to change and they resented my every effort. They knew I was about to turn their comfortable little world of laziness into one of work. Some were not willing to change and worked against me constantly.

The residents were unhappy, the families were unhappy, too, and they were looking to me to change it. The facility was in trouble, but I had hope that things could change.

I did not know Federal or State Regulations even existed but I did know good nursing care. One resident at a time I started to try to change things. I did have a nurse consultant from corporate that was available for me if I had questions. He was supposed to come and “orient” me soon.

I had been there for two weeks, flying around by my proverbial britches, when I was summoned to the front office by a very frantic nursing secretary. There in the lobby stood four women and two men. The administrator had gone somewhere without leaving a number for me to reach him. I quickly learned that these six very serious looking people were from the state. They were there to “survey” the facility.

The DON was gone to lunch so I told the surveyors that I had been there for two weeks and I was in charge.

I called corporate and my consultant said, “Just do what they ask, I’ll be there in four hours.”

The surveyors remained in the facility for four days. Corporate came in like the cavalry and my administrator spent a great deal of time in his office. I think he was crying. When he wasn’t in his office, he was just standing around looking really stupid.

Elizabeth and I worked with the surveyors. Frankly, I was glad to see them. I was glad that they were there. For the first time, I had hope that things were definitely going to change. I had a feeling that a positive outcome was possible even when the evidence appeared to be to the contrary. We sure were getting a lot of attention from corporate and that is exactly what we needed. 

On the exit interview when the surveyors had finished and were ready to leave, administration was called into conference-- with some very angry surveyors. The evidence was overwhelming that the facility was in terrible trouble. They had written thirty eight serious deficiencies most of them in nursing and dietary. The problems were based on a scale in 1994 and these all were Level-A deficiencies, which meant that the residents were in immediate jeopardy. It meant that there was evidence of actual harm. The surveyors told us that we had thirty five days to turn this all around.

They would be back in thirty five days and if they did not see drastic changes the doors would be locked and the residents would be removed. I praised God. It was a blessing. This is exactly what I had prayed for—help. I had prayed for help and help had arrived.

The administrator was fired and a new administrator arrived the next day. The DON walked out without notice and I was offered the job. After I met with the new administrator I decided to take the job. She and I were like two peas in a pod. We were on the same page and both knew that with God’s help we could do this. We could affect change together. That hope immediately bonded and sustained us.

I was assigned a nurse consultant that stayed with me for the thirty five day period. She was wonderful and taught me so much. The difficulties seemed to be impossible but when we tackled them one by one, we began to foster change.

The nursing care issues were never going to be fixed until we changed the heart of the staff. They had lost their hope a long time ago. We knew that instilling hope in them was the only way to change the care they were giving. For years they had been left on their own. They had no leadership. They were like neglected children.

Most of them wanted to change, some of them did not. We slowly but surely discovered who wanted change and who didn’t. It was difficult to fire someone that had been there for twenty five years, but it had to be done. We only had to fire a few nurses. The others had good hearts and looked forward to the facility being better.

Within a week the expectation that change was occurring, created optimism in the staff. They began to anticipate that together as a team we could make the changes needed to keep the facility open-and to keep the residents happy and healthy. For the first time in many years it seemed possible to them that what they desired for the facility was likely to happen.

As time progressed and positive changes were made there was a new feeling in the facility. The staff was happy and it showed. The residents started to feel that we really cared about them and they began to hold up their heads, and smile. The families realized that we were serious about changing the care that the resident’s received. All this new found hope led to positive attitudes and perseverance from the staff.

Our administrative team was consistently professional and executed the plans for change. We needed to prove to the staff, residents and families that their hope was not in vain. As a team we realized we were free to change the circumstances and that together we could do it.

Every couple of days we would post a large banner at the time clock. We used acronyms for hope. Each one instilling more of a positive attitude in the staff. It was a trickle down effect. The more positive the staff became the better care the resident’s received.

Some of the acronyms came to us from staff team members.

*Harnessing Our Power to Excel

*Heart Outreach-Positive End

*Healing Our Patient’s Environment

*Have Only Positive Expectations

*Hearts Offering Professional Excellence

*Help One Person Excel

*Hat’s Off for Professional Excellence

Thirty five days quickly passed. The state surveyors came back ready to shut us down. I have no idea of what they were going to do with one hundred and three elderly or otherwise debilitated residents, but they were prepared to do what they needed to do.

They surveyed as we watched with anticipation. We had done everything we could possibly do to improve the care in thirty five days. Now all we could do was sit back and watch. We had nothing to hide and told the staff to be courteous and honest with the surveyors.

The results were astonishing. Our residents had weight gain and no one had lost any, pressure ulcers were healing, and we had no new in house acquired wounds. We had safely reduced the use of restraints and we had programs in place to continue to improve quality of care. The odor was gone. The enhanced quality of care had taken care of that problem at the source.

The day came for the exit interview with the surveyors. We held our breath as they cited us with several Level B deficiencies, mostly physical plant picky stuff. There were no Level A deficiencies and the ones that we had before were lifted. They were not going to close the doors.

Surveyors never compliment. They are there to find problems not to pat you on the back. But before they left, they told us they knew the facility had changed the minute they walked in the door. They said it was amazing how the atmosphere had changed. We smiled because we knew hope did it.

Oh, they always kept a close eye on us and visited often. But five years and many surveys later the nursing department earned a deficiency free survey. They could not find one problem, testimony to excellent quality of care.

The surveyors just could not leave without writing a deficiency on something. They actually got under the outside dumpster with a toothbrush and wrote us up because our dumpsters were dirty.

Hope had conquered! We had a huge party for every shift. The residents, families and staff celebrated every victory together. We could not have done it without doing it as a team that really cared. We had evolved into a compassionate nursing department that took pride in the care we provided.

I thanked God because I knew it was by His hand that hope prevailed in a very ominous situation.

©Angela Posey-Arnold RN BSN

Gracenotes1@bellsouth.net

www.angelaposeyarnold.com

Order your copy today at Amazon.com or send an email to angela@angelaposeyarnold.com for a signed copy.

PayPal accepted--see links page.

As a Director of Nursing she always had an open door policy, she still does. She can be reached here through her website email at angela@angelaposeyarnold.com, or on her blogsite at www.angelaposeyarnold.wordpress.com

Order your copy of THE NIGHTINGALE PROTOCOL today from the Publisher--at www.publishamerica.com or from any major online book retailer. www.amazon.com

You can order signed copies by sending an email to angela@angelaposeyarnold.com.

Meditations on Hope: Nurses Stories about Motivation and Inspiration was officially released by Kaplan Publishing in October 2008.

I am so pleased to have one of my stories included in the book.

Flying By The Seat of My Scrub Pants is featured on pages 70-80.

Also released this month by Kaplan is another book in this series:

REFLECTIONS ON DOCTORS by Nurses is available now online and where all good books are sold.

My story is included on page 59-65--The Best Doctor This Side of Heaven.

The last book in this series is Final Moments: Nurses on Death and Dying. My story is entitled, "It's Heaven I See."

We are all so excited about these three new books and the interest in nurses and the profession.

Look for both of these online and in bookstores.