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  1. allnurses

    I Should Be in Jail

    This article was written by a member of allnurses. Due to the delicate and emotionally charged nature of the article as well as details, the member wanted the topic posted anonymously. If other readers have articles they would like published anonymously, please contact me by private message. Let's start out with my first encounter with a parent. I was a paramedic (a newbie..a rookie..an innocent.,,) called to a home of a 4 month old that rolled off of a couch. The baby is seizing and the father is talking about how he was making the baby a bottle. He was alone with the kid and the mom was at work. He claimed to put the baby on the couch and the baby rolled off the couch. A short couch...onto carpet. The story didn't add up. The baby seized the entire 30 minutes it took us to get to the nearest hospital, and then later died from massive head trauma. Shaken baby syndrome. That was some fall. This was my induction into real life. I was out of my protective cocoon and my rose colored glasses cracked in the truth of real life. I have scraped children off of the highway who were unrestrained; I have whisked children out of homes that were besieged with fighting under the protection of cops; and I have taken children to the ED scared to be touched by anyone. The pressure of being a paramedic became too much, so I chose a new profession...pediatric nursing! (insert snarkiness here). I was working in the ED when a mom brought in her 13 year old. Both were afraid and the mom said the dad would be there soon. Mom did not have custody, and the dad was not happy the kid was in the ED. Dad, I am sure after meeting him, is in a gang. The cops were brought in, the mom asked to leave, the dad was cursing up a storm and I confronted him. "We will absolutely not tolerate that type of behavior in the hospital, in a CHILDREN'S HOSPITAL. If you don't sit down and be quiet, you will be escorted out." Nicer than a punch, and I kept my job. I myself was escorted by security to my car after work....fearing what may await me. A 15 year old on life support who OD'd to see if her mom loved her. She did not want to die, she wrote me in a note when she was intubated, she just wanted to see if her mom cared. The child took a turn for the worst with multi-system organ failure. As we strived to make her comfortable and keep her body in a hypothermic state, the mom was mad at ME because the room was too cold. She tried to fire me from being her daughters nurse. This after she so nonchalantly said, "pull the plug". I stayed at the bedside and held her hand as she passed away, mom went to go eat. A 13 year old dying from HIV/AIDS. The dad wanting to be at her side, the step-mom wanting to go do stuff. The dad confided in me once, when he was irritated with his wife, that his daughter was never treated fairly by his wife. He wanted to bring his daughter home to hospice and wanted to redo her room - a makeover - just how she would have loved it. The wife would not hear of it, since the girl was 'gonna die anyway'. And she did, in the hospital room with nursing staff at her side. The mother of an 18 month old who was beaten by the mom's boyfriend. The grandmother had unofficial custody since the day the child was born. She had unofficial custody of 3 of the children because the mom was always partying and never had time for the kids. When the family decided to remove the child from life support after the baby was declared to have brain death, the mother banned the grandmother from the room. That was the only time I did not let a parent help me bathe a patient after the patient died....and I gave them a time limit for grieving as well. The fact that the mother was holding her dead child and talking about going to Chili's and a movie later in the day sort of made up my mind, along with her acting like this was a party and yelling at her brother to "go get me a coke, hey, my baby just died and you need to be nice to me", and "hey, you know that ************ was going to go get a new car today?" Absolutely no feeling at all about the loss of a child, but enough bitterness in her to block the one true person who cared for the baby from being at his side. The four year old who was NPO for surgery. As usual, the patient did not go to OR before lunch and she became fussy and..hungry...I walked past her room to hear her father yell at her to "Shut up!" as she was crying. I went in right away and she was reaching for his lunch. His McDonald's fries and burger he was munching down on. I absolutely kicked him out of the room (sans roundhouse kick to the face). I know that people deal with grief in unusual ways. I have seen grief, I have seen the absolute absence of grief, and I have seen those who pretend to have grief. For me, the people who have not one ounce of compassion for the child who most needs their love are the ones who I cannot and will not ever understand. I know that people don't think beyond their own needs, even when a child is crying and does not understand what is happening. But it doesn't mean I agree with it, or have to like it. As a nurse, the hardest part of my job is to not say and do what I really think and feel. Or I would have been in jail a LONG time ago. What have you seen that makes you want to commit an assault? I-Should-Be-in-Jail.pdf
  2. nilknarf

    The Gift I Didn't Want to Give

    If Carrie Lawson had tried to invoke a feeling of serenity by the way she'd designed her home, she'd succeeded. The walls were a painted light green, and the curtains a complimentary olive. The furniture looked plush and comfortable. The lighting and soft music added to the overall charm of the room. But Carrie had never planned for the latest addition to the room: a stark, steel-railed hospital bed. On that bed was her husband, Jeffrey. On the day I met him, Jeffrey put that room to its ultimate test: congested, jaundiced and moaning incoherently; Jeffrey was a stark contrast to the room's serenity. Jeffrey was one of my first hospice patients. I'd spent the previous two weeks working with a nurse who had 30 years' hospice experience. I'd tried to absorb all the knowledge she'd given. I thought I was ready for the "Jeffreys" I'd have to care for. My introduction and opening explanations to Carrie fell flat. Her responses to me were quiet and clipped. I felt her hostility before I'd had a chance to warrant it. My questions drew eye rolls before she gave me brief, clipped answers. Her eyes kept drifting to Jeffrey; then they'd stare off into the distance. All my training hadn't prepared me for stiff, rejecting posture and her unwelcoming ears. As the visit ended, I asked if she had any questions. She asked why one of his symptoms seemed to be increasing so quickly. Relieved that she seemed to want clinical knowledge, I gave her a brief review of Jeffrey's disease and its anticipated course of progress. My words were met with silence. But, then, her anger came. "I want a different nurse," she spat. "You act like he's a page in a textbook and like you're looking at a scorecard for his future." Her words hit me hard. I'd wanted so much to be a comfort to her. My heart filled with remorse and fear: what if this was how I'd be greeted by all my future patients? But I swallowed my pride and finished the visit as quickly as possible - and later, asked my supervisor to send a different nurse for Jeffrey. That was hard, because what if the supervisor wrote me off as a bad risk for this job? She didn't. Instead, she reminded me one of the ways people try to regain control is by expressing anger. She pointed to my account of Carrie's flattened responses to my questions. She asked me to imagine how it might feel to Carrie - who had, obviously, worked so hard to instill a sense of serenity into her life. She asked me how that person might feel; to have to cope with uncertainty and chaos, in the form of her husband's illness and impending death. She asked me to try to understand that Carrie might be very angry at this intrusion into the serenity she'd planned, for her life. I began to understand: since Carrie would likely find it difficult to be angry at her husband, she had to find a target for that anger. She had found one: me. "In a way, you gave Carrie a gift," my supervisor told me. "You gave her someone to be angry with." Seeing the sense of this didn't make it easy to accept Carrie's angry rejection - but it did make sense. In time, I would meet many other "Carrie's" - and those words have always stayed with me. I remind myself that sometimes, one of the gifts I can give someone is the gift of someone to be angry with. It's not a gift I want to give, but it may be the one that someone most needs.
  3. It was shortly after labor day when I walked into the emergency room to see a client who had been found unresponsive and rushed to the hospital. I walked to the front desk, identified myself, and requested to see him. The woman behind the desk smiled kindly at me and asked: "Are you family?" I opened my mouth to respond and closed it again I did not know how to answer. This client, who had I known for 5 years, had no family. When a coworker visited him in the hospital weeks before, she had been present when a staff member asked him about family members. He had been very clear on the fact there was none. Was I family? When my normally calm administrator called me, her voice broke when she asked me to go to the ER to check on him, as she had just gotten a call from a very upset and worried aide. She had known him for much longer than I had, had gone to see him recently in the hospital, and was genuinely upset. It was her that had visited him a few weeks ago in the same hospital. Clearly, she was his family. Was I family? His aide was upset because she cared for him and had been with him more often than her own child. He has suddenly declined, and he needed her. She had come at all hours of the day and night, paid and unpaid, to care for him. She was scared. Of course she was family. Was I family? I had spent my drive there thinking of him. But I had also thought just as much about the girls in my office, all who had gotten out of their beds to care for him late at night, supported him when he was sad and angry, and loved him through it all. Girls who answered the phone at 1 am when he needed something, who talked to him during the day when he called for reasons that weren't really reasons. Of course, they were family. Was I family? She asked again. Yes, I replied. I am part of his family. And after the kind liaison sat me down and handed me tissues, I sat with him til it was time for me to go tell our family he was gone. When I arrived back at my office, I hugged, cried with and held our family, as we mourned one of our own. I don't say this enough, but I thank God for our family I wonder sometimes if other nurses or medical professionals go through this. I know we are taught not to form intense attachments to patients as it could cloud our judgment. I feel like my attachment to some has actually helped. Knowing them as well as I do has let me pick up on little things I may not have otherwise. These bonds have allowed my staff to care for patients in a way they normally wouldn't be able to. For patients like this one, who had no one but us, how does one walk into his home on a regular basis and not feed the basic human need for human connection? Isn't it part of our job to care for the client both physically and emotionally? Mental health and physical health can and often do go hand in hand. No one should be alone in the world. Especially not when so many people go in and out of their home every single day. Honestly, I feel like many nurses and medical professionals do. Doesn't everyone have that "one patient"?
  4. Joyful2bee

    I Had No Idea!

    H. was scheduled for the removal of a colon polyp after a colonoscopy failed to reach the tissue for biopsy. My husband was a very obese diabetic, who had recovered from a Wallenberg Stroke four years before with only a residual weakness in his balance center. His return to his job four months later demonstrated great determination and strength to endure the rigorous therapy required to achieve this recovery. These qualities helped him later as you will see. Responsibility, Loneliness, and Fear We arrived in the pre-operative area early for the prep for the surgery. I watched as the staff rolled my husband of 35 years away from me into an area where I could not go. I had been his advocate and caregiver after the stroke and felt very protective and responsible for him. I felt so helpless and anxious for his well being now. The thought that surgeons are human and can make mistakes hovered in my mind. While waiting for our son to arrive, I felt so alone and helpless. As soon as he arrived I felt his support shoring up my strength and calmness. A family member needs someone to help them spend the long hours that tick by so slowly during the surgery and recovery room care of a loved one. They don't know if there will be complications. Encourage them to call someone if they are alone. Regardless of years of experience and understanding of how things go in the hospital, I felt very alone until M came. Anxiety of Potential Complications So we waited. M, our son, was concerned that they might not be able to inflate the weight of his father's abdominal adipose tissue for the lap surgery. Sure enough, the surgeon came out and told us they needed to make a mid-line incision to reach the polyp. We understood and I gave consent. Soon an anesthetist came out and told us that three different anesthesiologists had been unable to put a central line in my husband's neck because it was so short and obese. I gave consent for a PIC line. Stress was mounting! What else could go wrong? What if he had another stroke? What if he had more complications? Even with the information given to the family, anxiety can run rampant especially when there are already complications. We soon found out about complications. After his surgery which actually went better than it started, there was no bed in ICU, so he was placed in CCU overnight for monitoring while on an epidural drip. Exhaustion His O2 saturation dropped into the 70s so he needed oxygen. He had a nasogastric tube and was supposed to be using his CPAP for his severe sleep apnea. Trying to fit a CPAP mask over a nasogastric tube was impossible to do. So we kept the oxygen flowing and raised his head slightly. I had been an ICU/CCU nurse for 17 years and didn't mind helping the nurses in the unit. During the night in a confused state, he repeatedly removed his oxygen mask. So about every 15 minutes the O2 saturation alarms declared his dropping oxygen level; I would hop up quickly and put the O2 back on his face. Finally, in exasperation or desperation, I ordered him to put his oxygen back on! He glared at me and said, "NO!" and removed it again! I am a very kind, polite and nice person, but was severely sleep deprived, had lots of stress, and worry that day. I said something I would never say normally. "Fine! Take the oxygen off! When you pass out, I'll just put it back on again!" I believe the nurses realized how exhausted I was and told me they could watch him so I could sleep. Yes, people do not behave normally when they haven't had enough sleep and are stressed out! Ask for a chaplain to help the family member be realistic about what they can do and how much sleep they need and make them leave for a while. Need More than Reassurances Please deal kindly and compassionately with the family's irritation or anger. Remember how many times someone has told you, "Don't worry, things will be fine." But they weren't? Words don't always help. Allow the family to express their fears to help them. It helps just to know someone is listening. Remember they are turning their beloved over to doctors, nurses and staff who they have never met before, who may be very busy, and who may not understand the patient's requests or needs. Then there are more "What ifs." "What if he develops another problem?" What if he won't be able to go back to work or his hobbies? What if...?" Believe me, there are many imagined "What ifs." That night one nurse did something I will never forget. My husband liked to be cold so there was a fan blowing on him. I like to be warm but I wanted to see him and him to see me at all times. So I pulled the recliner to his bedside and faced him. One angel brought a pile of heated blankets and without being asked to literally tucked me in! I never felt so cared for since I was a child! She understood and was so kind! I slept some after that. If you can, take time to listen or offer a small kindness for the family. Offer to call their pastor, the hospital chaplain, or the supervisor. Advocacy and Responsibility After a couple of nights, the epidural was removed and the doctor ordered Percocet two tablets every 4 hours for pain. I know the doctor was trying to keep him comfortable and considering my husband's size and history of back surgery and sciatica he ordered a large dose. The thing he did not consider was that my husband was narcotic naive. After one day H could not sit up; slept all the time; drank very little; and ate nothing. So on day three the doctor came and told my husband in no uncertain terms that he "had to get up." The doctor's tone of voice was the one they use when they are being firm with a manipulative or lazy patient. I was a bit upset that he assumed that H was lazy! But I knew something else had to be done. Since I knew H was not lazy. I began to worry that he might have had a second stroke. After several futile attempts by the staff to get H up, I spoke with the hospitalist that night. My husband had a high tolerance for pain, was very independent, and absolutely not lazy. I had to be his advocate. The hospitalist decreased the Percocet. As H came out of the drug-induced stupor he started acting like himself. He refused any more pain medicine as soon as he was lucid enough to understand what had happened. He related how he had been having hallucinations, confusion and terror attacks! Finally, he was moving around and helped staff get him up. He preferred to have pain rather than losing control of his own mind. It took physical therapy three weeks during his stay and after his discharge to increase his strength to near normalcy. Fears Being a nurse I know and understand that doctors and nurses are people and they make mistakes. We all do. But when my loved one has so many problems and complications I could not help but worry about mistakes or misjudgments being made. Plus there were always the questions that caused fear: How long will he need to recover? Will he be able to go back to work soon? (He loved his job.) I knew he had lots of sick time and had a good stable job but some patients don't. Some families may be very anxious about how to pay for the hospital stay plus the tests, IV fluids, lab work, radiologist bill and so many bills for so many treatments. Get them someone from case management to help them navigate this sea of bills they will receive. Reality: Complications After 11 days for what should have been a three-day stay, the staples were removed and H was discharged. But that is still not the end of this story. Three days after the staples were removed it was evident that his abdomen had not healed well. The wound dehisced in four places. The largest area was a tunneled wound 1 inch by 1 ½ inches and two inches deep in the middle of the incision. It took four months for the areas to heal. I cleaned and packed them twice a day for him. Imagine the stark terror of a non-medical person if they had seen their loved one's wound opening up and then having to treat it. Conclusion So family members need their own nurse? Well, not really. They just need lots of understanding and compassion from the ones caring for their loved one. We know nurses cannot do everything. When you cannot help in some area ask for help. But try to understand what the family is going through. Remember, "Walk a mile in someone's moccasins before you judge them." A lot goes on that we don't know about in the family's mind.
  5. I observed the following clinical scenario several times over the last few months and wonder if it is just episodic events or something more. There is a type of patients who openly abuse acute care system. Such patients have a multitude of chronic conditions which can be managed successfully on outpatient basis, but willfully ignore all recommendations, teachings and the rest of it. Instead, they come to ER within 24 -72 hours after discharge stating symptoms which, as they know perfectly well, would warrant readmission, such as chest pain. Once admitted, they terrorize providers and the rest of staff, refuse interventions which are recommended, demand increase of opioids, benzos and other "good stuff" and, in general, refuse to go home till receiving as much of "customer experience" as possible. The cycle is repeated X times. Then, one beautiful day, karma struck. The patient somehow bent the stick too much and totally and profoundly upset provider and nurses. Therefore, he couldn't get more of his beloved dilaudid 1 mg IVP Q2h, no more phenegran IV, appropriate 2 grams sodium/ADA1500 diet instead of regular, no private room which "they always put me in because that's what I want", and his call lights are somehow always got answered the last. Nurses even stop obligingly wipe his butt upon demand, even though "they always did it for me before". After a couple of temper tantrums, the patient leaves AMA or upon the first opportunity to do so, with a loud promise to (never shop there again) never come back to this bad, bad hospital where "nobody cares for me". That all is a common and well known and I wouldn't bother with it. But I saw several times recently that the patients in question truly disappeared from the ER for several weeks and, when they finally came back, they were there for legitimate reasons. Moreover, their behavior changed quite a bit. They stopped doing things which caused acute decompensations, such as skipping insulins and breathing treatments. They started to take most of their meds regularly, not only "ma' pain pills". They became more flexible with home and office care. They get flu shots and avoid large gatherings of people during flu season. In other words, they finally started doing what we wanted them to do for years before. I was so mystified that I asked two of them, indirectly, what happened. The answers were: since I cannot get what I want here, then I do not want to go here anymore unless there is no choice; so, I am just trying to stay out of this hospital. You told me that I have to do (X, Y, Z), so I give it all a try, so I might not have to go where I was treated so badly and couldn't get what I wanted. These observations prompted me to ask a silly question: can "customer service" paradigm actually attract chronically sick patients with significant knowledge about the system in hospitals and therefore negatively affect their health on the long run? And, as an opposite, can lack of "customer service" prompt these patients to finally take better care of themselves and therefore provide significant benefits for them? I would be thankful for others' observations and ideas about this topic. "Customer service" is pushed down the throats of all health care providers nowadays, but I never saw any research showing its benefits or lack of them in terms of long-term disease process.
  6. spotangel

    I wish I could see you!

    Mr. Francis Ross's eyes were closed, his breathing shallow. I walked into his room. He was surrounded by his family. To the outside world they looked like a very close knit family. I knew better, bearing witness to the daily infighting inside and outside that hospital room. The reason was very simple. Francis was dying, was a DNR and the family stood to gain a lot of money. There was a tiny hitch. The ex-wife Clarissa had showed up now professing undying love for him. She claimed that he was going to get better and that she would nurse him back to health. Francis clung on to her and her words. His children could not stand her; calling her a fake, gold digger. They felt that he could not see past her honeyed talk. Matter of fact, he could not see as he was blind now. The diabetes had claimed his eyes. Francis had left his wife to marry Clarissa when he was a hot shot lawyer. His wife died a few years later and their children held that against him. Later when his luck and money were down Clarissa left him, divorced him and got married to someone else younger and richer. Francis realized his mistake, reached out to his children and mended his fences. For the next 20 years as he got sicker, his kids took turns to bring him to the hospital. This seemed to be his last visit as he was in multi organ failure. No medical treatment was working. Somehow, Clarissa found out and was back in his life. The evening before, I heard that there had been a bedside wedding. The children had found out that Clarissa was back in their father's life and were livid. Looking at the fatigue on Francis face, I gently herded the group out of the unit and went back to him. His BP was low and his labs had looked real bad. Since he was on palliative care we were giving comfort measures only as per his wishes. "Annie?" "Yes, Francis?" "I need your help." "What can I do to help you?" "I need a priest. Can you get me one?" "May I ask why?" "I want to get my last sacraments and confess. I know I am dying .Aren't you Catholic?" "Yes! Let me see what I can do. How do you feel about dying?" "What can I do? I can't change it. I want to talk to a priest." I called our hospital page operator who had all the on call and on duty pager numbers. The priest had gone on vacation to Africa and would not be back for 2 weeks. The backup number went to a message center. I called the Nursing Supervisor and asked for help. She made a few calls but could not get anyone. I then thought of calling my local parish priest who looked like a Chuck Norris double. Father Nick aka Chuck Norris, was a young and energetic priest. Bless his heart; he made that half an hour ride in 15 minutes and got preferred parking by the hospital entrance as I had called security at the front desk. Father gave him his last rites and he was at peace. I thanked father and he left. I allowed the family to take turns to visit and then leave. Clarissa left saying that she would be back after a quick shower. Four hours passed, no Clarissa. Francis condition was worsening although he remained alert throughout. It was almost time for me to leave. I gave report to RN Joan Wallace. Also updated her that Clarissa may return after her shower! I went to Francis's room. "Goodnight Francis! See you tomorrow!" "Annie will you come in here please!" I stepped closer. "Can I give you a hug? Thank you for calling father Chuck Norris (I had told him that Father Nick was a Norris double!). I feel so peaceful". We chuckled softly in perfect accord. "Sure, Francis, I love hugs! You are very welcome!" I hugged him gently as he was all skin and bones. "I wish I could see you child!" "You never know Francis, you just might! Remember our motto; never lose hope. Bye Francis!" "Bye! Annie! Bless you!" Hoping to see him the next day, I left. It took me half hour to reach home. Thankfully I got a parking on the street after a couple of drive arounds. Walking into the quiet apartment; I let a sigh of relief. The day was over. As it was summer, the sky was still bright and there was plenty of sunshine in the room. My husband had taken the older two who were toddlers then, in the double stroller for a walk in the park and was not back. As I sat down in my living room and untied my shoe laces, I froze. I could feel a presence in the room but could not see anyone. The air was still and expectant. In my bones, I felt, I knew it was as if someone was watching me. Strangely, I was unafraid and it felt peaceful and not scary. I instinctively looked at the clock. The time was 8.42pm. "Francis, if that is you, go in peace to God! I guess you can see me now! Glad you got me with only my shoes off!" I was unaware of the tears trickling down my face as I smiled at my weak joke. Just as it came, it was gone. I hurriedly removed my shoes, washed my hands and picked up the phone. I called my unit and asked for Joan Wallace. Joan picked up the phone. "Annie, you won't believe this!" she said in a rush. "Remember Francis, that sick guy in room 684?" "Yes?' "He just passed. The Nursing Attendant went to take his vitals and found him pulseless. The doctor pronounced him. He is calling Clarissa and his children now." "What time was he pronounced?" I asked quietly. "Around 8.40pm" How on earth did he know where I lived, I wondered. I sat and said a prayer for his soul. As I pondered on the visit, I realized that he had made his wish come true as anything was possible now that he no longer was burdened by his earthly body. As I opened the door to welcome my noisy family back and hugged the kids and their dad, I whispered to the still air, "It was good to see you Francis! Remember, never lose hope! With hope, all things are possible!"
  7. Cynthiahowardrnphd

    Part 2: The Good the Bad and the Ugly Boundaries

    The Ugly (Absent) Boundaries Let's first look at what happens without any boundaries. Not being able to set any boundaries or limits can result when someone does not like being alone or when they are not aware of their own needs. Physically this can show up with people not respecting the personal space of others and emotionally by feeling everything very intensely. This person may over react to what is going on and be overly dependent on others for their emotional wellbeing. Have you had any coworkers or friends who always needed reassurance from you? On the other hand, a person without any boundaries may also hold onto resentments for a long time and feel like a perpetual victim. This would be a negative Nancy always complaining about how they were wronged somehow. You can see how not having any boundaries can make relationships and communication difficult. To make things worse, a person who cannot set boundaries can be very critical of others when they attempt to set limits. This can create a backlash of guilt and or frustration as the healthy person seeks to move away from individual who has not yet recognized they are their own person. Regardless of how hard it is - continue to set limits and speak up for yourself lest you end up in the codependency trap. If you are this person who has not set boundaries and recognize that you are just too dependent on others for their approval, congratulations! Awareness is the first step to making changes. Begin with small changes that have low risk. For example, if friends want to go to a certain restaurant and you really want to go to another one, make the suggestion for your choice. Then as you build a comfort level expressing your preferences you can take bigger risks with boundaries at work. The Bad (Rigid) Boundaries Getting along with someone who cannot set boundaries can be initially easier than some who has rigid boundaries. Eventually, they both will chip away at successful and healthy relationships. Someone with rigid boundaries may appear still, stoic, standoffish having difficulty with physical and emotional closeness. This makes it tough to build trust in a relationship as this person is hard to read and can come off as disinterested or indifferent. They may end up feeling misunderstood because their lack of emotional expression is misread by others. Other people may be resentful because this person does not participate in the relationship. At work, this person may be consistent yet not able to give back to others and read the cues that someone needs help. They may wait to be asked for help rather than initiate an offer. Again this causes problems with those people who are more emotionally available. If you are this person who watches everyone else engage but holds back out of fear of exposing too much or feeling awkward, start by observing someone you admire. What are the gestures they use to engage that you could model? Start small as it really is the small shifts in behavior that make the biggest impact. Try smiling more. Smiles are so universal and a smile will break the ice and encourage a connection. With patients put a hand on their hand or a light touch on the shoulder to let them know you care and are there for them. As you allow your own feelings to come forward and gently guide you, you will be able to relax your boundaries and join in. The Good (Healthy ) Boundaries What do healthy boundaries look like? Unfortunately, there is not always an effective role model in the workplace. Setting boundaries is NOT a place you arrive at and then never again experience an awkward moment. It is dynamic and you will continue to grow in this skill. Keep that in mind so you have realistic expectations for yourself. A person with healthy boundaries is very clear about what they like and don't like. If you struggle with boundaries this may come off as irritating, selfish and elite. "Who does she think she is, asking to go to the first lunch..." This may be a reaction to someone making a request for lunch because they know their blood sugar drops and if they did not eat early, their energy levels wane. Why wouldn't you want to ensure you have the option in order to do your job well? You can tell this person is not elite and or entitled because setting healthy boundaries means you also respect those of others and you are able to compromise and negotiate when needed. This person shares their viewpoint and is open to hearing a different view from others. Respecting other people's physical and emotional space, this person asks permission before touching someone or asking personal questions. As you go about developing this critical skill of setting boundaries, spend a little time checking in with yourself and finding out what is important, what you need from others, what is negotiable and what isn't. Initially, you may err on being too rigid if you have never set limits before - that is ok. Keep working at it. You may be too loose and will quickly learn as you get overwhelmed with other people's demands. Tune into your emotions, learn from them and then take action. Your life will only be as good as your ability to take care of yourself. You are worth it. For Part 1 of this series, please go to Let Negativity Roll off Your Back: Learn to Set Boundaries
  8. Jacqueline.Damm

    Complacency in Healthcare

    Webster's Dictionary defines complacency in a way that we, as a people, can all understand. As nurses and caregivers, we know deep down that complacency is taken to an entirely different level within our scope. It is a weighted situation that causes a slew of issues of which safety takes precedence over all. Let me reel you in a little deeper... As a nursing student, I followed a wound care nurse that was performing a monthly study on the prevalence of wound progression while in the hospital. We rounded on a patient's room and whipped off their socks. In an instant, we were stunned to find a blackened foot that had completely lost perfusion-- when? No one knew. The report from the nurse, "I just didn't think of taking off their socks when checking pulses." When inquired as to why, 'I... I guess I just got lazy.' This patient lost their foot. Once again, as a nursing student in the GI suite watching colonoscopy after colonoscopy, a woman came in for a study due to an extensive family history of colon cancer. As the probe was removed and she was slightly stirring from her twilight sleep, someone made an inappropriate joke at her expense. The entire room started laughing. The patient then looked up at me with tears in her eyes, "They are laughing at me, aren't they?" I lied in order to save face. Uncool my friends. Uncool. A nurse I was working with a fellow comrade who felt too proud to ask for help with a blood infusion on a cardiac step-down unit. As I'm sure you can assume, this patient suffered from pulmonary hypertension as well as a very poor ejection fraction with apparent symptoms of heart failure exacerbation. They ran the blood too fast, didn't inquire to the MD about Lasix in conjunction with the infusion. Here comes massive fluid overload and a rapid response call. Avoidable? Indeed. Taking a step away from nurses, call into question a physician who flits in and out of the hospital who thinks that a ticking time bomb of a case (pulmonary hypertension, hypertension, kidney failure without dialysis and COPD) isn't worth abrupt addressing. I walk in and find the patient talking one minute, unresponsive the next. After bedside intubation and a run down the hallway to the ICU, the patient almost died (bless vasopressors). When the physician rounded on the floor they peeked into the room-- "Oh, they are gone, I'm assuming to the ICU? [shoulder shrug] Okay." May I mention not answering pages (most of them stat) and the fact that physical compensation wore out and almost killed this man. The physician had no shame. One last example... A CNA rounded on a patient in my unit. This individual was extremely confused, was assisted to the bathroom, then helped back to bed. Great right? Wrong. The bed alarm wasn't set nor were the bed rails up. I was running down the hall when I saw the patient literally roll out of bed and smash their head on the floor. It was a sound I would love to forget. I am sure that many of you will look at these cases and think words like: negligence, ethical issues, etc. You are right for sure. But what I can also bring to the table about all of these stories is that each of the individuals involved had been approaching their jobs with a complacent attitude. All differing levels, but it was present, and it was absolutely affecting their care. Complacency is a filthy animal. It makes Facebook at work more important than hourly rounding. It makes that extra long break of greater importance than double checking those pulses post cardiac cath. It means blowing off education and cheating on hospital required testing and skills check-offs because "we just don't have time." We all know that our jobs hold immense importance and are very high risk, to us as well as those we see on a daily basis. If you think about it, the decisions we make on a daily basis can stop or even restart a heart. I don't know about you, but to me, this will always be an immensely frightening aspect of our careers. What I ask of you is if you feel yourself sliding, none of us are above it mind you, take a step back. It is of utmost importance for us to draw the line when it needs to be marked (WITH BLINDING SIGNS). We need to understand our limits as caregivers. In order to save ourselves as well as our patients and our teams we have got to have to courage to state when our threshold has been met. I can recall in the last two weeks when I had to draw the line and ask for help because I couldn't take another [insert touchy situation here], or I would just break. IT'S OKAY! YOU ARE HUMAN! We are fallible and at times inflexible. Let that crazy super-nurse idea in your head relax and take a reprieve. I will never forget what an amazingly talented ICU doctor and anesthesiologist told me that day I left the GI suite with the laughing matter. The doctor grabbed me by the arm and reminded me in all seriousness, "It is our job to protect and do no harm. Every day this is our goal. As soon as you see yourself sliding, it's time to stop before you hurt someone." So use those days off. Ask for help. Take a mental health day. Because when we allow for complacency to take over and rule our care, that is the day that a nurse did more harm than good. Florence expects the best, our patients expect the best, their families, the doctors, even you. So let's provide the best care we can. In doing this we need to know our limits and be willing to draw those lines.
  9. classicalcat

    Ghosts Are All Around Us

    Ah, the questions that our children ask: "Where did I come from?" "How does Santa Claus fly around the world in ONE NIGHT?" or... "Do you believe in ghosts, mommy?" Some questions are easier to answer than others. I have never seen a ghost--that ethereal mist that makes the hair on the back of your neck stand on end. The kind that makes the room suddenly turn bone-chilling cold. But that doesn't make me doubt their existence. As a nurse, I have seen their influence: the ghosts of the past--those shadowy glimpses of those who once lived, who never leave us. The ghosts of the present, who haunt us daily. Those of the future, who we would like to change, but wonder if we can. It was a beautiful summer day, when the sky was so blue that it seemed endless. This outside beauty seemed an unfair contrast to the dark, gloomy room, as I held the hand of my dying patient. "Martha, is that you?" he said as he looked at me. "No, I am not Martha, I am the nursing assistant," I replied. I knew that he had lost his wife a few years ago. "Martha, please stay, "he cried. "I am here," I said. "I am not leaving." He died peacefully, with his wife's name on his lips. On this day, I was the ghost. I had another patient, a new mother who seemed overly concerned about everything that her newborn was doing or not doing. "I think his lips are blue!" she would say. Or... "can you please check his temperature again? He seems too hot." Or... "he just isn't breathing right." It was kind of driving me crazy on a day that was already busy. Near the end of the shift, I finally had some time to go through the rest of her chart. And there it was: She had lost her first baby to SIDS, when he was only two months old. On this day, her first baby was the ghost. When I was a nursing student, I had to do my obligatory four-day rotation in mental health. I had mixed emotions about this. On one hand, I was thinking, this could be a nightmare, and on the other hand--it might just be interesting. It was actually a little of both. I was given a lot of autonomy at the facility, given that I was a nursing student. The nurse in charge basically said: here is a list of "safe" patients--you can give them their meds this morning. Um, OK. As I made my way around the unit, I wasn't sure what I expected, but I encountered patients who seemed very ordinary to me. Until I went into the fifth room. I heard voices from behind the closed door. I thought it was a private room. When I knocked and entered, there was a man sitting on his bed having a conversation. He questioned....and he answered. "Who are you talking to?" I asked. "The Prophet Elijah," he answered. What am I supposed to say now? I dove right in. "Can you tell me your name?" "God," he answered. Oh. I double checked his wristband, and gave him his meds, while he continued his conversation. On this day...the ghosts were within his mind. It was a cold, rainy day in December. I walked into my patient's room, not knowing what to expect. The report on paper didn't look so good. Teenage mother, history of depression, history of abuse. The scene was surprising. A lovely, young mother sat in her bed breastfeeding her baby. "Look, she has latched on this time without help!" she exclaimed with pride in her voice. "Good job!" I replied, sharing her enthusiasm. Then I noticed another woman in the corner of the room. She sat in the rocking chair with a sullen look on her face. She looked unkempt and smelled of cigarette smoke. Her hands were shaking. "I need to get some fresh air," she said and exited the room quickly. My patient looked embarrassed for her mother. The mother didn't return that day. We had an order not to let the stepfather into the unit due to his history of abusing our patient. I got to know my patient throughout the shift. She was tearful at times. "I am so scared that I will end up like her...she has made such bad decisions...bring that %^hole into our house." I realized that the ghost of her future self was haunting her. "You aren't your mother, and the decisions you make will be your own," I said. So many times in my nursing career, I have felt more of a counselor than a nurse. But I have come to realize that nursing is all of that--you can't separate taking care of the physical body from that of the mind and spirit. We have to take care of the patients and their ghosts--they are all around us.
  10. Have Nurse

    It Never Occurred To Me.

    We'll call him John. John was 7 feet 2 inches tall. At 65 years of age, he had long brownish-gray hair, that he wore in a clumsy ponytail. He suffered from morbid obesity which made it difficult to ambulate as evidenced by his shortness of breath. A Viet Nam veteran, homeless, was found wandering the streets with a very high blood glucose level. He claimed he didn't know he had diabetes, which was possible. John hadn't seen a doctor in years. He was polite and cooperative, up independently and ambulating in the halls when we met. He had a distinct strong body odor. His day nurse informed me earlier that "He won't take a shower." I wondered why. Remembering that there is a reason for every kind of behavior, I decided to mull it around a bit before broaching the subject. He shared with me stories of his military service, how he got to be homeless and how he found himself in the hospital. "I was married once," he began. "It lasted 20 years....but then...she got sick and I couldn't keep up with the bills. We lost our house, she died....and suddenly it was all gone." He was sitting on his bed. I had pulled up a chair. It wouldn't be long before I had to do rounds again for vitals and meds, but I sensed a wounded spirit in him. A burden not just on his body, but in his heart as well. The elevator doors down the hall opened. The smell of hot food wafted down the halls. "John, " I asked gently, "Is there anyone I can call for you? A friend? Anyone?" He shook his head sadly. "Supper trays are arriving. Will you eat?" I was worried that his blood sugar would take a dive if he didn't. He nodded. I smiled at him and retrieved the tray. I still hadn't asked him about his refusal to take a shower. He allowed the staff to change his towels and linens. As John ate his supper, I reviewed his chart again and noticed how many times the previous shifts had offered him hygiene assistance but he would politely refuse. I also noticed that no one had charted on asking him why. Looking at the Allergies section of the chart, I noted no issues with soap or laundry products. Was he afraid of water? How long had it been since he had a decent shower or bath? Our homeless communities have access to showers and facilities so I was coming up empty on this one. Since he was a veteran, I knew he could handle it if I was direct with him, but it would need to be tempered with respect. Off I went down the hall. I walked into his bathroom, turned on the shower, set up supplies and towels and brought in a clean fresh oversized gown and fresh robe. He glanced up in surprise. I smiled at him and pulled up the chair again. His eyes still had that hint of sadness, so I reached for his hand and said: "John, part of my duties as your nurse is to not only keep you safe and help you get better, but I owe you the honor of being truthful and to offer possible solutions when at all possible. The staff, as well as myself, have noticed that you have not been able to get a shower in during your stay. You are beginning to give off a very strong odor and I am concerned that along with your medical condition, that you may be setting yourself up unknowingly for infection. The odor comes from bacteria, which loves to grow in dark, moist areas." I took a breath. "There are places on your skin that you need to get clean." I wasn't prepared for his response. "Well, " he began slowly, "I want to take a shower. But I didn't want to embarrass the young ladies taking care of me.....I'm so big and I can't reach where I need to, and I didn't want to make those young girls uncomfortable." This man was a true gentleman. "John," I asked, " I would not be uncomfortable with assisting you. Will you allow me?" He nodded with relief. I smiled. "After you, Sir." Yep, there's a reason for every kind of behavior. And sometimes, it's just plain courtesy.
  11. spotangel

    I Lost My Baby And My Phone!

    The night Nursing Supervisor was giving me report. I was taking over half the hospital including ICU, CCU, ER, LR, NICU, Postpartum and a bunch of other units. The supervisor told me about a patient who was on one to one observation and security watch. During my rounds I went to her unit. I spoke to the nurses who were all having a rough time with her for the last few days. I could hear her yelling at the top of her lungs demanding her phone and her speech reminded me of the Jerry Springer show! Every second word was a curse word! She recently had a fetal demise and had multiple psy hospitalizations in the past. I was told that a situation developed the day before and security watch was initiated along with one to one observation. The father of the baby was barred from coming in and as he stirred up the patient and set her off every time he was at the bedside or on the phone with her. Finally the situation became so hostile that he was barred from coming into the hospital.She was refusing medications and was very labile. The doctors wanted her to sign a behavioral contract before the phone was returned and she refused. The nurses went in and offered medications for agitation and she refused. I walked in quietly into the room and introduced myself and shook her hand. She looked me up and down. I softly told her, " I am so sorry for your loss." I asked her if that made her sad and angry. She nodded her eyes never leaving my face.I asked her did it feel like a hole in her heart? She nodded again, her face crumpling. I then looked her straight in the eye and asked, " May I give you a hug?" She nodded. I took out my ID from my white coat, laid it at the bedside table along with my report and stepped closer to her bed. I opened my arms and she fell into them sobbing. I held her murmuring reassurances and acknowledging her loss. I told her that she was a brave and strong woman and would get through each day, one day at a time. I told her that it was ok to get sad and mad after losing her baby but it was not ok to hurt herself or others in the process. I requested her not to hurt herself or others. I looked behind me at the staff and the security guard and told her, " All these people you see are here to help you not hurt you. You have to remember that every day they get up from their warm beds and come out in this cold weather to the hospital to help patients like you. They have families that want them safe home and the end of the day. So please don't hurt my staff or yourself". She nodded and smiled through her tears. I was struck at how that smile transformed her face and commented, " How pretty you look when you smile!" One of the staff commented that she also had a beautiful voice and could sing! Now that she was calmer, I asked her if she would sing for us. After the initial bout of shyness, she started singing, "Amazing Grace how sweet the sound". She sounded like an angel! I joined her in the second stanza and so did half the staff there and the security guard in his baritone! It was a beautiful moment and there were a lot of smiles and tears! I thanked the lord in my heart that he choose to change an ugly situation into something beautiful that we could all relate to. I went back to the nurses station and asked security to bring up her phone.We convinced her to sign a behavioral contract. Although she was upset that she could not keep the phone for long periods of time, we reassured her that it was all dependent on her behavior. The charge RN convinced the doctor to leave her phone with her for the time being as she was calm playing on the phone and reaching out to family. She also wanted to see pictures of her daughter who had died who she had named Lilly, that she had on the phone. The last I saw her, she was quietly playing on the phone. I left the unit satisfied that she was in safe caring hands.
  12. nurseed12

    Mentoring: A Nursing Connection

    As of the latest statistics the average age of a nurse is 41 years old and more than 50% surveyed has decided nursing as their second career (Jones, 2016). Hired nurses are of a much later age group and is noted that these nurses bring more energy, more focus, and more mentorship to the practice (Saunders, H., & Vehviläinen-Julkunen, K., 2016). What second career nurses exhibit has been demonstrated to improve patient outcomes (Johnson, Butler, Harootunian, Wilson, & Linan, (2016). Younger nurses hired need a mentorship programs to enhance their knowledge and skills. These programs also equip them with tools to survive their first year of nursing. One tool that I use at the bedside with newer nurses is the tool of gaining a connection. Having a connection aids in the growth of trust with the patient and knowledge within the new nurse or nursing student. One unfortunate patient event aided my demonstration of the connection within our patient population. As a cardiac nurse, I helped Mr. J. S. heal after an unfortunate snakebite. This created a series of medical issues for Mr. J. S. and concerns for his wife. I mentored a new student who was afraid of snakes but not afraid of the medical management that ensued in Mr. J.S.'s care. He was intubated, on several drips, he was "touch and go" for several days., prior to my receiving him as a patient. Once we were able to start weaning the medications to keep his blood pressure at an acceptable level, stop giving antivenom, and wean him from the ventilator he started to come around slowly and also recognize his loved ones that surrounded him for days. Again, this was my time to connect and mentor. As a mentor, I attempted to gain a connection with my new student. One night I started my shift and I just opened up the conversation of how Mr. J. S. came across the snake at first. Did he like snakes? Did he go around snakes often? His wife of 13 years started to tell me the story even as I was giving him nightly medications down his feeding tube. She said: "He loves snakes and other reptiles. He always wanted to keep a few. The family and the kids said no. So, he actually goes out fishing and attempts to connect with one from time to time. He has no intention to keep, just admire. He learned so much from his dad that was his connection to nature. He wanted to somehow carry that tradition to his next adventure." His wife mentioned this with tears in her eyes, knowing that her husband may not be doing well and slowly dying. Others may fear snakes, even reading about them but me I am different. I wished to connect. Her not knowing that I enjoy several reptiles myself. I opened up the conversation further. "Nursing is not my first career. Biology is my first career. I love turtles. I studied several classes of turtles and with this knowledge and experience gained a fascination for other reptiles including snakes. Some of the fellow nurses may consider me weird but like in most cases I am fascinated. " With snakebites especially if the snake is caught, it needs to be brought with the patient. I have had other snake bite patients and we would store the snake on the counter inside the patient's room. I would be the only one of the staff fascinated enough to admire what was in the jar. Of course, the subject was already dead but venom can still carry on with contact. So, knowledge is power in this case because I noticed the type of snake and how dangerous this creature is to this patient. His wife and I spoke over several hours interim of myself taking care of my other patients. She seemed at the end of the conversation connected and relieved in some small way. She gave me a warm smile at the end of our conversation and said she needed to go home to take a nap. We said our goodbyes and she went home...but with a small connection somehow. The next morning, she had arrived early. Mr. J. S. was extubated and off two of the medications keeping his blood pressure at a stable level. When she entered his room he started the conversation by saying "hello honey and how long have I been here". She looked at me in tears and this time with a strong grateful smile. I couldn't have been more pleased. Again ... a connection. Nursing is not just patient care it is also about making a connection. It is hard to receive trust from our patients but if one can achieve a connection the trust will come and build as the relationship continues. References Johnson, W. G., Butler, R., Harootunian, G., Wilson, B., & Linan, M. (2016). Registered Nurses: The Curious Case of a Persistent Shortage. Journal of Nursing Scholarship, 48(4), 387-396. DOI: 10.1111/jnu.12218 Jones, S. J. (2016). Establishing a Nurse Mentor Program to Improve Nurse Satisfaction and Intent to Stay. Doctor of Nursing Practice Capstone Projects. 15. Encompass: A Digital Archive of EKU's Creativity, Scholarship and History Capstone Project Saunders, H., & Vehviläinen‐Julkunen, K. (2016). Nurses' Evidence‐Based Practice Beliefs and the Role of Evidence‐Based Practice Mentors at University Hospitals in Finland. Worldviews on Evidence‐Based Nursing, 12 (21), 1-10. DOI: 10.1111/wvn.12189
  13. jeastridge

    Learning to Talk

    The doctor walked into the exam room where the patient sat on the edge of the exam table. In her late 50's, she was slender and held herself erect, tense as if preparing to slide off that paper-covered surface. The young doctor, maybe in her mid 20's self-consciously shuffled the papers she had in her hand. She stood a couple of feet from the patient and made eye contact. "I have the results of your tests, Mrs. T.," she said in a somber voice. "I've been anxious to hear them," was the reply. "You have a malignancy." The words were followed by a shriek of joy from the patient. "Oh, good, I was so afraid you were going to say that it was cancer." She held her hands to her mouth and seemed to hold back sobs of relief. The doctor began to stutter and her eyes widened, "No, yes, I mean...What I meant to say is that it is cancer, Mrs. T. I'm sorry I wasn't clear." The patient's relief gave way to a horrified look, followed by tears and mumbled words, "It can't be; it just can't be." Fortunately, the above scenario was part of a practice session in a class for medical students. The "doctor" was a young first year, learning that it matters what words we use when we talk with patients. I can remember as a hospice nurse, doing admissions and being careful about word choice. After explanations of our services, detailed checklists and signatures, the process usually culminated with a question and answer session just to make sure the patient and their family knew what to expect from us, their new hospice nurses. We tried to wait until the patient or the family asked about topics related to prognosis and then double checked to see what their medical provider had already communicated. Sometimes they did ask the tough questions: "So how long do I have?" or "What is going to happen as I die?" or "What do I do if I get to where I can't communicate?" It's important to consider how we answer questions that our patients pose to us and that we impart what truth we can with gentleness and compassion. In discussing this topic, my friend said, "Yes nurses need to talk....and so do doctors. Many times the doctor has told the patient a lot about their condition thinking they have covered everything. But the patient is confused by the 'Doctor Talk' and is embarrassed to ask for clarification. Then it is left up to the nurse to be the interpreter." How do we know what to say? Ask Questions Back First Clarify what they know, how much information they have and how they have interpreted what they know so far. It's Perfectly Fine to Say, "I Don't Know" Sometimes it is exactly the right thing to say. We are not at liberty, as nurses, to impart information about prognosis or testing unless the doctor has already had a chance to talk with them. Then we can clarify or help them understand what was said and what it means. It can be helpful to go one step further and say, "I will try to find out," but only when we really feel some measure of confidence that we will be able to find out. If we say we will and then get busy and don't get time to follow up, we will want to be sure and let the patient know what we were not able to follow up. Otherwise they may feel lied to or betrayed. Answer Only What They Ask We learn this with kids, often by answering a different question than they intended to ask. If the patient asks, "Will I have pain?" then it is helpful to answer that question and talk about strategies we will help them use to cope with the pain, without going into other symptom management problems that might arise later. Staying focused on the question at hand is hard to do, but an important learned skill. Know Yourself Work on your own issues when it comes to talking with patients. If people frequently mention that you talk a lot, then it might be time to pause and hold back from saying everything you think needs to be said. If you are quiet and maybe answer questions with one word responses, it may be time to expand your horizons in terms of patient conversations. Learning new ways to communicate with patients is not necessarily a skill that comes naturally; as with all of our professional nursing skills, we must hone our trade, observe others who are experts in the field, and learn as we go. Sometimes You Have to Initiate the Questions Part of being good at caring for our patients involves listening to what they don't ask as well as what they do. When a patient is silent, appears distressed or depressed, it may be time for the nurse to ask probing questions. I can remember a hospice patient who never, ever had any questions. He was dying from lung cancer and breathing made a lot of conversation difficult, but he was closed off from his family and from us as his hospice nurses. We tried to engage him but our usual approaches just didn't seem to break through. Finally, one of the PCTs sat down next to him and said, "I'm worried about you. You are awfully quiet. Will you share with me what's on your mind? I promise I will listen and try to help as best I can." The patient went on to share his anger about his condition and the fact that he did not want to be in hospice-he wasn't angry with us, he said, just the fact that he was sick. Their conversation ended with her squeezing his hand and acknowledging that she had really heard him, "I'm sorry that this happened to you. It really stinks." That encounter seemed to help break the ice in our caring for this man. He never did talk a lot or ask many questions, but her question to him seemed to clear the air. Whoever thought nurses need to learn to talk? As with all areas of nursing, learning to talk with patients and communicate well is a skill. It may come more naturally to some than to others, but there is no doubt that we can all improve, take hints from one another and offer pats on the back to our peers who do a good job talking.
  14. sbush86

    "Bad Patients" - A Labor of Love

    Who was your last "bad" patient? Mine was ThreeTimes an Hour. At least,that was the average timing of my patient ringing the call bell that night. Often times he rang more (rarely less), leading to a night remembered as one of the longest shifts of my nursing career. All thanks to a pesky prostate and an elderly gentleman who required assistance to stand. Its funny to look back and think about how much time I spent in that room, helping this man onto thin, frail legs as he attempted to hold on to the plastic urinal with equally frail hands (always with my hand underneath it - never trust shaking fingers to hold a urinal, as I have learned the hard way!). As soon as he produced more liquid gold, I would help him back into bed, ensure his pillow was fluffed and the call button was in reach, and then run out of the room to check on my other patients, get tasks done, and chart as much as possible before the inevitable ring of the call bell returned, marking another twenty minutes as passing. By the time morning rolled around, I was exhausted. The addition of the straight forward task of helping Three Times an Hour to my other workload meant I was one tired lady. When the next shift finally came in, they saw the haggard look in my eyes and assumed the worst - was this a "bad" patient? We have all been there. You walk in at the start of a shift, and see the look in your colleagues' eyes. "Is this a bad patient?" we wonder (or perhaps say brazenly aloud). Is this one who demands much but needs very little - Rude and Condescending, perhaps? Bed-Ridden While On Lactulose, maybe? Needs a Linen Change As Soon as the Bed is Clean (also known as the Back Slayer, the Blanket Hog, or the Leaky Rowboat)? The list goes on for what constitutes, in a broad term, a "bad patient". For myself, however, I have learned much and can appreciate much from these less than savory folks, these who are eagerly dumped onto the next shift as quickly as possible. Don't get me wrong - I get exhausted and frustrated as well, telling myself vehemently that "this isn't what I went to school for!". This particular night was no different - I found myself cursing under my breath each time the call bell went off, each time I found myself already running behind on a myriad of tasks ("why do old guys have to pee standing up? Why?!"). Every twenty minutes, I was expected at the bedside, not to help perform life-saving care or even contribute to the overall diagnostic standing of this man, but to help him with something he genuinely needed assistance with. But isn't this the heart of nursing, all jokes aside? No, we are not merely bedpan cleaners, butt-wipers, or order-followers - we are much more than that. But at times, in these more humbling moments of humanity, I would see in myself what is terrifying to comprehend - my own vulnerability. I see the future: I am not sick, my parents are not sick, my siblings are not sick, we are not weak or fragile - but we will be. Even more frightening? The knowledge that such frailty is not limited to the old; physical demise cannot be compartmentalized to worry about later. And that, I believe, is what makes nurses so special. We see in others, on a regular basis, that which the rest of society gets to conveniently forget about - that is, at least, until they or a loved one are the ones clasping the bedrails with trembling hands. We act as caregivers and healers, but also asa barrier - the very sick can present an ugly truth to those who retain their health. They are, in the very seconds we are cleaning them up, helping them stand, or turning them over, facing the very thing humans like to forget about- demons that we as nurses can stand between, and, for the moment, at least,form a wall of caring that can make even the smaller things feel like uplifting victories. Often, when I drive by hospitals, I look up at the windows and wonder what illness lies behind them, what battles are being waged, but more often than not, I also think about who is performing the exhaustive, thankless work of the Three Timesan Hour patient, my brother or sister aiding in the quest to maintain dignity. I wonder, as I steal a glance up at what must be windows to inpatient units of all kinds, if others do the same - do other caregivers feel moments of solidarity with the souls working that day? Do others feel the pain and fatigue of their cohorts, valiantly working inside? It can be hard to explain to others why nursing is so special, how we not only make a difference for others, but how those we care for can give to us more than weever expect. It can be frustrating to be reduced to a doctor's handmaiden or a glorified pill-pusher. People wrinkle their noses at our stories,and tell us they don't know how we do it. I am grateful for the chance to do it. It isn those moments of looking into someone's eyes as they are frightened, alone, depressed, or embarrassed that I find my work the most humbling. While it may be easy to say,as a new nurse, that you never want a shift like that, you never want to givethe immobile patient a Kayexalate enema or have the patient who needs so many little things that they amount to an enormous mountain, I believe they are necessary for building stronger nurses - if we allow it, those patients can teach us more than we ever imagined. I don't remember my other patients from that night - their acuity, their needs,their care escapes me - but I remember very strongly this man and the care I provided him. Although he was my most recent, Three Times an Hour won't be my last "bad" patient. Next time, in the midst of perspiring profusely onto my scrubs as I perform whatever draining task awaits, my hope is that I remember how I feel when I am outside looking up at the hospital, oddly thankful for the opportunity to humble myself and be called a nurse, holding the beasts at bay.
  15. Ballistex

    What you didn't know

    You knew I was late at bringing you the ice water you had asked for. I know you knew this because the nurse who relieved me that day told me about how you complained for quite some time about it. How you couldn't believe I couldn't keep up with the two patients I had in the CDU. You knew you didn't want to be in the hospital on Christmas Eve. You knew you had more important things to be doing. You knew you had family waiting for you to get home. But here are a few things you didn't know. You didn't know that my other patient, just across the hall from you, a 23 year old daughter of a loving family, mother of a 3 year old boy, had just gone from bad to very much worse. You didn't know how I kept my voice calm in the room as I told my aide to call for the doctor even though my internal voice was screeching. You didn't know how many times I kept telling myself this wasn't happening. I had taken a job away from my usual ICU so this wouldn't happen. You didn't know, as I did, that her heart was going to fail her three seconds before she did. You didn't know the fear in her mother's eyes as I caught her gaze as I was compressing her daughter's chest. You didn't know about the controlled chaos that the code team always brings with it, the intubation, the bagging, the endless rounds of code drugs. You didn't know the word I uttered when the doctor finally gave up, nor the hatred with which it was uttered. You didn't know how I begged him for one more minute even though I knew it would make no difference. You didn't know I was left alone in the room to clean up the aftermath, to make a very unnatural scene look somewhat natural for the family when they came back in. You didn't know that while I was getting that ice water that you received late I was thinking about what I could have possibly missed that would have made a difference. You didn't know that by the time I gave you that ice water I was blaming myself. You didn't know that after the family left I sat by her and told her how sorry I was that I failed. You didn't know how incredibly heavy her body was as I assisted the funeral home worker transfer it from my bed to his stretcher. You didn't know that on that Christmas morning I wouldn't be thinking of my son and his third Christmas, but of another 3 year old boy instead, a boy who would forever remember Christmas not as a time of joy, but instead as the day he lost his mother. You didn't know that a part of me will always remember it that way as well. You didn't know any of these things because I didn't let you see them as I gave you that ice water, late as it was. I simply apologized and asked if there was anything else I could do for you. The fact that you didn't know any of those things is a source of pride to me. It proves that I can go about my duties with a calm demeanor, regardless of what calamity may have happened. That fact says something about me, but as I get older I'm not sure it says anything positive. In fact, it seems to point to something very tiring indeed.
  16. I heard her yelling as I walked down the hall of the Neuro ICU toward her room. As her Parish Nurse, I had visited the 90 year old Nancy on multiple occasions in her home, then in the assisted living facility she went to before hearing that she was hospitalized with an unknown infection and was not doing well. I put on the protective isolation garb and slipped through the sliding glass door only to hear magnified the screams and yells that were already audible down the hall. Nancy's two nieces stood by, one of either side of the bed, trying to calm their aunt who appeared to have acute confusion probably associated with her current condition -later diagnosed as a UTI. As soon as Nancy saw me, she reached out her mittened hand-"Help me! You've just got to help me get these off! Listen, you know me, you know that I don't like to be tied down. Now, if you want to, you CAN help me. Just do it. I need you." Gulp. Even knowing that the mittens were on for a reason, I had to dig deep to respond in any sort of way that might possibly be helpful. I tried to use a soothing manner, a calm voice, reassuring her that I would look into it and see what we could do. My lack of immediate action only seemed to inflame the issue further and her screams reached a new crescendo of volume. Eventually, finding that I was not being helpful at all, quite possibly the opposite, I retreated to the hall, out of the line of her sight and motioned for one of the nieces to join me in the hall. We talked things over and I discovered that this acute episode had been going on for almost 16 hours, enough to wear them both out. As we talked, I looked for answers to pertinent questions: What was the plan? How far along into the plan were we? What had Nancy expressed as her wishes? What could we do to help make Nancy more comfortable whether in full treatment mode or not? Nancy's nurse happened along, and we began to discuss the plan together. As Nancy's long term advocate (she only had these nieces and no other family), the niece expressed again that Nancy had repeatedly stated her desire to "die peacefully," as recently as 2 days before this episode. The nurse was able to clarify that things did not appear to be going well and that she showed some signs of organ failure. We went on to ask the nurse to page the doctor so that everyone could understand the plan and get a clearer picture of the way forward. In the end, the nieces decided to make her a DNR and they requested sedation and pain medication. As advocates for our patients, it is hard sometimes to determine the way forward. Whether we are the parish nurses, case managers, facility nurses or ICU floor nurses, as professionals we all want to do our very best for our patients. Sometimes, in this day and age of having to float to cover the shifts, and having EMRs that fail to tell us the whole story, we flounder and find ourselves unsure how to proceed because we simply do not have enough of the background story to know what the patient and the family would want. How do we get around this current state of affairs? How can we help each other be the best advocates possible for our patients? Listen- When families come to visit, ask a few well-placed questions about the patient, where they lived prior to this stay and what they mentation level was. Families often think that nurses can somehow magically tell that their loved one has been suffering from Alzheimer's for the past couple of years and is declining rapidly. They often assume that we know more than we do, thinking that all those forms they filled out previously have made their way into our hands. Sadly, we know that communication is one of our biggest current problems in medicine -a complete irony since we spend a great deal of our time documenting and, in theory, communicating. Advance Directives-We always ask if people have one, but we less often check to see what it says. "Even though advance directives have been promoted by health professionals for nearly 50 years, only about a third of U.S. adults have them, according to a recent study." (Americans Still Avoiding End-Of-Life Care Planning : Shots - Health News : NPR) It's helpful, for example, to know if the patient who has had a stroke is adamantly opposed to feeding tubes. If we know that, we are looking at a different type of care going forward. Of course, Advance Directives can be changed by the patient and care proxy in real time, but establishing the groundwork of what they say initially can help everyone involved to stand on firmer footing. Anticipate problems- As professional nurses, we know how to look ahead at what might be coming down the care pathway. We might see the beginning of an attack of acute anxiety in an inpatient such as Nancy, at which point we could consider asking the family or facility if this has been a problem in the past or is it new onset. As we give them instructions for care after discharge we look ahead at what might come up and what they can do to address problems: practical suggestions that address particular issues that are likely to surface, e.g. UTI after Foley inpatient, weight gain with CHF, insomnia with Prednisone, etc. After those days in ICU, as her condition continued to deteriorate, Nancy was transferred to inpatient hospice care and died peacefully about a week later. Although I felt bad that she suffered so much during her illness, I was also grateful to be able to advocate for her in a meaningful way. What are some practical ways that you advocate for your patients?
  17. My story as a Congenital Heart Defect (CHD) Warrior starts long before I ever considered nursing in the cardiothoracic operating room to be 'my calling'. I was 5 when my pediatrician noticed an irregularity during a routine physical and referred me to a cardiologist as a precautionary measure. The resulting echo revealed a murmur and subsequently, aortic stenosis. I was asymptomatic at the time and I was closely followed by a cardiologist into my young adult life. Flash forward to when I began full-time scrubbing on our high-risk cardiothoracic surgery team and I noticed that I would become unusually fatigued and short-of-breath during marathon cases. After seeing my cardiologist and talking about the symptoms, it was clear that action needed to be taken. Ironically, I did not seek treatment at the institution I worked at - there's a privacy to personal health that I want to keep personal. I trust my coworkers immensely, but would never want to burden them with knowing a friend and colleague was on their table. Leading up to my open-heart surgery for an AVR, it was natural to think about every doomsday scenario that we, as surgical professionals, have seen happen. It may be weird to say this, but in some ways, 'ignorance is bliss'. But throughout this process, I learned some very valuable tips from the 'other' perspective: Customizing the conversation is everything As a CVOR nurse, I wanted to know everything - who would be on the team, how many years of experience those team members had, what the hospital's mortality rates were for all CVOR procedures, etc. Your average patient is not going to know this, but I think it's super important to tailor the dialogue and in some cases, probe the patient if they would like to know certain things. Many patients are so lost that they don't even know where to start with questions. Care must be provided to the whole family Open heart surgery may be performed on one person, but the whole family lives it. And I think there needs to be more focus on the family aspect - particularly with regards to post-op care, expectations of complications, etc. I think this is where OR nurses can really thrive - bridging the medicine with the relationship. Providing assurance without a guarantee No surgical team can or should ever guarantee a successful outcome, especially in open-heart surgery. That being said, the 'cold' nature of CVOR practitioners is often very real. I, more than anybody, understand that a level of objectivity is helpful in such a high-stakes environment. But, I also think assurance that the team's experience and skill-level is putting the patient in 'good hands' goes a long way for both patient and family. The sound of silence When I was wheeled into the O.R., my senses which were earlier very tired and anxious, were heightened to a level that can't be described. I remember every detail as I was moved to 'the table'. I remember hearing the side conversations, the clanking of all of the instruments, the 'count' being performed by the scrub nurse, and even the 'snapping' of the gloves as team members suited up. It made me even more nervous, but then something miraculous happened. The circulator quietly came up to me and asked if she'd like to hold my hand as I drifted off. I took her up on that offer and instantly, the silence and coldness turned my world into warmth and compassion. It was the first and last time I felt more like a person and less like a 'case'. My surgery went without issue and today, I enjoy a very normal life that enables me to do all the things (including scrubbing with some of the most talented cardiothoracic surgical teams) that I like to do. However, the experience of being on that table, has made me more self-aware of patient care. You may be the last voice or the last hand Unfortunately, high-risk cardiothoracic surgery comes with...high-risk. There are a number of our patients who never make it off of that table. Knowing that you may be the last voice they hear or the last hand they touch encompasses a gravity that is often uncomfortable to grasp. But, it is very real. "Humanizing" the experience for the patient makes a world of difference whether that patient works in cardiothoracic surgery or is a blue collar steel worker. Surgery is the great equalizer - it puts the rich and the poor in the same position of vulnerability, and I think that is often overlooked. Your everyday is somebody else's everything I am part of a team that cracks sternums every day and therefore, it's easy to get in the mindset of 'routine' and 'just another day'. But for that person on the table, it is the most vulnerable time ever for them and their families. There's no secret formula for addressing this, but self-awareness of the gravity that another day's work for you is 'the most dreaded day' for your patient and their family is so important. You can remain objective while still being vested A cardiothoracic surgeon once told me, 'there is so much going on in my mind to stop a heart, fix it, and get it restarted, that I don't have the capacity nor the inclination to learn about that patient - I need to be tunnel-vision from first consult to discharge.' There are times when I've felt like this, especially with younger adults - I didn't want to get to know them and learn about their hopes and dreams as a person. It's a natural defense mechanism after seeing patients pass before your very eyes. But, after going through it myself, I do think that treating your patient like a person and not like a case, actually makes me more vested in all areas of their care. There are limitations, but those limitations should never take away the fact that the person under your drapes needs compassionate care from their team, which means talking to them like people, putting things into layman's terms, ensuring they are comfortable and understand what is going to happen, and being there for them as it happens. Cardiothoracic surgery is a high-stakes environment that is unlike any other specialty - after scrubbing multiple services, the heart rooms are the ones that stand out as being so different. They are much more structured, require larger teams who often only specialize in hearts, and very rarely give practitioners second chances when mistakes happen. But, the environment for the team can be enhanced to soften the patient experience. I am so grateful for those who took care of me and saw to it that I not only got through it, but felt like the team was getting through it with me and for me.
  18. SarahLeeRN

    Saying I'm Sorry

    I am writing because I wanted to tell you that I am sorry. I know that you didn't ask for that. You just went in for a routine procedure that was supposed to change your life. It did change your life-just not in the way that you planned, I know. You were so gracious, to everyone involved. You were angry but understanding. You knew that you were human, being operated on and cared for by humans. "It will be ok," you told yourself. "A few weeks of rehab, and then I can go home. Get back to normal." You know that you were told the risks. You signed the paperwork. Even though you are living out a mistake -whether human or destined, you signed- you knew the risks. You were a farmer before you got sick. You worked hard, every day of your life. Slept less than you worked. If there was a problem, you worked through it. You will work through this. Every time we change the dressing, we try something new. More paste, more tape, more padding, more styles. Thicker, thinner, stretchy, taut. Still it won't hold. Forty-five minutes per dressing change-the hopeful comment by each nurse: "This dressing should hold all day now!" It only holds an hour. Your skin is excoriating. Red. Raw. Painful. We bring in everyone that we can find. Opinions? We will take them! If engineers can build bridges and dams, so can we. We will not be defeated. I speak with the surgeon, other nurses, other doctors. "Why don't we try this? How about that?" Everyone has a suggestion. But still every hour it leaks. A week and a half pass. You are so strong. Of course, you are cranky, you are human. Of course you yell at the pain, the irritation. But you still work through it. Because that is what you have always done. I walk by your room. I am not your direct care nurse tonight, but your call light is on. You know me anyway. We are old friends by now. I enter and you point at it. We look at each other. My heart sinks, because I don't know what to do. I have tried everything, from the nurses' supply to the janitor's closet and it still doesn't hold. I feel despair-I have been here for fifteen hours, short-staffed we are it seems again. I don't have time for another forty-five minute change that won't even hold... You say, "I have been waiting...it needs changing again..." and then I see. Your worn hands are holding your graying head and you are bent over in your chair. Sobs come from deep within your soul. Your body is shaking. Water is running down your hands. Crying, crying, crying. "I am so sick of this!" you sob. "Will I ever be able to go home?" you plead. Tears are falling and falling. Tears from a man who worked his sorrows away on a tractor all of his life. Who probably only ever cried alone. Your lights are on, but your room is dark. This room was not designed with good lighting in the first place, but as discouragement sets in, it looks like the darkest hour of a winter night. And I don't have a flashlight. You are sniffling, crying so hard you are hurting your dressing. Your face and nose are turning red. I am standing next to you, looking down at you, my despair in the sub-basement of basements with you. And I want to cry, too. I want sit down and cry until I have no tears left. I want to cry because you didn't ask for this. I want to cry because I can't fix it- even though I have tried. I want to curl up into a ball right next to you in that dark room and cry and cry and cry. I want to cry because I have been here all day long with almost no break and not enough staff and not enough time... But then I realize that I want to cry because I am not a self-sacrificing martyr. I have spent more of my day today thinking about myself and my own problems, my own lack of staff and lack of time and lack of solution rather than about you. I am sorry. I want to you to be able to go home, to have a good quality of the life you have left. I want to find a solution. I want us to work together and find something that will work. I want to show you encouragement and strength, and a fighting spirit.... I am sorry. Tonight I cannot. I, the RN, the caregiver, the manager, the human, am not as strong as I thought I was. I have no more answers, no more ideas, and no more solutions. Then I remember that my strength comes from Christ, and apart from Him I am weak and I have nothing. You and even other nurses have looked to me for the answers- or at least to be the solution finder to this special problem. I knew in my head that I didn't have all of the answers, or even the ability to find all of the answers. I tried and I tried. But now in this room with you, I feel in my soul my weakness and my lack of solution for you. I want to thank you. In that moment you showed me. You showed me that I could not fix this alone. You showed me that when you or I are out of answers, God has them. You showed me that this was more about you and your sorrow than about what nursing and medicine as professions failed or succeeded in doing. The answers to the whys of your sorrow, the solution- if there is one, only the Lord knows. You showed me how to be a nurse tonight. Tonight the only human action I had left to do was to kneel down beside you, hand you a Kleenex, and say, "I am so, so sorry." And crying with you, we try again.
  19. It was an ordinary Saturday and I was working as the day-shift charge nurse on the medical-surgical floor of a small community hospital. We were extremely busy due to it being flu and pneumonia season. As I worked actively on charting morning assessments, I heard the words "Code Blue" called over the intercom system. It was protocol in our facility that all Registered Nurses (RNs) had to attend a code blue. During the week we had plenty of help when a code was called, but on the weekend we typically only had two RN's, a Respiratory Therapist, a clerk, and the physician. When I arrived at the Emergency Room (ER), the ER nurse and the clerk had just gotten the patient transferred from the wheelchair to the stretcher. The ER nurse proceeded to give a report on what had happened. She said that the patient had been brought in by her husband complaining of difficulty "catching her breath" and some chest discomfort. The patient was awake and alert upon arrival to the ER, but was not able to speak. Before she could be transferred to the stretcher, however, she lost consciousness. She had no pulse and was not breathing. We started CPR and contacted the on-call physician. Thankfully, it did not take long for him to arrive. Within a few minutes we had gotten a slow, weak pulse and had intubated her. She remained unconscious. A chest x-ray showed that both of her lungs had collapsed due to a large amount of fluid in her pleural cavity. The decision was made to insert chest tubes bilaterally. Upon insertion of the right chest tube, a large amount of foul-smelling drainage shot out of the tube and across the trauma room. The same scenario happened when the left chest tube was inserted. Almost immediately, the patient started making an effort to breathe on her own. Her pulse rate had started to increase, but her blood pressure remained low. She was receiving a large amount of intravenous (IV) fluids and had started to become edematous. I have always made a habit of talking to my patients even if they were unconscious. I explained to her that I was going to remove her rings because she was starting to swell, but since she was unconscious, she did not respond. I then proceeded to remove her rings, but found it to be very difficult due to the significant amount of edema that she already had in her hands. I remember telling the other RN that I was not sure if I could get them off and inquired about whether or not she thought we should cut them off. It was at this time that the patient took her right hand and grasped the rings on her left ring finger and wiggled them off. After getting them off, she reached over and handed them to me. Her eyes never opened the entire time, but she had tears streaming from them. We were all in disbelief. I immediately started trying to calm her by explaining what was going on and informed her that we were doing everything we could to help her. She was still intubated and being bagged, but I made the decision to bring her family in one at a time, starting with her husband. When her husband entered the room, I handed the rings to him and explained what had happened. I informed him that even though she appeared unconscious, she was still able to hear him. As he started to talk to her, the tears streamed down her face. It was truly one of the saddest things I have ever witnessed. Each one of her three children came in and were informed that she could still hear them. They spoke to her and told her that they loved her. Not long afterwards, she was airlifted to a larger hospital where she subsequently died shortly after arrival. The cause of her death was a ruptured esophagus. I was so glad that I was able to give this family and the patient a few more minutes together. This incident also helped to solidify my beliefs in communicating with the patient even when it appears that they cannot hear the words that are being spoken to them. There are so many different experiences that I have had as a nurse, and each one has affected the kind of nurse that I have become. Some have made me stronger and some have made me realize how vulnerable I am. Although the outcome of the personal experience I described was a negative one, it made a positive impact on my nursing career and I will never forget her or the lesson she taught me. Every time I take care of a patient that I believe is unconscious, I think of her. Her death has affected the care of more people than she or her family will ever realize.
  20. This is a frustration many leaders experience: patient survey results that do not align with what patients say during rounds. The problem lies in the questions we ask during rounding and the information these questions gather. Many leaders ask patients if they are satisfied with their care; however, this question measures happiness rather than the care provided and thus doesn't give an accurate gauge of the patient experience. Instead, ask these three questions to identify the gaps in patient care that affect survey results. Responses to these questions will provide actionable data that can be used to create simple reports that reveal what your patients are experiencing and what you can do to improve their care. 1. "Why do you use your call light?" When there is high call light usage, it often means the care team is not proactively meeting patients' needs. This can negatively impact HCAHPS scores for responsiveness, pain and communication, and subsequently, overall ratings. Develop a checklist with typical patient responses and mark why each patient used their call light during rounds. This will equip you with the data you need to identify trends and coach your team in any problem areas. For example, if patients are consistently using their call buttons for pain medicine, you know to focus on strategies that specifically address pain management. 2. "Is the patient's board updated?" The patient's communication board is the link that ensures the entire care team is on the same page about a patient's plan of care. It also serves as a visual reminder for the patient about what to expect. If the plan of care is missing on a patient's board, it can contribute to low results in the care transitions composite. And for patients admitted to the hospital from the emergency department, an incomplete ED communication board can cause lower HCAHPS survey scores in the nurse communication composite. When you round, audit each patient's board to make sure it is updated, complete and written in terms the patient can understand. Keep note of any missing or incomplete elements and create an organization-wide standard for care boards to build consistent cross-departmental communication. 3. "Can you describe the education you received before coming in for surgery?" In the ambulatory setting, patient education can affect several domains on the OAS CAHPS survey, including communications about the procedure and recovery. If only a low percentage of patients can recall the instructions given to them, you must work with your team to more effectively communicate with them. Using keywords, clear language and the teach-back method will help ensure patients understand all aspects of the surgery, from pre-procedure to recovery. Each of these questions will provide you with meaningful data to help you get to the bottom of low survey results. Once you understand what your patients are really saying, you can give them the exceptional care they deserve. By Erin Shipley, RN, MSN, healthcare coach at Studer Group
  21. Informing patients of abnormal assessment findings or lab values can be hard. On the one hand, you want to be honest and forthcoming, yet, you don't want to cause unnecessary stress or alarm for the patient. How do you go about delivering this information in a seamless manner that meets all of the above? Here are a few tips you can put into practice today that will help you when discussing tough conversations with your patients. Pay Attention to Tone When you're talking to your patient about their test results, they're likely hanging on every word. And, it's not just the words you use, but the way you use them that they interpret. The tone of your voice communicates what you're feeling when you speak. Tone can be changed by other factors, such as how you're feeling that day or other things on your mind. You might not be good at understanding your own tone of voice when you speak. Whatever the reason, be sure that your words are correct and your tone is conversational and caring. Speak Clearly, Not Loudly Have you ever witnessed a conversation where someone didn't understand the information being given, and instead of changing the message, the speaker started talker louder? Unfortunately, we've all done this. When communication starts to get off track, you might naturally change your tone and volume without even knowing it. The next time you're having a difficult conversation with a patient, be sure to speak slowly and clearly. Keep the volume of your voice at a moderate level. Avoid Acronyms or Big Medical Words You talk fluent nurse, but your patients don't. Try to avoid acronyms and big medical words whenever possible. If you must use either, be ready to explain what they mean in simple terms. Know Your Audience This is one of the best communication tips for any type of communication. It doesn't matter if you're giving a lecture to nurses or talking to a patient - you should always know your audience. This means you might need to ask a few questions to gauge the patient's current level of understanding of their disease process. This can come in handy if the patient is a health care provider too. Remember that just because the patient is a nurse, doctor, or another clinician - they still need to be taught about their illness. And, they may have family or other caregivers with them, who need to understand the information so that they can support the patient. Stop Talking and Listen You might think that you need to tell the patient everything before you stop to assess where they are in the journey of understanding, but this might not be the best strategy. Try to pause after small bits of information and allow a little silence to enter the space between you and your patient. This gives them the opportunity to express understanding or ask questions. Listening is one of the best communication skills to know what your patient is understanding. And, you might also connect with them on a different level if you use active listening. Use Reflection to Gauge Understanding Also known as the "teach-back method," reflection gives your patient the opportunity to demonstrate to you what they've learned. To use this method, ask the patient to restate, in their own words, what you taught them. This allows you to check their level of understanding of the information you provided. Remember Your Body Language Speaks Too You walk past the nurse's station and notice a coworker talking to a family member. Your co-worker has their arms crossed over their chest, and they're looking down the hall at another nurse. You later hear them tell the unit manager they have no idea why the family member expressed concern about their communication skills. You silently replay the scene you saw earlier and thing to yourself - "it was your body language." Always strive to match your body language, words, and the intent of the conversation. If you want your patient to open up - you need to mimic this through your words and behaviors. Keep your arms down to your side or in your lap to show that you are open to receiving feedback. Maintain good posture and eye contact. Pay attention to the expression on your face, and smile, when appropriate. Assess For Communication Needs I recently witnessed an interaction between a registration staff member and a non-English speaking patient. First, the registrar increased the volume of her voice when she thought the patient wasn't understanding. Then, her tone changed, until she finally realized the patient didn't speak English. She quickly got on the phone with an interpreter, but while waiting to get this process started, the registration staff working with this patient ignored them. She didn't engage with the patient at all. In fact, she actually turned her back to the patient and even told another staff member, "They don't understand, so I'm just not talking to them." While the patient didn't understand the words, they certainly understood the body language and the message being sent by the staff member turning their back on them. Once the patient heard the interpreter speak their native tongue, everything about them changed - they smiled, their body language relaxed, and they maintained eye contact with the interpreter on the video call. This was an excellent example of what not to do when you have a patient with special communication needs. Remain open when communicating with patients so that you can recognize these needs. If a patient doesn't understand you, change your approach and then consider if there are special needs that you're not meeting. No matter how good your communication skills are, you can always improve. Challenge yourself to consider using just one of these tips the next time you're in a difficult conversation with a patient. Do you have other tips? Place your thoughts in the comments below, we would love to hear them.
  22. I work PRN at a hospice house. I was taking care of a patient that had been with us for 2 months and was very well known to the full-time staff, yet I had only taken care of her on 3 occasions. There had been several issues with the family due to cultural differences but the times I had taken care of her she was alone and resting. Until Thanksgiving. One of her sons called me into her room and very politely asked to have her transferred to the hospital to pursue life-saving measures. I was a bit taken aback as this was not a situation I had encountered yet. I maintained composure and professionally educated the son on his mother's condition (poorly responsive, no PO intake for days, weak pulses) and the limited resources the hospital would be able to provide, only delaying the inevitable. He relayed this to another family member on the phone who was adamant this was what they wanted. I spoke with the HCPOA who also confirmed this request, and followed policy by making the medical director and clinical supervisor aware and then calling EMS. The son signed the revocation form. When EMS came to transport the patient, they tried to educate the son as well to no avail. Her failing body was transferred to a stretcher and taken out of the hospice house. The entire interaction from beginning to end lasted only an hour. I know that my direct interaction with the family was professional and without judgment, but afterwards with my co-workers, I was angry and judgmental. And I carried that mindset with me home and for the rest of the night. I judged their decisions. I assumed they were uneducated on their mother's condition and prognosis. That they were being selfish and causing their loved one to suffer more. As a nurse, I assumed I knew best. I've seen countless people pass away at the hospice house. I've educated and re-educated family members who are grieving too badly to understand. Some are more accepting than others. Some just can't let go. But when they are too distracted, too tired, and too afraid to face reality, it is not my place to judge. The next morning as I was driving to my full-time job I prayed and reflected on my thoughts and actions. I felt ashamed of my lack of compassion and empathy. Why didn't I place myself in their shoes? Why did I feel the need to speak my bitterness and judgment on a situation I had no real knowledge about? Why was I carrying a burden that had nothing to do with me? As healthcare workers sometimes all we can do is educate. Patients most of the time actually won't do as they are instructed. They are often noncompliant with their treatments. It can be frustrating for us. But it is not our disease. Ultimately it is not our decision and it is not our life. It is easy for us to vent to our co-workers (and sometimes necessary) but it is not our place to judge. We end up carrying that negativity with us whether we realize it or not. The next time you are involved in a situation that is ethically controversial, that goes against your knowledge, that is testing your patience and that you may disagree with, take a deep breath. Try and take an understanding approach from the patient's or family member's point of view. We do not know their entire life story, their family dynamics, or their thought process. It is our job to educate, listen, advocate, and support. It is not our place to judge.
  23. Have Nurse

    Jake's Choice

    "He's had a few close calls this past week," I was told has I prepared to visit this man who lived out in the mountains. "He's a crotchety fella and not too keen to go to the E.D. so do what you can if anything goes wrong." "Great," I thought, "This should be interesting." We'll call him "Jake." Jake was a 76 year old man who suffered from COPD, Diabetes Mellitus and Peripheral Vascular Disease. He was also a fairly recent double bilateral amputee above the knees. His struggle with COPD left him on oxygen 24/7. However, he didn't always wear it, nor was he always compliant regarding his neb use. In short, he often sabotaged himself. Recently discharged from his surgery, he lived on a small farm up in the Maine mountains with his son, a developmentally disabled 22 year old, and his chickens and ponies. He wasn't one of my regulars. His Case Manager was out for the day and I was asked to see him on the weekend. I grabbed my supplies and headed out. Jake's place was about a 25 minute drive from town. When I arrived, I was amazed how long his driveway was. A dirt road off of another dirt road. "If it was dark out, I would have missed it." I told myself. I slowly backed my vehicle off to the side being mindful of the chickens who insisted on escorting me up the walk. I knocked and was greeted by Jake's son. "Dad's in here," he pointed to the living room. The T-V was blaring. Jake was seated at his kitchen table, in his wheelchair, baseball cap on his head. He looked tired and was having some difficulty breathing. "Hi, Jake," I introduced myself, opening my bag after tossing down a barrier and whipping out my hand sanitizer. "My name is Cynthia. I filling in today for your nurse. Let's check that oxygen level and get you more comfortable." I was concerned. His heart rate was high, skin was moist and his color was a bit gray. Even though he was a CO2 retainer, I cranked his O2 from 2.5 to 3.5 while I scrambled for a neb from his box. It can be dangerous to increase oxygen on a CO2 retainer as their body has compensated the lack of O2 for over a long period of time. Weaning them down too quickly can have deadly consequences. He denied chest pain. But Jake had standing orders to increase his oxygen for saturation parameters, but to wean him slowly as soon as we could back down to his normal rate of 2.5L per nasal cannula. Of course, we were to let the Physician know. I listened to Jake's lungs. Not knowing what his baseline was made it a bit tricky. I didn't like what I was hearing. His sats were still in the mid 80's. "Jake," I said, "If I can't get you stable quickly, I should send you in." He grabbed my arm. I winced. "No hospital!!!" He said emphatically, shaking his head forcefully. I glanced to his son, still sitting on the couch, watching T-V. He was oblivious to the distress, or maybe he was just use to it? I could see the idea of going to the Emergency Room was making him worse. "O.K., Jake," I relented. "You're the boss, but I am going to make sure you take your breathing treatments and I mean now. I cannot even begin to do your ordered dressing changes until I know you are breathing better. "I've got time, so what do you say?' He nodded, and took his nebulizer. I began to document, listened to his lungs again, documented some more. Much improved. He coughed up a lot of mucous. His sats increased to 92%. I began the process of slowly weaning him down over the next hour. I washed my hands again to set up the dressing for his bilateral stumps. The wounds themselves actually looked good but nutrition, blood and oxygen perfusion would play a big part in his healing process. I glanced at the kitchen, noting the dishes in the sink and the dirty stove. With Jake's permission, I did a quick visual of what was in his refrigerator. "Jake, what did you eat today for breakfast?" "I ate eggs and coffee." He stated. We had a discussion about food choices, the part that they play in building substrates for cells to mesh, etc. "I know that it takes a lot of energy for you to eat, and it's great that you are eating protein so it's fine to go slow, but please try to eat vegetables, fruits and whole grains and all of it if you can." "No one told me that!" I stayed silent because to keep good relations with clients and caregivers, there are times when one simply cannot rise to the bait. I am sure his caregivers went over this, as it was on his Care Plan. I reviewed the Care Plan with him instead. My visit with Jake was long. Between the education regarding his disease processes, the need to use his medications and oxygen appropriately, the monitoring for infection regarding his wounds, it took some time. But by nursing and God's grace, he was pulled back to his baseline. His dressings changed, his vitals stable, his color much improved, his discomfort abated, for now at least, I felt I could leave his house. As I said goodbye and thanked him for trusting me with his care, my gaze wandered to the window. The pastures so green, lilac fragrance in the air, the ponies scampering enjoying the summer breeze. For a while, all was well once again in Jake's world.....for now.
  24. While working as a nurse-tech in nursing school, I would often get assigned the Psych patients or the HIPAA-No patients (usually those who were incarcerated or under some kind of police watch), who were admitted to our floor for their traumatic injuries. It seemed that if we had one of these patients, we had about 6 of them, all at the same time. One night, I was really tired and just felt I could not make it through the whole night, especially with these very needy and very draining patients. Well, I was in for some real introspection. In my upbringing and due to some very traumatic personal events in my family, I always said and thought I would have a very hard time caring for a patient who had committed murder or some other violent crime. What I didn't know was that I wouldn't always know what a patient may have done on their own free time. During this shift, we admitted a, "John Doe," who was under police watch and observation. I knew he was coming from the prison, but, I did not know any of his past history-just that he had sustained some injuries in a prison fight. When I greeted him, he immediately said to me, "You're the only one who has smiled and looked directly at me." I was a little taken aback, because I had not even realized I was doing those things. Throughout the night, as I cared for him, I made sure he had fresh water, snacks, and clean linen. He was handcuffed to the bed rails and there were always 2 or 3 officers with him. Since I'm generally not afraid to talk to people and I know most people love talking about themselves, I began to talk with "John." Me: "So, if you don't mind me asking, how did you get all these cuts on your body?" John: "Well, I was caught by two different groups or gangs. They was trying to teach me a lesson." Me: "A lesson? Well, I admit, I am a little 'jail-naïve,' but, it seems that if they cut you this many times, they were really trying to really injure you or worse." John: "Nah, not really. If they wanted to kill me, they could have and would have. They was just trying to teach me that the next time, it will be worse." Me: "Again, if I'm being nosey, tell me, and I will shut-up. I just like to get to know my patients a little more than what I read on paper." John: "Nah, you good. I appreciate that, really, 'cuz, most people, even doctors and nurses, don't really talk to me, so, the fact that you axin is different." Me: "I guess, what I really want to know is why they cut you all over your body like this?" John: "See, they wanted to get back at me for snitchin and they think I'm tryin to get out of stuff. It's just how it is, but, I ain't worried, tho, 'cuz, if they gonna take me, ain't nothing gonna stop 'em." Me: "Are you afraid? First, I would be afraid of going to jail; but, even more so, I know I would be afraid to go back to that environment where I knew my life could be ended in a snap." John: "Nah, I'm not afraid, not really. It just goes with the territory." He must have seen the look on my face and saw the incredulous look on my face, too. As we kept talking, I finally asked him, "What are you in for?" to which "John," replied, "I was accused of attempted murder." "Accused, or actually," I asked. "John," said, "Well, Ms. Evette, I can only say I was accused, 'cuz I haven't been tried yet, but, I was in a position where I had to defend myself from this dude who had a hit on me, and he saw me in a bar, tried to hit me, and I got to him first. That's all I can say." I agreed with him, but, when I left the room, I found myself talking to myself, and going back and forth between the ideas of justice, retribution, punishment, and criminality. I was also astounded that I did not feel conflicted about caring for this man, even knowing a little more of his history. The next day, "John," was discharged and as we walked down to the secure area to place him in the police van, he turned to me, looked me straight in the eye, and said, "Thank you, Ms. Evette. Thank you for talking to me, asking me about me, and just being real with me. I really appreciate you doing that. It meant a lot to me." Now that I'm an RN, I've been told, "Thank you," many times, and each time it is music to my ears. But, this time, this, "Thank you," cut much deeper!
  25. spotangel

    SHE COMES FIRST!

    "Annie, I need your help!" My usually unflappable ED charge nurse Nilda look frazzled "What's going on?" "I just spend 20 minutes with that guy in room 14, Mr. Uptown. His heart rate is 186; he's dizzy and refusing treatment. He wants to go home." "OK, Nilda, I am on it. Thanks!" I quickly scanned his EMR. HTN and 76 years of age, rarely was in the hospital, no allergies. I went in. Mr. Uptown was thin and frail looking, hooked up to the monitor. He was tachycardia and hypotensive. He was on IV fluids. I introduced myself as evening manager of the ED and asked him how I could help him. "Get me out of here! I want to go home." "Why did you come to the ED then if you did not want help?" "I thought my pressure was up and they would give me something and send me home. I don't want to stay!" "Who do you live with at home?" "My daughter Celine. She is 55 years old." "What about your wife?" "She died 12 years ago. I have been taking care of my daughter Celine." "What do you mean? Why are you taking care of your daughter?" I was puzzled. "She cannot take care of herself. She is mentally retarded (his words) and cannot get out of bed herself. I feed her, bath her, clean her and do everything for her." "I see. Do you have any help?" "No. I cannot leave her by herself. I only run to the store and then come back. I have to go. She is alone for 4 hours now and is probably peed and pooped on herself." He was tearing up. "Is there anyone that can watch her when you are in the hospital?" "No! She is my only child and I don't have anybody that could stay with her. She comes first! I have to go. Please help me Nurse Annie!" The tears were falling down those worn cheeks. I knew we could not let him go as he was unstable and symptomatic with dizziness. My mind went into overdrive. "Mr. Uptown, you came for help and we will help you. Do you live nearby?" "20 minutes by cab". "If I can get your daughter to you, will you stay?" "Yes! I want help but I am worried about her. I cannot leave her alone." "I understand completely. I am a mother and would want my child to be safe too. Will you trust me with your house keys? Give them to me. I will speak to the social worker; we will call the police, go to your house, pick up your daughter and bring her to the ED in an ambulance. How does that sound?" "Can you really do that?" "I will try my best and keep you updated ok?" I said as he handed me a bunch of keys and showed me the keys to the front door. I went out the room, discussed the situation with Pamela the social worker who was all for it! I called the local police precinct and ambulance service (EMS).The cops were there in 5 minutes and EMS promised to meet us at Mr. Uptown's house. I went back to room 14 and informed the patient who consented to treatment. I informed his team and they swung into action trying to stabilize him. Meanwhile Pam and I took a ride with our friendly cops (sirens on request!) sitting in the backseat of a cop car, our knees touching the front seat, the windows barred on the sides and in the front! Definitely cramped and not a luxury ride! I met Sasha and Kim, EMS staff, at the front door, after a 7 minute high speed ride! I unlocked the door and we stepped in, the cops in the front with their guns ready just in case. We rounded into the dining room of the silent house and stood with our mouths open. A rooster was walking around the dining room table and 2 cats sunning themselves at the window sill. Outside in the backyard, I counted six hens and a few chickens. The rooster ignored us as Sasha grinned and said "Dinner, anyone?!" Past the dining room was Celine's room as Mr. Uptown had told me. I entered first and saw her lying on the bed, staring at me, frightened. The others waited outside the room. I slowly approached her and knelt by her bed. I spoke to her softly. "Hi Celine! I am Annie. I am a nurse. Your dad sent me to get you to him. He is in the hospital." She did not reply as she was nonverbal and made only few sounds but no words. She smelt of urine and feces. "I am going to get Shasha and Kim my friends to help you get ready." I smiled at her as Shasha and Kim slowly came into the room. The cops kept out of sight, to keep her calm. We quickly put on gloves, gown and cleaned her thoroughly and got her ready. Her back was soaked with urine and so were her sheets. I was in awe as her skin was intact, soft and healthy looking. The house was clean and well kept. I admired Mr. Uptown for doing this all on his own, day after day. Within 15 minutes we had her ready and in the ambulance. The cops left after I carefully locked the front door on our way out. "Maybe we can come back for fresh chicken!" Shasha said with a smile. "Not on my watch!" I laughed as I patted the keys, safe in my pocket. We took off in the ambulance sirens blaring. When we reached the ED, I had Nilda triage her and get a set of vitals. I went to room 14 and checked in on Mr. Uptown whose condition was stable. He was admitted to Telemetry. I gave him an update, his keys and he was very grateful. A little later, we got their stretchers side by side and Celine smiled when she saw her dad. We admitted for 'weakness" workup. I coordinated with admissions and expedited beds for them and got them out of the ED. I high fived Nilda and left for the day, happy. They were not on the same floor. We got her a sitter who took care of her and dad was allowed to visit her. Social work got involved and helped dad find placement near his house as he could clearly not take care of her at this point. The day before she was placed in a nursing home, I spoke to the Nursing supervisor of the hospital and got them in the same room to spend their last night together as family. She was placed in the nursing home close for him to visit, once discharged. I saw him twice after that in the ED for cardiac issues. His daughter was safe, secure and he was at peace although he missed her and was lonely. I always wondered what happened to him and Celine. Since then, I have seen many older parents with disabled adults and they confide their worries and lack of support or help. I always hook them up with the social worker to get them started with services and planning for the future. As nurses we are in this unique position where patients confide their inner fears once you gain their confidence. What we do with that information can go beyond the physical complaint they come for and address what is truly important to them.
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