nurse at large: saying goodbye

When I started nursing school in 1974, Dr. Kubler-Ross’ book On Death and Dying was only five years old.  It had become part of the nursing curriculum, but was still considered new material and the notion of “stages” of grief was still novel.  Through the course of my career I have tried to test it, not because I didn’t believe in stages of grief but because I thought there might be other models.  My conclusion is that  Dr. Kubler-Ross has been spot-on in terms of dealing with patients, and now I know her theories also fit my own major life changes.

This morning I heard a story on the radio about a woman whose career as a magazine editor came to an abrupt halt.  She wrote a book about the aftermath and told about things like staying in her pajamas all day, eating peanut butter from a plate to make it seem a meal, and so on.  She learned to appreciate her daily life, the reporter said, and found new joy in gardening and taking care of her home.  But she mourned the loss of her work routine and the job she had loved.

Strange, isn’t it, that this story finally brought my own situation into focus.  I lost my job after a serious injury, but didn’t stop trying to work as a nurse (Stage I:  Denial).  I clawed and scratched my way into another nursing role, taking on much more than anyone thought I could manage, and wasn’t able to keep it together (Stage II:  Bargaining).  I became filled with righteous indignation that my own profession hadn’t found a way to save me; the hospital to which I had been so loyal had dumped me at my most vulnerable moment–thus causing my ultimate failure (Stage III:  Anger).  But nobody really cares about why you can’t do something.  This is American, land of pragmatism.  Either do something or get out of the way.  I tried desperately to keep my nursing identity while living in a state of inertia until I finally realized how far from the mainstream I had traveled (Stage IV:  Depression). 

Today the light finally dawned.  I am done.  When the doctor said I couldn’t return to nursing, that meant I couldn’t return to nursing.  I can’t manage the physical demands.  I can’t manage the mental or emotional demands.  I am done.  There is no way to deny, bargain, or bully my way into renewing my nursing license when I know I’ll never be able to meet the practice requirement.  I am no longer a nurse (Stage V:  Acceptance).

I remember how busy I used to feel, the constant buzz in my head, the pressure of being not quite finished with anything.  I loved that state of mind–that continuous adrenaline high.  I felt smart.  I felt useful, productive, important, brave, strong.  I didn’t like going to work when I was exhausted and I got tired of the endless schedule changes, sleeplessness, and irritability that went with the deal–but I still miss it.  For almost five years I’ve sifted through the good and bad, trying to salvage something, because nursing has been my identity. 

I couldn’t finish out on my own terms.  It hasn’t been fair.  It’s been painful in every way.  But it’s OK.  I had a good run.  I don’t know what’s ahead, but I do know this part of my life is finished.  I see a lot of you still standing on nursing’s shore as my little boat sails off to sea.  Remember that I admire and respect you all and I wish I could have stayed, but I have to go.  Today is the day I’m saying…Goodbye.

nurse at large: sick call

“A professional is one who does his best work when he feels the least like working,” said Frank Lloyd Wright.  It took me years to get on board the Work Even When You Feel Like Death Warmed Over bandwagon, but I did eventually get on.  Let’s face it–no matter what anybody says about “Don’t come to work if you’re symptomatic,” nurses just can’t call in sick.

I developed mononucleosis during my first year as a professional nurse.  I was working on an open heart/EENT/general surgery unit in a very large city hospital.  I thought calling in sick when I felt as though I couldn’t move and my fever was 101 would be a good idea.  Unfortunately, not.  I got away with it for a few days but then was told I needed to buck up and come in.  This, of course, added another symptom to the sorry mess:  the huge chip on my shoulder became a real burden.

Eventually I came to understand a bedrock truth of clinical work:  if you’re not there, somebody else will have to do the work.  Somebody who has a day off will be called in, or somebody who is already working will have to do a double shift, or somebody will have to take extra patients.  Eventually I was that “somebody” often enough to not want to put my colleagues in the same position.  That’s how it works.  You know how the other guy feels when that call comes in.

So, when I came down with the grippe (as my grandmother would call it) three weeks ago, I can honestly say it’s been the first time in my life I’ve been able to stay home, drink liquids and get plenty of rest.  During the first few days of my illness I was hopeful that my complete devotion to getting well would pay off.  It didn’t take long for me to reach the conclusion I would never have predicted:  staying home doesn’t really help.  In fact, there were times I wished I could go to work just to get my mind off my symptoms.  Now, of course, there is the matter of contagion–which is another whole story–but generally speaking, laying low and centering one’s life around the tea kettle and a box of tissues isn’t all it’s cracked up to be.

Maybe Americans are too obsessed with productivity.  Maybe nurses have too many co-dependent behaviors.  Maybe the system needs to be more responsive to the needs of sick employees.  Maybe we need to work harder at wellness.  Maybe.  Based on my tiny unscientific experiment, though, I’d have to conclude that sometimes it’s OK to just tape up and stay in the game.

Nurse at large: “The first thing we do, let’s kill all the lawyers” (Shakespeare, henry vi)

I’m neither naive nor violent and I believe this is, and should be, a nation of laws.  But once in a while my co-workers and I  used to indulge in a fantasy:  we go to take care of a labor patient and we just TAKE CARE of her.  There is no charting, other than what we need for our own decision-making and continuity with other professionals.  We are able to discuss risks, options, choices, and our own judgement with her as her labor progresses.  We don’t collect a lot of information “just in case somebody decides to come back and sue me.”  When the delivery is complete and/or it’s time for us to go home, we don’t have to spend more time with the charting than we spent with the care.

It’s almost impossible to sustain this fantasy in my own imagination.  We’ve all become so used to “defensive practice” we can hardly think of anything else.  And those of us who have been in nursing for any length of time know there are plenty of legitimate actions brought against health professionals.  Surely safeguards are needed to protect the public from sloppy practice.

But…do we have better outcomes as a result of being so litigious?  And what about the cost for the nurses themselves?  What kind of workforce do you get when everybody fears legal reprisal, no matter how careful and meticulous their own practices may be?  My own informal poll of nurses leaving nursing consistently shows that they enjoyed patient care but could no longer take the stress of over-documentation and demanding scheduling (which is another area where “risk management departments”–that is, lawyers– influence decision-making).

Am I advocating tort reform?  I’m really not sure.  At this point, my hope is for nurses to be able to at least imagine the contours of their own practices, holding themselves accountable to one another and to the patient, in a spirit of trust and cooperation.  I am saddened by the current mood of distrust and defensiveness around the most basic areas of practice.  I was lucky enough to be in nursing before the rampant paranoia set in.  I know we can’t, and shouldn’t, return to the days of the nurse as patient care “handmaiden.”  We struggled to legitimize our role and we need to be accountable.  There was something so affirming, though, in the simplicity of the “healing hands” role.  We were assumed to be selfless, optimistic, calm, well-informed, and charitable.  Most of us were.  Surely we can incorporate some of this history as we move forward.  Otherwise, we’ve simply switched to become “handmaidens” of The Chart, The Risk Management Model–the lawyers.

Perhaps Mr. Shakespeare’s best advice to nurses is in another quotation:  “Love all, trust a few, do wrong to none.” 

And let that patient in prodromal labor sleep through the three a.m. vitals check if she’s been stable.  What a wonderful world it could be…

nurse at large: cherry ames, everynurse

Follow the example of Cherry Ames, our cheerful, self-effacing, innocent, industrious–and, yes, glamorous–nurse heroine and you, too, will have the career dreams are made of.  Don your crisp uniform, blush at the suave young intern, cower when the overweening Head Nurse arrives at the station, courageously transform the sick into the well:  this will be your daily fare.  Little by little you will master the mysteries of Nursing and perforce be swept up into what Grosset & Dunlap call “The Adventures of a Young and Dedicated Career Nurse.”   As of the 1944 printing of my copy of Cherry Ames, Senior Nurse, these included:  student nurse, senior nurse, Army nurse, chief nurse, flight nurse, veterans’ nurse, cruise nurse, night supervisor, mountaineer nurse, clinic nurse, dude ranch nurse, rest home nurse, country doctor’s nurse, boarding school nurse, department store nurse, camp nurse, island nurse, rural nurse, staff nurse, companion nurse, and (my favorite) jungle nurse.  Who could resist such a beguiling profession?

Several serious nursing scholars have written about the “nurse book” phenomenon that started around the time of WWII and continued through the next several decades.  The books were strong propoganda in a world where young women were starting to be needed in the “working world.”  In these books, nursing was never a job.  It was sometimes a profession, and almost always a “calling.”  The world of caring for the sick was ultra-romanticized and very womanly–sort of a ramped-up version of being a wife and mother.  Take for example this excerpt from Senior Nurse.  Cherry has just gone off duty and is walking to the Nurses’ Hall:

Cherry loved the yard at this twilight hour.  That brief surge of homesickness disappeared, for the hospital was her real home.  White-clad nurse and interns called greetings to her as they hurried down the paths from one building to another.  In the many windows, lights would soon be going on.  Something between happiness and sorrow welled up in Cherry.  It was something very sweet, almost too poignant to bear.  She loved this hospital so!  She loved its quiet white wards, full of patients, its tiny kitchens, the busy utility rooms, the cool gray laboratory, the hushed white corridors smelling of soapsuds, the ambulances clangning up before Emergency Ward, this green wandering yard dotted with buildings which housed special branches of medicine.

Most of all, Cherry loved nursing itself.  Her dream was the dream of being a nurse, of helping people on a grand scale in the most important way there is…

Yikes!  She even loves the utility rooms.

I’m not going to give the digression about how all this Shaped Nursing.  You get it.  But I will leave you with my favorite example of “Nurse Lit,” one that I think serves as a turning point in the mythology.

Nurse of the wine country.  Now there’s a gig worth dreaming about.

nurse at large: oxford v. croc

Listen, my children, and I’ll tell you of the dress code from days gone by.  Lace-up white oxfords, freshly polished.  White stockings.  White uniform (it’s a dress–no slacks allowed), school pin, school cap.  You may wear a wedding band and a watch, but no other jewelry.  Hair must clear the collar.  Navy blue sweater worn at the nurses’ station only.  Nails short and clean, no polish.   Your head nurse will check your hands from time to time, but rarely will she find anyone deviating from the standards.  We were all convinced  they contributed to the cleanliness of the ward and an air of calm professionalism.  Who would want to be cared for by a nurse in a purple uniform with decals on her fingernails?  Unthinkable.

Wasn’t it difficult to maneuver in such a get-up?  Well, yes.  One had to be very careful when crouching down to, say, empty a Foley because one’s garters might show.  And there were–stains.  The worst part, though, had to be those damn shoes.  Some people think the greatest achievement of the late twentieth century was the personal computer.  I say it was the comfortable shoe.

Once in a while, one’s uniform would become so *soiled* as to require a complete change of clothes.  And exactly what type of  clean clothing does one find in a hospital in the middle of the night?  OR scrubs.  They felt so comfortable and so–freeing.  One could bend, stretch, climb, crouch, and jump without fear of exposure.  We were convinced.  The long, and truly bloody, struggle to free ourselves from uniform tyranny began with the polyester pantsuit (a scrub/uniform compromise) and surged ahead to the admission of colors other than white; eventually the capitulation was complete.  Scrubs.  For everyone, all the time.  And no more oxfords!

So, tonight when you’re scrubbing NG drainage off your crocs with an alcohol wipe, just remember the nurses of yore who were busy with the white shoe polish and whisper a prayer of thanks.  Then, please cut your fingernails.  One has to draw the line somewhere.

nurse at large: snickers. it’s what’s for dinner.

 

OK, it’s 2 p.m. and you didn’t get to lunch because you had to restart an IV, help with a discharge, and admit a woman in active labor with baby number three.  She’s now fully dilated and pushing.  Your co-worker, Sandy,  just came in to relieve you for five minutes so you could go to the bathroom.  You realize you’ve GOT to eat something because your blood sugar is tanking.  You have the following foods available:  1) Two Quaker “Simple Harvest” All Natural Honey Roasted Nut granola bars, 2) a Michelina’s Lean Gourmet rotini with prosciutto and basil microwave entrée, 3) a Snickers bar.  Which do you choose?

Obviously, even though Sandy is a good sport and probably wouldn’t mind, you don’t have time to heat up the microwave entree, much less sit down and eat it.  You know there’s nothing much worse than a microwave entree, heated and left behind for a while–which is very likely what would happen.  That leaves the granola bars and the Snickers.  A no-brainer.  You choose the Snickers, and not just because it tastes so much better.  You know if you eat the granola bars your mouth will be all dry and nasty, then you’ll have to get something to drink.  Then you’ll need to pee again, and there’s no way you’ll be able to leave that delivery room for at least an hour or two once the baby pops out.  Besides, you can leave a half-eaten Snickers bar on the desk and it will be just fine when you get back–whenever that may be.

What if you actually made the decision based on nutritional information?  You know, the way you tell patients to do it.  Here’s the analysis, looking at calorie content, fat, and protein.

1)  Two Quaker Simple Harvest granola bars (total net wt. 2.46 oz.):  360 calories with 60 calories from fat,  6 gm. protein.

2)  Michelina Lean Gourmet rotini entrée (net wt. 8 oz.):  310 calories with 90 calories from fat, 12 gm. protein.

3)  Snickers bar (net wt. 2.07 oz.):  280 calories with 130 calories from fat, 4 gm. protein.

So, although it’s not the BEST meal you can get, it’s at least in the ballpark.  Totally portable, able to be eaten at intervals, delicious, and always available in the vending machine.  Or at the gas station, which is where I picked up my “research” bar this morning.  Snickers.  It’s also what’s for breakfast.

nurse at large: who wants to know?

If you’re a patient and you know what’s good for you, you won’t get sassy during an interview with anybody in the health care industry.  Every interview is run by a gatekeeper and your compliance is key:  in fact, being compliant is one of the most important skills you bring to the table.  You will answer the same questions again and again and again; at some point you’ll be tempted to ask whether anybody is reading the answers.  Don’t these people talk to one another?  Where is all this information going?  Who wants to know?

My experience as a patient tells me the interview/assessment system is very brittle, especially in outpatient settings.  I’ve literally been told by licensed health care staff I need to answer a question because they have to “fill in the blank” before they can move the computer form to the next screen.  The pain scale scenario I described in an earlier post is just one example of how the health care industry shapes information gathering to suit a very particular matrix; there are lots of other examples as well.  Backed by research and clinical trials, information-gathering systems are rigid and mandatory, designed to yield specific types of profiles.  It’s easy to see that, over time, the shape of the information determines the shape/presentation/ behavior/expectations of the patient as well as the practitioner.

Lots of ethical questions arise in this context.  I’d like to look at one simple question, one every practitioner can and should ask of himself at frequent intervals:  What am I going to do with this information?

We, as nurses, need to remember every question we ask increases the patient’s vulnerability.  Sharing deeply personal information is not without psychic cost.  Repeating the details of an assault,  describing a complicated birth, reciting the list of medications that ultimately didn’t work may be simply “medical history” to YOU, but to the patient they are her life story.  Patients share this intimate story believing it will advance the process of their care.  Will it?

Several examples from my own experience:  I’ve been asked my surgical history dozens of times.  Certainly, as a “pain patient,” my response to surgery is relevant.  However, NOT ONCE have I been asked any questions about my surgical experiences (such as responses to anesthesia, use of pain medication, recovery time, etc.).  What are you doing with the information?  Similarly, I’ve been asked to used the 1-10 pain scale rating system hundreds of times.  NOT ONCE has my answer prompted any immediate nursing intervention–it literally hasn’t mattered if I rated my pain a “3″ or a “15.”  My answer has been recorded, sometimes with a noticable arch of the eyebrow, but nothing else has happened.  And, frankly, what are you doing with THAT information?  If somebody has been in pain for five years, what do you make of the numbers on that scale?

You don’t have time to discuss the metaphysics of all your questions with every patient–I know that.  But please at least have them clear in your own thinking.  Maybe you just need to fill in a blank.  Maybe you’re actually checking for inconsistencies, trying to “trip up” somebody you think is gaming the system.  Maybe there are some questions you’d rather avoid (history of domestic assault?  spiritual beliefs? to name two big ones…) and you’re just recording the information in case somebody else wants it.  Maybe you’re practicing defensively, gathering information so nobody can come back and sue you.  Get it straight in your own head, even if you’re not going to share all the underpinnings with your patient.

No matter what kind of “model” you use in your practice, you need to remember all patient information is ultimately subjective.  Patients have hopes and expectations, some outside the limits of the industry’s ability to intervene.  You may think it’s impossible to practice in a sea of ambiguity, that structures and algorithms are necessary to process data in a usable way.  Maybe you’re right.  Yet, the anxiety produced when needs meet resources is the place where nursing care begins.  You might have to step outside the box.

nurse at large: pain, schmain

Describe your pain.  Is it burning?  Crushing?  Constant? 

My pain is a huge iron anchor from a battleship, half buried in ice slag somewhere in the Arctic, surrounded by toxic waste drums leaking caustic fluid onto it, burning and freezing, heavy, impossible to free.

So, it’s burning? 

My pain is a tiny, naked animal dangling in the open maw of a giant shark, brushing against the first row of razor sharp teeth, frozen in fear of the crushing bite, curled against the raw wetness of the shark’s breath.

So, is the pain crushing or burning?

My arm is the rope stretched between opposing tug of war teams, being pulled in both directions with immense force, then drenched with gasoline and set alight.

No need to get all medieval…(growing impatient).  Rate your pain on the pain scale from 1-10 with one being no pain and 10 the worst pain you’ve ever felt.

I don’t know.  Sometimes I think it’s the worst pain possible, but then it gets worse still.

Rate it from 1-10.

I really can’t.  I don’t remember what the baseline was like.  I have no idea what the upper limit can be on any given day.  I’m in pain all the time.  After a few years, the pain scale doesn’t mean anything.

1-10, please.

[At this point, I say "9".  You just want to fill in the blanks on your paperwork.  So be it.]

And you, the clinician, at this point are starting to have an opinion about me.  I’m being difficult.  Uncooperative.  Possible drug seeking behavior.

I was once a clinician, too, and I know how it goes.  In your mind there is a matrix of pain/behavior/intervention/resolution for many, many typical conditions.  A woman is in labor–you expect certain levels of pain at certain intervals, certain interventions will help relieve it, eventually it will resolve.  Same with a fracture.  Gunshot wounds.  Headache.  Different situations, different timelines, but they all follow a curve in your mind and when someone moves off that curve, you have an opinion.  Your opinion, as mine used to be, is that the problem must now be “psychological.”

A lot has been written about chronic pain.  I don’t need to review the literature here–I’m sure a lot of it is useful and accurate.  But I’d like to briefly explore the way your expectations harden your experience with a patient in pain.  I want to somehow convince you of the “realness” of constant pain and urge you not to be afraid of it.  I want to help you recognize that at least some of your patients in pain are brave and tired and appreciative of your affirmation, even if you can’t fix them.

For now, let’s just say I think the pain scale approach is fairly useless in the long term.  Pain is a thing some of us have to live with.  As we go along, we develop ways of coping with the amount of pain that can’t be relieved.  Please don’t be so skeptical.  Help us find ways to make daily life easier, to conserve our limited energy, to help focus our scattered concentration. 

We’ll return to this topic again soon.  Right now I think I’ll lie down on the heating pad for a while.  It’s a 10.

nurse at large: got cane?

 

When do you jump out of bed and say, “I’m buying myself a cane!”  Why do you need one?  Frank Lloyd Wright apparently needed a cane for pointing at things, but most people have other uses in mind.  When I was a nurse in clinical practice, I would have put the cane issue in the mobility category, done an assessment, consulted the physician, and made a referral to physical therapy.  Maybe I would have helped procure the cane, reinforce cane walking instructions, and assess the patient’s adaptation to cane life.  The real world, though, runs a little differently.  Sometimes people just amble out and buy canes on their own, willy- nilly.  I was one of those.

I bought my first cane when my gait started getting, to put it technically, all wanky.  I wasn’t sure my legs were going to do what I thought they were, so I went to the drugstore and bought one of these medical-supply grade canes.  I immediately felt better.  The cane provided some stability, a little pause where I could rest for a fraction of a second and compose myself for my next move.  I learned the first DIY cane lesson:  it helps take the pressure off.  Walking, when you’re uncertain about your balance or your position in space, is a tense ordeal.

Eventually my physiatrist and the physical therapist got involved and I received cane walking instruction.  However, they didn’t really delineate my cane use parameters; they left me “free-ranging.”  I started to understand about having good days and bad days mobility-wise.  I realized there would be times I’d need the cane for a few minutes, but otherwise be OK.  That’s when I bought the purple print fold-up cane.  Walking with a cane really slows you down and takes up one hand (that otherwise might be holding packages or opening doors).  Also, a cane is unwieldy when you sit down in your theater seat or on the bus.  The fold-up solves a lot of problems.  Plus it looks cool.

I don’t yet have a cane with flames on it like Dr. House’s.  I do, though, have a handsome black Italian “walking stick” I received for Christmas a few years ago.  I save it for special occasions. 

The tip of the cane plus your two legs create the three points of a plane.  Geometrically speaking, that automatically provides stability.  People see you with a cane and they give you extra space; they also lower their expectations of your ability to navigate complicated patterns.  With extra stability, space, and time you can carve out your wanky gait without as much worry about falling or getting hurt.  This is an excruciating business, actually.  I know some people are militant about how being “disabled” shouldn’t keep one out of the mainstream, but the mainstream is pretty daunting when you can’t swim at the same rate as the other fish.  When you see someone walking with a cane, be aware he is using a load of mental energy to get from point A to point B.  It’s OK to give an encouraging smile.  And I think it’s always OK to hold the door open…

nurse at large: mad eye gtts. skillz

 

A Case Study:  Joey, age 7, needs eye drops in his right eye every twelve hours to treat a progressive degenerative eye disease that will eventually result in blindness.  He had a left side enucleation (removal of the eye) six months ago which he tolerated remarkably well.  His family is supportive, but very nervous about his eye care and worried about his future blindness.  He is an active guy, otherwise healthy, with a very positive attitude.  However, he is understandably squirmy when his eye drops are due.  Our challenge is to develop a daily routine for eye drop administration that is workable for Joey and at least two family members.  Right now, only mom is able to give the eye drops and she needs backup.  Ideas?

Discussion:  Eye drops are tricky.  If you’re giving them for a one-shot deal, you can use the come-from-the-side sneak attack strategy, but long-term daily use demands a different approach.  In this case, as is generally true, everybody will have an easier time if the patient has a relaxed face.  Relaxing the face is itself a challenge.  In Joey’s case, we found a good relaxation trigger by accident while treating his enucleation post-op:  applying moist compresses, alternately cold and warm, on the incision area helped relax his entire face.  When his face was relaxed, it was easier to administer the drops in the fellow eye.  Obviously, the entire process went more smoothly when he was in a quiet environment and the care giver was not rushed.  Joey was encouraged to sit quietly before getting the drops; he began to associate the “quiet time” away from siblings as a positive experience. He was given “treats” (ideas: stickers, apple slices, etc.–whatever is used as positive reinforcement) following the administration of the drops.  After the surgical incision healed we continued to used warm compresses on the face for a few minutes before giving the drops–classical conditioning at its finest.  Now we are working with family members to use the facial relaxing techniques on fellow adults before moving on to Joey’s care.  Encouraging consistency, relaxation, an unhurried tempo, and positive reinforcement is making the process easier for everyone.

FULL DISCLOSURE:  “Joey” is really our Pekingese dog, Otis.   I have learned a lot from doing his eye care these last six months.  I realize my approach while working as an EENT nurse, chunking out pre-op eye drops, will not work in the long term.  You do have to be deft, of course, but the take home message is “take enough time and work on relaxation cues.”   Nobody, man nor beast, likes to have something coming at his eye.  Be sure to prepare the dropper (gently roll the bottle, unscrew the cap, load the dropper end so you’re not madly shaking it) before getting the patient ready.  Have the patient comfortably seated; place a warm compress on the fellow eye or forehead–whatever position is relaxing; give a reward (Otis gets Liva Snaps).

I’m working with my husband to help him learn Otis’ eye care.  He’s freaked out, but willing to try.  We’re both very sad about Otis’ inevitable blindness from glaucoma, but we will stave it off as long as we can with good eye care.