Meningitis

from Pediatrics for Parents .. 

By Belson, Martin MD 

Types of Meningitis Meningitis is an inflammation and swelling of the tissues that cover the brain and spinal cord. It is usually caused by a bacterial or viral infection that invades the cerebral spinal fluid (CSF), the fluid that protects and cushions the brain and spinal cord. Many of the bacteria or viruses that can cause meningitis are common causes of other everyday illnesses. However, sometimes they spread through the bloodstream to the CSF from an infection in another part of the body. In some cases of bacterial meningitis, the bacteria spread directly to the CSF from a nearby infection, such as a serious ear infection or severe sinus infection. 

Bacterial meningitis is less common than viral meningitis (also called aseptic meningitis) but is usually much more serious and can be life threatening if not treated promptly. Haemophilus influenzae type b (Hib) used to be the leading cause of bacterial meningitis but now a vaccine is given to all children as part of their routine immunizations. Today, Streptococcus pneumoniae (also known as pneumococcus) and Neisseria meningitidis (which causes meningococcal meningitis) are the leading causes of bacterial meningitis. About 90% of cases of viral meningitis are caused by members of a group of viruses known as enteroviruses, such as coxsackie virus. 

Signs and Symptoms 

The signs and symptoms of meningitis depend on factors such as the age of the child and the type of germ causing the infection. The signs and symptoms of viral meningitis are usually milder than those of bacterial meningitis. The first signs and symptoms of meningitis may be noticeable several days after a child has had a routine illness such as diarrhea and vomiting or a cold. 

Signs and symptoms in newborns or infants may include fever, sleeping more than usual, irritability, poor feeding, inconsolable crying, a bulging fontanel (soft spot on an infant's head) or seizures. Signs and symptoms in children older than one year may include fever, vomiting, headache, confusion, irritability, lethargy, neck and/or back pain, neck stiffness, photophobia (eyes sensitive to light) or seizures. 

Complications 

Complications, if any, depend on the child's age, the germ causing the infection, any other complications, and the promptness and type of treatment the child receives. The complications of bacterial meningitis can be severe and include neurological problems such as visual impairment, hearing loss, and seizures. Although some children develop long-lasting neurological problems from bacterial meningitis, most who receive prompt diagnosis and treatment recover fully. The majority of cases of viral meningitis resolve with no complications. 

Diagnosis 

Early diagnosis and treatment are crucial. Bacterial meningitis is diagnosed by growing bacteria from a sample of CSF. Cerebral spinal fluid is obtained by performing a spinal tap, in which a needle is inserted into an area in the lower back where fluid in the spinal canal is easily accessed. The doctor performing the spinal tap will explain the procedure in detail, including a few potential risks, such as bleeding or infection at the needle site. If the sample of CSF does not grow a bacterial germ, then the case of meningitis is considered to be from a virus. Identification of the type of bacteria responsible is important so that the best antibiotic can be used to treat the child. 

Treatment 

Treatment for bacterial meningitis involves intravenous (IV) antibiotics and hospitalization. The child may be started on antibiotics before the results of the spinal tap are available. Treatment for viral meningitis is usually given to relieve the symptoms and most children recover on their own without treatment. Treatment should include plenty of rest and fluids, and acetaminophen (Tylenol) or ibuprofen (Advil or Motrin) can be used to relieve fever and headache. 

A child who has viral meningitis may also be hospitalized depending on the severity of her symptoms. A child with meningitis may be given steroids to help reduce inflammation of the meninges, depending on the cause of the disease. A 2005 study published in Archives of Disease in Childhood showed improved outcome in children with pneuniococcal meningitis who were given dexamethasone, a steroid, along with antibiotics. 

Contagion 

A person who has meningitis or, more commonly, who has a common infection (e.g., pneumonia or gastroenteritis) caused by the same germ, can spread meningitis. The germs that can cause meningitis can be spread from person to person through tiny drops of fluid from the throat and nose of someone who is infected (through coughing or sneezing) or can be spread through contact with a person's infected stool. Sharing eating utensils, drinking glasses and tissues may spread infection as well. 

Neisseria meningitidis can spread between two persons who have had close or prolonged contact (e.g., same household, daycare center). People who are considered close contacts of a person with meningitis caused by this bacterium should receive antibiotics to prevent them from getting the disease. Fortunately, just because someone becomes infected with a particular germ does not automatically mean that person will get meningitis. In some cases, people may carry a germ that can cause meningitis without becoming ill; however, they can still spread the germ to others. 

Prevention 

Good hygiene (i.e. washing hands) is an important way to prevent infection. In cases of meningococcal meningitis or meningitis due to Haemophilus influenzae type b (Hib), doctors may decide to give antibiotics to anyone who has been in close contact with the person who is ill to help prevent additional cases. 

Routine immunization against the following germs is one of the most important steps in preventing meningitis: Haemophilus influenzae type b (Hib), Streptococcus pneumoniae (pneumococcus), measles, mumps and Neisseria meningitidis (meningococcus). 

For Streptococcus pneumonia, pneuniococcal conjugate vaccine (Prevnar) is recommended for all children two to 23 months and for children aged 24 - 59 months with weak immune systems (e.g., sickle cell disease). Immunization with this vaccine has led to an important decline in meningitis from Streptococcus in children two to 23 months. 

For Neisseria meningitidis (meningococcus), a vaccine was licensed in 2005 and is recommended for all children aged 11 to 12, children entering high school, college freshman living in dormitories, and children with immune disorders. 

Copyright Pediatrics for Parents, Inc. Dec 2008 

(c) 2008 Pediatrics for Parents. Provided by ProQuest LLC. All rights Reserved.

A service of YellowBrix, Inc. 

Study: No Link Between Autism, Vaccines

Study: No Link Between Autism, Vaccines

Italian Study Rules Out Thimerosal Fears


new study from Italy adds to a mountain of evidence that a mercury-based preservative once used in many vaccines doesn't hurt children, offering more reassurance to parents. 

Are Vaccines Safe?

In the early 1990s, thousands of healthy Italian babies in a study of whooping cough vaccines got two different amounts of the preservative thimerosal from all their routine shots. 

Ten years later, 1,403 of those children took a battery of brain function tests. Researchers found small differences in only two of 24 measurements and those "might be attributable to chance," they wrote in the February issue of the journal Pediatrics, which was released Monday. 

Only one case of autism was found, and that was in the group that got the lower level of thimerosal. 

Autism is a complex disorder featuring repetitive behaviors and poor social interaction and communication skills. Scientists generally believe genetics plays a role in causing the disorder; a theory that thimerosal is to blame has been repeatedly discounted in scientific studies.

Registered Nurses' Job Satisfaction in Navy Hospitals

from Military Medicine .. 

By Zangaro, George A USN NC Johantgen, Meg PhD RN 

ASSOCIATION OF MILITARY SURGEONS OF THE U.S.The United States continues to grapple with a critical shortage of registered nurses. Because hospitals employ large numbers of registered nurses they face the challenge of recruiting and retaining competent nurse employees. Nursing administrators, and hospital leaders, will be better positioned to retain registered nurses by better understanding the factors that influence recruitment and retention.1 U.S. military hospitals are particularly vulnerable to the nursing shortage because of the increased demand for acute care services for service members who sustained injuries in Operation Iraqi Freedom (OIF) and Operation Enduring Freedom (OEF). Job satisfaction has been studied previously, but this is the first examination of a population of nurses composed of both active duty Navy nurses and civilian nurses. BACKGROUND 

Nurses are the largest single group of health care workers in U.S. military hospitals and are providing significant amounts of care for casualities of the conflicts in Iraq and Afghanistan. In this challenging environment, military health care leaders are confronted with how to recruit and retain registered nurses. Degradation of military or civilian nursing staff has the potential to seriously compromise the Navy's peacetime and operational mission. One approach to handle the increased demand for care has been to increase the use of civilian nurses in military hospitals, yet no studies have examined how these two groups differ or the factors that influence their job satisfaction in Navy hospitals. Having an understanding of nurses' perceptions of their workplace appears to enhance job satisfaction, reduce job stress, and improve retention efforts.2- 3 Kovner and colleagues reported that supervisor support, job stress, promotional opportunity, and routinization are all significant predictors of job satisfaction.2 Creating a work environment that encourages participative management, constant communication with staff, and visibility of the nurse manger in the clinical setting are some factors that have been associated with satisfaction and can be influenced by administrators. 

Although some personnel issues are common to all hospitals (e.g., salary, promotional opportunities, job stress, and job satisfaction), the Navy has unique issues that affect nurse recruitment and retention. A Navy nurse is required to sign a contract for a fixed number of years and will likely be asked to move their residence and work site every 3 or 4 years. These can be considered to be not attractive to some nurses. The Navy must also be concerned with the broader issues that affect the civilian nursing workforce since civilian nurses supplement military nurses in many military hospitals. Civilian nurses are becoming more difficult to recruit and retain in the military sector as opportunities increase in the civilian sector. 

A strategy used to address recruitment and retention has been to identify and address factors influencing job satisfaction. Several studies of military nurses' job satisfaction have been conducted, but few have been published and the studies may not reflect the more recent shortages and wartime operational needs.4-* None of the previous studies have compared satisfaction of military and civilian nurses in Navy hospitals. Economists, psychologists, and sociologists have all contributed to the development of the models of employee satisfaction, commitment, and turnover. Price and Mueller's theory acknowledged that employees enter the workplace with certain expectations and values.7 If these expectations and values are found in the workplace, the employee will be more satisfied, committed to the organization, and less likely to leave. These factors are most practically assessed in a survey instrument that is administered to employees. The concepts measured include autonomy, promotional opportunity, role ambiguity, routinization, coworker support, and several others. Price and Mueller's instrument is supported with empirical evidence from several different samples including nurses in hospitals,8,9 nurses holding doctoral degrees,10 hospital-based military health care personnel," military physicians,12 dental hygieniste,13 and all employees in a U.S. Veterans Administration Medical Center.14 Most recently Kovner and colleagues used the Price and Mueller conceptual model to guide their study of recent nursing graduates.8,15 

The nursing literature is replete with studies linking employee factors and work-related factors with job satisfaction.2,8,16-20 In studies conducted at military and civilian facilities job satisfaction has been positively related to autonomy, coworker and supervisor support, resource adequacy, professional growth, promotional opportunity, and distributive justice.2,4-6,10,11,20-22 Routinization and role ambiguity have been negatively related to nurse job satisfaction.2,10,11 

Military nurses and civilian nurses working for the U.S. government represent a relatively unexamined population. Moreover, there are distinct differences between military nurses and civilians employed in military facilities. For example, civilian nurses are often older, more experienced, and work part time. Military nurses have a larger proportion of males and higher education levels since a bachelor's degree is required for entry to each of the military nurse corps. Investigating differences in these two groups was expected to uncover new information about job satisfaction that would begin to fill gaps in current knowledge. 

METHODS 

Sample 

Using a cross-sectional design, a paper survey was administered anonymously to nurses working at three Navy hospitals on the East Coast. Sample size was based on Tabachnick and Fidell's recommendation that 10 respondents per variable are needed for adequate power in linear regression.23 Assuming that 10-12 predictors would be used in the model, the sample size was more than adequate (military = 283 and civilian = 213). Data were collected, after Institutional Review Board approval at the three organizations. It was estimated that -1,173 nurses meet the inclusion criteria. The return of the questionnaire was considered implied consent. 

The eligible nurses included Navy staff registered nurses with the rank of Ensign (0-1) through Lieutenant Commander (0-4) and civilian registered nurses employed in the Federal General Schedule (GS) system in grades GS-9 through GS- 12. These employment levels were selected because they include most of the nurses who provide clinical care for inpatients. In the military, nurses in the ranks of 01 to 04 have the highest attrition rates. This is a critical group of nurses that are highly desired to be retained because of their clinical competence. 

Procedures 

Questionnaires were distributed using a modified Dillman approach.24 An e-mail was sent to all eligible nurses inviting them to participate in the upcoming survey. Two weeks later, the questionnaires were placed in each nurse's unit mail box. Two options were offered for returning the completed questionnaire. After placing the questionnaire in an envelope, the questionnaire could be placed into a designated box on the nursing unit or it could be sent via the hospital's internal mail system to the principal investigator (PI) at the hospital's research office. A reminder e-mail was sent to all nurses 3 weeks after the initial contact and a reminder postcard was placed in their mailboxes. Finally, an e-mail reminder was sent to all potential respondents 7 days before the data collection period was to end. 

Measures 

A modification of Price and Mueller's model of turnover guided the concepts examined in this study (see Figure I).7 The survey was adjusted to account for military concepts by modifying items to address specific military issues. The mapping of items to the concepts of the Price and Mueller model were maintained. Table I presents the constructs measured in the study, a conceptual definition of each, the number of items used to measure each concept, and mean and standard deviation for each scale used in the analysis. All items were measured on a 5-point Likert scale with anchors of 1 = strongly disagree and 5 = strongly agree. These items have been found to be reliable and valid in previous research.2,7,12 For example, the three items used to assess routinization were related to variety in the job, having the opportunity to do different things on the job, and repetitiveness of the job (see Price and Mueller7 for a summary of each concept and the items used to measure each concept). In the current sample, the average alpha coefficient was 0.74 for all items in the model. The survey also included open-ended questions where nurses could add comments. 

Analysis 

Data were analyzed using SPSS version 15.0. Descriptive statistics were compared to characterize the demographics characteristics of the military and civilian sample of nurses. Linear regression analysis was used to determine significant predictors of job satisfaction. Statistical assumptions of linearity and normality were tested and all assumptions were met. Multicollinearity was assessed using the tolerance test and variance inflation factor.23 Since age and rank were highly correlated with both tenure and experience, only tenure and experience were included in the models as control variables. As the focus of the study was on isolating the factors that influence satisfaction, the analysis was conducted in two steps. In step one the demographic variables were entered, followed by the Price and Mueller concepts. RESULTS 

A total of 496 usable questionnaires were returned for a response rate of 42%. Military nurses had a response rate of 35% (283/806) as compared to a 58% (213/367) response rate for civilian nurses. Table II depicts the demographic charac- teristics for the sample. More than half of the respondents were military nurses (57%). The distinct differences in Navy and civilian nurses are evident. There was a difference in age with 84% of the military nurses being between 21 and 40 as compared to only 19% of the civilian nurses. The majority of the nurses who completed the questionnaire were female in both groups although the military sample was one-third male (33%) as compared to only 7% of civilians. The military nurses represented the range of ranks whereas nearly two- thirds of the civilian nurses were in GS- 12 pay grade. All mil- itary nurses had a bachelor's degree or higher whereas 70% of the civilian sample had a bachelor's degree. Half of the civilian nurses had been working at the present organization for over 7 years as compared to the military nurses who had only 5% working in the organization for more than 7 years. This difference in tenure is expected because military nurses are changing duty stations every 2 to 4 years. The civilian nurses were also more experienced as reflected in the fact that 61% report being a registered nurse for 4 or more years whereas only 8% of the military nurses had that much experience. The military nurses were registered nurses for 6.33 years and the civilian nurses were registered nurses for 22.44 years. 

Since the purpose of the study was to compare the relative influence of factors influencing satisfaction of military and civilian nurses two demographic characteristics - tenure and years of nursing experience - were entered into the model as control variables. Regression models were fitted separately for both military and civilian nurse subgroups. As shown in Table III, the models were significant and explain a substantial portion of variance in job satisfaction for both military (51%) and civil service nurses (55%). The standardized negative coefficients indicate that routinization has the strongest negative association with job satisfaction for both military and civil service nurses. Higher levels of routinization predicted lower levels of job satisfaction, even controlling for tenure in the organization and years of experience. Promotional opportunity was a significant predictor of job satisfaction for both military and civilian nurses, although the influence was stronger for the military nurses. For military nurses, resource adequacy and supervisor support were also significant predictors of job satisfaction, although coworker support and role ambiguity were significant for civilian nurses. Increasing amounts of role ambiguity were associated with lower levels of satisfaction. 

DISCUSSION 

This study has added additional information to the knowledge concerning job satisfaction in nurses by investigating two distinct nurse populations who work in the U.S. military health sector. Moreover, the survey items were derived from a comprehensive retention model and composite scores were created on the basis of the model. 

The strongest predictor of satisfaction for both groups was routinization and it was negatively associated with job satisfaction. This indicates that the more routinization employees experience on the job the less satisfied they are. Interestingly, the mean score for the routinization items in both groups was very similar (2.58 for military nurses and 2.60 for civilian nurses) and this represents a fairly low score compared to the other concepts in the model. The significant positive relationship between promotional opportunity and job satisfaction for both cohorts was also not unexpected. Nurses who perceive opportunities for promotion are more likely to be satisfied. This relationship is consistent with the Magnet hospital force standard of professional development (http:// www.nurse credentialing.org/model/index.htm).25 On the basis of these findings, hospital and nursing administrators should consider that order and discipline are good, but more promotional opportunities are needed to ensure nurse satisfaction. 

For Navy nurses promotion offers instant benefits including public recognition (i.e., through uniform insignia), increased positional authority (i.e., through achieving a higher military rank), and increased pay. These characteristics promote higher self- worth, thus leading to increased job satisfaction. 

In contrast, the potential for promotion of the civilian nurses is quite limited in many Navy hospitals. On the basis of the narrative comments from civilian nurses, many did not feel they have an opportunity for promotion. Civilians expressed a strong sentiment that there is no clear career path available to them as there is for the military personnel. These findings may be particularly relevant to nursing administration in military hospitals because civilian nurses are playing a critical role on the military health care team. In addition to the loss of military nurses because of deployments to the combat theaters, there has been a move over the past decade to decrease the number of active duty nurses serving in the U.S. Department of Defense (and to replace them with civilian contract nurses). 

The findings also demonstrate that having adequate resources to do their job contributes to job satisfaction in Navy nurses. This finding is not surprising because to provide quality care to patients, supplies and support services must be available to the staff. This relationship is also consistent with the Magnet hospital force standard of consultation and resources (http:// www.nursecredentialing.org/model/ index.htm)25 The Navy nurses affirmed previous findings that supervisor support was a significant contributor to job satisfaction. This finding was supported by narrative comments related to concerns about leadership deficits in their supervisors. Military nurses in the early stages of their careers are likely to recognize the benefit of having more senior mentors who can guide their career. In a study of U.S. Army nurses serving in the Reserve component, nurses with less military seniority who had a mentor reported higher levels of job satisfaction and career commitment.26 Prevosto noted that mentored relationships help the novice nurse become acclimated into the military culture. 

For civil service nurses, coworker support was the second strongest predictor of satisfaction. This may be the result of civilian nurses coming into military settings, where they are not part of the military hierarchy and must rely on coworkers to clarify their role and navigate the organization. Likewise, higher role ambiguity was associated with lower satisfaction, suggesting that civilian nurses' roles are not clear. This finding is consistent with the narrative comments where both Navy and civilian nurses reported that they experienced a sense of teamwork and support from their peers. Coworker support has been identified as a crucial component in establishing a positive work environment.27 

One of the most important implications of the findings concerns civilian nurse retention in the military health sector. The current nursing shortage makes it difficult for the military to recruit and retain civilian nurses. The findings from this study have shown that there are different motivating and satisfying factors for military and civilian nurses. It would be desirable to tailor retention strategies differently for military and civilian nurses in military hospitals to enhance retention. 

At the organizational level, there may be value in integrating civilian nurses into the management structure. This might involve increased leadership opportunities and participation in governance and committee work. Civilian nurses, with their extensive years of experience are a valuable resource but based on narrative comments may be underutilized. Future research is needed to examine and test models that integrate more civilian nurses into the leadership team within the organization. 

At the hospital unit level, inclusion of more civilian nurses in management positions may add stability to operations. The findings from the study suggest a lack of coworker support and role ambiguity were related to dissatisfaction in civilian nurses. Strategies that increase teamwork and clarify civilian nursing roles may enhance satisfaction and should be examined. Finally, future research should examine the effect mentors have on both military and civilian nurses' job satisfaction. 

Several limitations of the study must be acknowledged. The satisfaction data were obtained from a convenience sample of nurses, not a random sample. Although the response rate was better than in similar nurse survey studies, there may be response bias. Data were collected at three large acute care Navy hospitals and the findings cannot be generalized to all military hospitals. As with any survey approach to data collection there is the potential for bias in self- report measures. 

The study used a well-established model and instrument to assess a large sample of Navy and civilian nurses who work side by side. The lack of significant influences of autonomy, distributive justice, and professional growth might be considered a good result since these issues have been identified as dissatisfiers by nurses in other studies. Yet, the importance of promotional opportunities, resource adequacy, and supervisor and coworker support are affirmed. Although some of the comments reported by nurses were critical in nature, the respondents also reported a strong sense of patriotism and were committed to caring for this patient population. Further investigation into factors affecting military nurses' job satisfaction and civilian nurses' job satisfaction must be explored, particularly as military operations continue overseas. ACKNOWLEDGMENTS 

This project was supported by TriService Nursing Research Program (Grant N02-031), Uniformed Services University of the Health Sciences. 

Copyright Association of Military Surgeons of the United States Jan 2009 

(c) 2009 Military Medicine. Provided by ProQuest LLC. All rights Reserved.

A service of YellowBrix, Inc. 

West Nile Encephalitis Claims Woman's Life

from Tulsa World .. 

By KIM ARCHER 

CUTLINESWithin a week of getting a mosquito bite while in her mother's backyard, a vibrant Broken Arrow woman became an invalid on a ventilator and feeding tube. 

Jerry Kay "Tootie" Froman had unknowingly contracted West Nile virus from that mosquito, said her daughter, Kristin Makhani. 

"You don't know which mosquito might have it," she said. 

Froman got the bite in 2007 at her mother's home around 52nd Street and Peoria Avenue. She died Monday at the age of 64 after a 16-month-long battle with the disease caused by the virus. 

"If she died so that somebody else doesn't, it just makes it easier. A prayer will have been answered," Makhani said. 

At first, doctors thought Froman had a stroke. She was confused and couldn't think of her own name. She was taken to the hospital, where she underwent all kinds of tests. The diagnosis was West Nile encephalitis, which is an infection of the brain caused by the West Nile virus. 

Most of the next 16 months, Froman was on a ventilator. She spent time in a rehabilitation facility and a nursing home. A form of staph infection called methicillin-resistant Staphylococcus aureus found its way to her lungs. Her blood pressure frequently dropped perilously low. She contracted pneumonia and many other virulent infections. Froman even suffered a mild heart attack and was in a coma for two weeks. 

"It changed her personality. She could do nothing for herself at all," Makhani said. 

Froman had long ago told her family she didn't want to live if her life were reduced to a bed and ventilator. That made her suffering even more painful for her family, who could only watch as the woman they loved became someone they didn't even know. 

"They had to restrain her once because she was combative. That wasn't her," Makhani said. 

She said she wants her mother's suffering not to have been in vain. 

"She was kindhearted and never met a stranger," Makhani said. "What she has been through I would not wish on anybody." 

In a written letter to her mother's friends and family, Makhani wrote: "Contrary to information from the CDC, West Nile can affect anyone at any age. Please protect yourself and your loved ones. Wear insect repellent. Avoid being outdoors at dusk during mosquito season. Share Tootie's story; something good needs to come out of this tragedy. It only takes one bite." 

Kim Archer 581-8315 

West Nile virus facts: 

Eight people in Oklahoma died from West Nile in 2007; no deaths were reported from the virus in 2008. 

Nationwide, 124 people died from the virus in 2007 and only 34 in 2008. 

The virus is carried by mosquitoes and is considered a seasonal epidemic that flares up in the summer and continues through the fall. 

One in 150 infected with the virus will develop severe illness. People older than 50 are more likely to develop severe symptoms. About 80 percent who are infected will never show symptoms. The rest may have symptoms such as fever, headache, body aches, nausea, vomiting, and sometimes swollen lymph glands or a skin rash on the chest, stomach and back. 

The best way to avoid getting West Nile virus is to prevent mosquito bites. Wear insect repellent. Make sure you have good screens on windows and doors. Empty any standing water in flower pots, bird baths and other containers. 

Services set for 1 p.m. Saturday 

Services for Jerry Kay "Tootie" Froman, 64, of Broken Arrow are scheduled for 1 p.m. Saturday at Moore's Southlawn Chapel, 9350 E. 51st St. 

Originally published by KIM ARCHER World Staff Writer. 

(c) 2009 Tulsa World. Provided by ProQuest LLC. All rights Reserved.

A service of YellowBrix, Inc. 

"Gotta Love Transcultural Nursing"

by RNACHIEVER

My transcultural nursing experience began eight years ago when I was deployed in, what I thought would be the least expected place I would ever be, the Kingdom of Saudi Arabia. Being a nurse from the Philippines, I was one of those who dreamed of coming to America for a greener pasteur, but because of unavailability of visa at that time, I ended up in Saudi Arabia. 


Not knowing how to speak Arabic & dealing with a totally different from my liberated but reserve culture was tough but was a challenge for me. After two years & three months of having lived & worked there, I embraced their culture beyond a point where I didn’t want to leave the country. I’ve learned to love the place & the people, to understand & respect their culture & to finally learn that they’re not really at all bad as I’ve always known them to be. They are indeed one of the God fearing people I’ve ever known. The most significant thing I’ve learned from them is their being vocal about praising & thanking God, thus the Arabic term “Alhamdulillah”, & believing in God’s will, “Insha’Alla”.

One of the most unforgettable experience that I had when I was in Saudi was that one night when I had this 81 year old male patient one day post op CABG who, I thought, had an episode of post-op Psychosis. I say this because one day pre-op, the patient was totally with it, very calm & cooperative, but then the day after the surgery, the patient was totally different. What I remember at that time was that, he was sitting in his bed awake, staring at me, and was very quiet. In Arabic, I asked him if he was having pain. He was not responding at all & he was just staring at me. He looked comfortable though & demonstrated no signs of pain so I thought he was ok & left to get his due antibiotics. As soon as I got back to him & was about to give the IV push antibiotic, he suddenly jumped out of his bed still with all those chest tubes, catheters & cables connected to him & became very agitated, shouting & shouting in Arabic words that I can hardly understand. My colleagues came to the rescue as the patient was becoming more agitated & combative. Nobody among us had any idea what he was talking about. One of my colleagues who was even well versed in Arabic could not even understand the words the patient was shouting saying that his Arabic was a dialect that must have been spoken by the natives. Knowing that we were in a really bad situation, we had to call the ICU resident, the supervisor, & the security at 2am. The resident came & in authority, spoke to patient & the patient suddenly calmed down but continued to talk harshly in Arabic & was pointing at me seemingly accusing me of something bad that I’ve done. I was shocked & speechless thinking what the hell was going on with the patient? Where did I go wrong? The resident approached me &, maybe seeing that I was very pale, calmly said, “It’s ok, the patient thought you were giving him urine instead of antibiotic.” I said, “What?!” Everybody who was there just bursts into laughter! I was relieved & realized where I went wrong. It was my failure to tell the patient that I was to give him his antibiotic & that was because I didn’t really know how to say it in Arabic. Although I tried to tell him that it was an antibiotic in Arabic, he may not have understood me because of the way I said it. Lesson learned: Must learn Arabic when you go to Saudi Arabia. 
Still having no Immigrant visa for U.S. after my two year contract in Saudi Arabia, I applied for a job in a hospital in Dubai & got deployed in 2005 for a another two year contract but just actually completed a year because I finally got my US Immigrant visa in 2006. 

Coming to Dubai was another totally different experience for me. Actually thought, I came to India because most people I saw there were actually Indians. I barely saw the natives on the streets. Most of the people I worked with were from U.S. & Europe, some from the neighboring Arab countries. The hospital where I worked was servicing mostly the Royal families & international patients which was more of a challenge for me because I had to deal with a diverse culture & different languages. It was a good though that the hospital had translators that can be paged anytime we needed them. 

My unforgettable experience there was something that really got me in trouble that I got suspended for one day. I had this Korean patient whom I thought was a business man who, according to the history as I read on his admission notes, had a cardiac arrest when he got to Dubai International Airport as soon as the plane landed. CPR was initiated & thank God, he was revived & rushed to the hospital. Again, I was on night shift at that time & I was assigned to the patient. Since our unit wasn’t really busy at that time, he was the only patient I had. The patient was perfectly stable when I got him. Everytime I came to him, he was brimming with smile & say 'thank you' everytime I did something for him. He never really spoke too much because he was not really fluent in English. All he said was thank you. Because of that, I really thought he was very nice.
As I was sitting there in front of him staring at the monitor, he must have thought I was getting bored so he reached out for his I-pod which was sitting at his bedside table & tried to hand it over to me with his right hand. His left hand pointing at his left ear as if trying to communicate he wanted me to have his I-pod & listen to whatever music he had on his I-Pod. I told him, "No, we are not allowed to listen to music here at work". He didn’t seem to understand me & he insisted on handing me over the I-Pod. He even came up with his second English phase, “It’s good, it’s good”. Thinking that I don’t want to disappoint him, I got the I-pod & pretended to put the earpiece on my ears. Although, it wasn’t turned on, I pretended I was listening, smiling & enjoying the music. He was smiling all the time & said, “good, good...” For about 15 min, he finally got to sleep & I felt I was falling asleep too. Because I was really getting bored & because of my curiosity for the songs he had on his I-pod, I turned on the I-pod & listened to it. To my surprised, the music, although it was Korean, was so much pleasing to my ear that I decided to leave it on. My colleagues looked at me & never really said a word. The night was uneventful. I left work in the morning while my Korean patient was sound asleep & left his I-Pod on his bedside table. In the middle of my sleep during that day, I got a call from the nursing office telling me that they got a complaint from a patient that I used his I-POD at work that night without asking him permission. Although, I tried to explain myself, I was at a lost in the end. The ultimatum: Suspension for one day! Lesson learned: Don’t be so naive thinking that a person is so nice when he could actually get you in BIIIGGG TROUBLE!

So I finally came to America in 2006. This is where I got to experience a lot more about transcultural nursing especially because I came to, what I guess, the most diverse cultural city in America: New York City! I got the share of experience with different cultures totally different from my culture but I’d say, it wasn’t really difficult to blend with them since I’ve already learned the easy way to deal with it.

My most unforgettable experience in America so far is when I had this 75 y/o male Armenian patient recovering from a traumatic brain injury secondary to a fall. According to the family, the patient had a sharp mind, intelligent, & very fluent in English prior to the incident & they were totally devastated to find out that their used to be intelligent father became very incoherent, totally confused & never spoke English after sustaining the brain injury. The patient reverted back to his native Armenian language & never really spoke & didn’t seem to understand English at all! It was one of my most difficult but also the most significant encounter that I had because it changed the way I deal with patients in terms of their mental status. 

The first night I received the patient, I was given the heads up about the patient’s mental status & behavior. I was told that neuro wise, the patient is in & out of confusion & is mostly confused during the night. The patient definitely needs a 1:1 observation but unfortunately because of no available staff to sit with the patient, I ended up being with the patient most of the time. For most of the time I was with the patient, the patient was persistently talking by himself words that I absolutely cannot understand. I asked the patient a few times, ‘Are you ok?’, and he would respond with litany of words absolutely foreign to me. That was for me a confirmation the patient was really confused. A few times, the patient tries to get out of bed but then I easily manage to get him back since he seemed to follow some commands. A lot of times, he would ask for sips of water by pointing at a cup at his bedside table. For most of the night, the patient, although almost never slept, was very calm. At 5:30 am in the morning, the lab technician came to draw blood from the patient. The technician was about to draw blood from the right hand of the patient when the patient suddenly started screaming, yelling & trying to pull his arm from the technician. Again, I was surprised to see the patient acting that way from being very calm the entire night so I thought it was just part of his confused mental state and I ignored whatever he was saying because I couldn’t understand him anyway. I tried to help the lab technician by holding the patient’s arm but the patient was strong enough to pull his arm away from us. He was continuously screaming & yelling at us & became more combative that I have to call a male nurse for help. As we were trying to calm the patient and as I was trying to hold his arm once again, I suddenly felt something weird on his right upper arm. Realizing what it was, I immediately tried to roll the patient’s sleeve & to my surprise, I saw what I thought was a closed AV fistula. I was totally taken aback! I ran to the nurses' station & review the patient's chart & there it was, I saw that the patient just had an AV fistula inserted a week ago. I felt so stupid at that time not knowing & mad that such a significant info was never endorsed to me. I then realized that the patient was not at all confused! He knew he had an AV fistula on his right arm so he resisted being stuck on that arm. It was one of the most important lessons I’ve learned: Don’t underestimate your patient’s mental state even though you’ve thought all along that the patient is incoherent or confused. In addition, it is always best to get a translator before doing any procedure for a foreign speaking patient.

My transcultural nursing experiences were, I would say, challenging, exciting, interesting & really fun. Transcultural nursing is one of the things that really made me so proud to be a nurse because everyday I deal with different people. I learn from each encounter that I had with them. Until now, I love the everyday experience. After all, I believe, that to be a really successful nurse, “you gotta love transcultural nursing”.

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