Where Science, Humanity and Art Converge

JParadisiRN blog began by discussing art and nursing. For the most part it remains so, through observations of the way science, humanity, and art converge, transferring these observations into blog posts.

Nursing is a tactile profession, at least when practiced at the bedside. It’s difficult to do the work of a nurse without actually touching people. Nurses learn that some skin or veins are so tough they almost repel an IV catheter, while other types are so fragile, even the paper tape used to secure a dressing or IV can easily tear it.

Nurses bathe the newborn’s firm, plump flesh, or rub lotion into the loose, wrinkled flesh of the elderly to prevent its breakdown. We measure and weigh the under and overweight, then calculate body surface area to administer the correct dose of chemotherapy.

This summer, I enrolled in an open life drawing studio. A model sits for a few hours, while artists, in meditative silence, draw the human body on paper.

Drawing is also a tactile experience: holding charcoal against toothed paper, making shapes and lines into limbs and torso, adding shadow to give them volume.

Patients and models allow nurses and artists into the sacred space of their nakedness. This privilege demands respect. Administering nursing care to a patient, or capturing the model’s likeness on paper requires concentration, skill, and love of humanity.

 

Latest Posts: AJN’s Off the Charts & New Nurse Niki

Drawing From Life is my latest post for Off the Charts, the blog of the American Journal of Nursing. It posted yesterday. Often the lines between art and nursing easily blur, like soft charcoal lines smudged on paper. You might want to check it out, or leave a comment.

The Adventures of Nurse Niki now posts new episodes on Mondays, instead of Thursdays. Be sure to read week’s episode, Moving On..

The Adventures of Nurse Niki Moves to Mondays!

The Adventures of Nurse Niki

The Adventures of Nurse Niki

I’m having fun re-prioritizing a few things, one of which is my other blog, The Adventures of Nurse Niki: fiction so life like, it’s almost real. I’m enjoying writing fiction more than I’d expected. Niki and her friends have integrated into my waking life, and the story lines come faster than I can write them down. Therefore, The Adventures of Nurse Niki will post on Mondays instead of Thursdays.

I am not shutting down JParadisiRN blog. This is a shift, not an ending. I’ll still post thoughts and images. In the meantime, tune in on Mondays for new episodes of  The Adventures of Nurse Niki: fiction so life like it’s almost real, starting today.

You can discuss or interact with Niki on The Adventures of Nurse Niki’s Facebook page. Please don’t forget to “Like” it too. Show Niki some love! Thank YOU!! to the readers following The Adventures of Nurse Niki, the retweets of @NurseNikiAdven (Hashtag #NurseNiki) and those who Like Nurse Niki’s Facebook Fan Page. The support is very much appreciated!

 

 

 

The Sacred Space of Patient Care

One of my hands is soaking in a shallow bowl of soapy water, while a nail technician holds the other, turning it one way, then the next. She files my chipped and broken nurse’s fingernails into a more attractive shape. As she does so, she says “relax” whenever I hold my hand too stiffly for her to manipulate it. This catches my attention, because I had just come from work, where I’d spent the day starting IVs in patients, telling them, “relax,” so the catheter would thread more easily into their veins.

by jparadisi

by jparadisi

I often preface starting an IV with, “I know this is easy for me to say, being I’m not the one getting stuck with the needle, but the more relaxed you are, the easier this will be.”

I realize that a manicure is a much more pleasant experience than having an IV placed. What manicures and IV starts have in common, however, is the need to trust someone, often a stranger, touching your body, and literally putting yourself in their hands.

With this in mind, I’m astounded by the trust patients put in nurses. I mean, think about how we poke them with needles, whether in their chest ports or in peripheral veins, and then infuse chemicals otherwise known as “chemotherapy” into their bloodstream; medications so potent that the patient signs a consent allowing us to do this to them. The chemicals are so powerful, in fact, they can cause other varieties of the very disease (cancer) we administer them to cure.

This is a pretty huge demonstration of trust.

Once a hairstylist stylist told me, “When I cut someone’s hair, I’m in their sacred space.” I’ve kept this statement in mind ever since, whether it was performing a bed bath in the ICU, or now, taking a blood pressure or drawing blood from a vein with a butterfly needle.

No matter how clear our communication with patients, no matter the level of caring we demonstrate, if we forget that we have entered the sacred space of our patient’s body, these administrations will not be received with the intended appreciation.

Developing a soft touch in patient care, whether it’s honoring an adhesive allergy by finding a less irritating occlusive dressing, offering to numb a peripheral IV site or port before inserting a needle into it, or simply placing a hand on the shoulder of a patient who is visibly upset, are ways we tell patients we respect the sacredness of their bodies. We are there to help them relax.

Nurses Make Birthdays, One Year at a Time

by jparadisi

by jparadisi

Part of our institution’s medication administration policy is asking patients to state their name and birth date, scrutinizing the information against the medication label. Patients of a certain age, more women than men, customarily wince while saying the year in which they were born. Often they say, “I’m getting so old.”

Perhaps it’s none of my business to respond, but as a cancer survivor and an oncology nurse, I can’t seem to help it. This reply escapes my mouth with hardly a thought in between: “That’s what we do here. We help you grow old, one birthday at a time. That’s why you and I are here.”

It always gets a laugh, and more often than not a, “Well, I suppose you’re right. That is what we’re doing here, isn’t it?”

Like many things in life, the ability to enjoy growing old is a matter of perspective.

It’s a funny world we live in. People bemoan their birthdays and growing old; yet endure chemotherapy and procedures, fighting to add years to lives threatened by disease.

I don’t love the effects of aging on my body. I color my hair to hide the gray. I exercise and eat right, and avoid over indulging in things that destroy a body’s ability to maintain its health. But these things enhance life, they do not prevent the inevitable. I know my days are limited. I know some day I will cease to exist in the manner I do now.

You may feel depressed by reading this post, but I say to you, knowing that life is finite is the most freeing of all thoughts. It bestows the gift of living everyday to the fullest, to make choices honoring integrity, and loving relationships. Life is too short to dwell in unhappiness. This is the least that nurses can do to honor the memory of the patients we have known and lost: live life as if each day were the last.

And, yes, I will take another slice of that birthday cake.

New Post: The Art of Nursing

May is all warm and fuzzy with Nurse’s Week. May renews love for what my mentor once dubbed “The noblest of professions.” May also marks the birthday of Florence Nightingale, the founder of modern nursing. I am a fan of Nightingale, her work, her integrity, and her devotion to nursing’s science.

 

The Art of Nursing by jparadisi

The Art of Nursing by jparadisi

So, please, don’t misunderstand when I say there is a quote by Nightingale from 1868 in which I find the tiniest flaw:

 Nursing is an art; and if it is to be made an art, requires as exclusive a devotion, as hard a preparation, as any painter’s or sculptor’s work; for what is the having to do with dead canvas or cold marble compared with having to do with the living body, the temple of God’s Spirit? Nursing is one of the fine arts; I had almost said, the finest of the fine arts.”

The troublesome part for me is describing “canvas or cold marble” as “dead.” As an artist, I tell you that there is no such thing as a dead canvas or sculptor’s stone. Yes, both are inanimate objects — no disagreement there. But anyone putting brush to canvas or chisel to stone knows that an interaction occurs between the artist and the medium. Writers know that a blank page stares back in judgmental and deafening silence. Art is a result of the interaction between the medium and the artist. As an art student, I once told an instructor, “I just want what I paint to look like what I see in my head.” Sympathetically, she replied, “That’s what all artists want. It never happens.”

Michelangelo said it best:

“Every block of stone has a statue inside it and it is the task of the sculptor to discover it.”

The personality of a canvas, stone, or blank page is manifested by its grain (tooth), flaws, and innate characteristics. Artists do not simply impose their will on canvas or stone. Art is the interaction between the artist and the medium.

So what does any of this have to do with nursing?

The art of nursing lies within a broader spectrum of skills than IV starts, and medication administration. It requires a nurse to discover the unique characteristics of each patient asking for help. Nurses chisel away at fear, pain, and grief to reveal a patient’s inner strengths and natural resiliency. We hold up a mirror, so our patients can see the beauty of the human spirit that we uncover.

Like canvas or stone, some patients are resistant to brush or chisel. Through devotion to our craft, we adapt our nursing skills to the realities of their character. Artists and nurses know a vision cannot be impressed upon a unreceptive surface, so we do what we can, knowing the result may fall short of our vision.

The nurse’s art, much like that of an artist or sculptor, utilizes the naturally occurring strengths and flaws in patients to create beauty from potential. The art exists within this interaction.

Happy Nurses Week!

The Adventures of Nurse Niki: Nurse Characters Doing Nurses’ Work

This post was originally published on RNFM Radio‘s blog October 2013

JParadisiRN

JParadisiRN

I’m one of those nurses other people hate watching TV medical dramas with. I shout out: “Intubate her now!” or congratulate myself on guessing a diagnosis from a minimal amount of script information. People watching these programs with me say, “It’s just a TV show.”

But the truth is, it’s not.

When the same nurse characters are recreated over and over for public consumption by the entertainment industry they become woven into public awareness, and accepted as fact. I wrote about this in a previous post for RNFM Radio.

After my appearance on RNFM Radio earlier this year, I realized I want to create nurse characters closer to the truth, struggling with feelings of social isolation caused by intimate association to the trauma of others, and the accountability to act on it.

Nurses do not only witness the suffering of others, nor do we only hold the hands of patients in pain, or their hair out of their faces while they puke. We assess their needs, get them the treatment needed to alleviate their symptoms, and administer it. Other times, we cover their profuse bleeding with our gloved hands, yell for help, and initiate the ministrations designed to help them hang on.

Except on TV. On TV, physicians do all of this work. In real life, I have had the pleasure of working with doctors who actually did hold the basin while a patient puked, and I’ve even had one assist with cleaning a code brown. These are special people, performing outside of the work doctors are usually expected to do, not because doctors wouldn’t necessarily do so, so much as because doctors are not usually present when these things happen, and nurses usually are.

Anyway, in The Adventures of Nurse Niki, nurses do the work of nurses. Physician characters appear proportionately to how they normally do in real hospital units: during rounds, when summoned from the call room, during codes, procedures, and for admissions and discharges. Doctors are not constantly at the hospital coordinating and administering patient care, because that is not their job. It’s the job of nurses.

None of this information is new to either nurses or anyone who has spent a lengthy time hospitalized, but it appears to be new information for producers and TV writers who continue to populate TV hospitals with doctors doing patient care, while the nurses stand by waiting to, or asking for, help. Some TV nurse characters enter medical school, I suspect, so they too can get a starring role.

The Adventures of Nurse Niki is an attempt to make a 3-dimensional main character whose life is interesting because she is a nurse, not because she works in the proximity of doctors.

 

Do Facebook Likes Help or Scam Patients?

by jparadisi

by jparadisi

I am cautious when initiating online interactions, with good reason.

Sometimes, being cautious feels uncomfortable, however. I’m talking about the Internet phenomenon of patients asking strangers for Likes, or even donations to cover the cost of their medical expenses on Facebook. Despite a high index of suspicion, like most nurses, I have a soft heart. When I see those sweet little faces of bald children asking me to help them get a bazillion Likes on Facebook, I think, “I’m a cancer nurse, how can I not click Like? What can it hurt?” But I don’t click Like, and I feel guilty.

What I want to know is: How does my Like help these children? Are they really out there anxiously waiting for me, a stranger, to Like their Facebook picture? Have their lives as cancer patients come down to this? Where’s Make a Wish? Wouldn’t they rather go to Disney Land, drive a racecar, or meet a teenage popstar? How exactly does my Like benefit them?

Worse yet, what if my Like does harm? It’s easy for anyone to click on a Facebook photograph, and to add it to a file on their computer. Then they can repost it, adding anything to the original post out of context. What if this cute little kid’s picture was used without either his or his parent’s knowledge, and is passing like a virus throughout cyberspace? Worse than that, what if the child is deceased and a family member discovers the picture unexpectedly?

Perhaps I’m reading too much into it. I only wonder, is this a valid use of social media? Then I feel guilty because some little kid with cancer wants my Like, and I won’t give it to him.

A newer version of Internet donations is crowdfunding, and uses social media platforms such as GoFundMe, or GiveForward. As an artist, I’m familiar with crowdfunding. Frequently, artists raise funds for projects through Kickstarter, but patients collecting donations in this manner to pay for medical expenses is a new phenomenon to me.

According to Crowdfunding a Cure, by Alice Park for Time Magazine, December 3, 2012: “Patients and their relatives are raising thousands of dollars to pay for surgeries, cancer treatments, and more.” The article continues to outline the waging of a successful fundraiser through social media contacts via Facebook, Twitter, and email campaigns. This being the case, it’s not unlikely that I’ll soon feel guilty deciding between emails meriting a contribution, and those that do not.

What do you think? Are you with Likes and donations? If this is the future of donations, how will it affect traditional cancer foundations’ collection and distribution of funds?

The Nursing Dilemma of Medical Marijuana

Medical marijuana is legal in Oregon, where I practice. In one sense, this seems to be an enlightened act of legislation for patients who cannot tolerate conventional medications or simply prefer an herbal approach to managing pain and/or nausea. Its use is particularly prevalent in among oncology patients, and those with chronic pain.

Still, it’s a nursing conundrum. The issue is that marijuana remains illegal at the federal level. Because of this, many hospitals are reluctant to allow prescription marijuana on their campuses. Although a 2009 Justice Department memo recommends that drug enforcement agents focus their investigations away from “clear and unambiguous” use of prescription marijuana, it also says users claiming legal use but not adhering to regulations may be prosecuted.

In light of this, hospitals take the conservative approach: Attending licensed medical practitioners are prevented from prescribing medical marijuana for hospitalized patients, and create policies prohibiting the use of medical marijuana on their campuses.

For pharmacists and nurses the problem is this:

  • Pharmacists can only dispense medications prescribed by licensed medical practitioners. The federal government classifies marijuana as a Schedule I drug, which means licensed medical practitioners cannot prescribe it.
  • Nurses administer medications only with an order obtained from licensed medical practitioners.

Nurses may have run-ins with patients and caregivers unfamiliar with this policy, and a patient’s home medication routine may be disrupted.

Though it does not happen often, I had the experience of treating a chemotherapy patient expecting to smoke marijuana between infusions to control nausea and vomiting. Initially caught off guard, I struggled to find a way to manage the situation.

The campus did not permit smoking, tobacco or otherwise. When I reviewed the hospital policy, it confirmed that the medical marijuana was not an exception. I explained this to the patient, who was understanding, but skeptical.

Reviewing the premedication orders, the oncologist had done a good job of covering nausea and vomiting with conventional medications. I asked the patient to give it a try. Always having a plan B, I promised that if the medications didn’t work, I’d call the oncologist and, if necessary, the department manager.

Fortunately, the conventional medications worked. The patient enjoyed a hearty lunch and held it down. For the future, I recommended the patient smoke marijuana at home before appointments, and afterwards if indicated.

Several states have enacted medical marijuana laws. Do you work in one of them? How does this affect your nursing practice?

 

Managing The Moderately Unstable Patient: The Challenge of Ambulatory Care Nursing

When a nurse educator makes the bold statement, “The moderately unstable patient is at the highest risk,” I’m interested in knowing why. I’ve thought about this statement ever since.

Wild Card by jparadisi

Wild Card by jparadisi

She explained that the task-oriented nature of ambulatory care units (ACU) is a contributing factor. While patients in the ACU are assessed by their physician or nurse practitioner for treatment readiness, and again assessed by the infusion RN during treatment, the primary goal of these appointments for patients and providers is to administer treatment, complete the appointment, and, for the providers, to move on to the next patient. The ACU patient then goes home to fend for his or herself until the next appointment.

If you spend only a small length of time at the triage nurse’s desk answering phones, the high risks faced by these moderately unstable patients are clear:

Pain
Chemotherapy-induced nausea and vomiting (CINV)
Blood clots
Febrile neutropenia
Depression
Herpes zoster shingles
Malnutrition
This list is not comprehensive. Individual risk factors such as living alone or comorbidities also play a role in overall risk factors.

Some risk factors that might occur during the ACU appointment:

Patient falls
Adverse drug reactions
Syncope
Patient and nurse are unaware that patient is unexpectedly unfit to drive after the appointment
The above factors often occur because the nurse caring for a particular patient is unfamiliar with that patient’s baseline functioning. This puts first-time patients, and nurses new to an established patient, at an increased risk for an unfortunate event.

So, how can ACU nurses protect patients and their nursing license in this fast paced, and rapidly expanding nursing specialty?

First, stop calling your place of work a clinic. The ACU is a specialty care area requiring its own unique set of nursing skills, and should be recognized as such.

Maintain a high level of suspicion. Asking the right question is more important than having all the answers. What you don’t know will harm your patient. One of the most common examples is explaining to a patient how to care for their back pain, only to later discover that the pain is shingles, which were missed because no one asked to see the patient’s back. Other important questions are: “When did you take your (fill in the blank) medication last?” If they haven’t recently, ask, “Why?” because the answer may surprise you. Asking the right questions is an essential part of a solid assessment.

Continuing education is critical to quality patient care. While ACU nursing may seem less demanding than inpatient nursing, it requires the same level of skill and vigilance.