Nurses Day 2013 has come and gone. I had a particularly good one, which I wrote a blog post The Best Nurses Day Gift: Enough Time for Patients for Off The Charts, the blog of the American Journal of Nursing.
Illustrating this post is my painting, What’s Left Behind.
A friend and I sat at a wine bar. Over a glass of Pinot Noir, the topic of blogging came up. I
photo by jparadisi
told her I was writing a post about the need to teach nurses how to talk to patients about dying.
She said, “Oh, you can’t talk about that all in one conversation. You have to talk about things like that in short, repeated conversations. It’s too much for someone to take in all at once.”
My friend is a diabetic educator, and she is better prepared to discuss life-changing illness with her clients than most nurses are to talk to theirs. Talking about the life-threatening aspects of diabetes is in her job description. Therefore, she’s been educated to do it.
Unlike clinical educators, nurses are hired for what we do to patients, not for talking to them. Although documenting patient education is part of our job description, it doesn’t carry the same weight of importance as, for instance, administering chemotherapy. Assuring that nurses and physicians are competent to discuss dying with patients is not a priority in health care delivery.
What if nurses and physicians were taught and supported in the necessary skills to bring the process of dying the same respect given to the process of giving birth?
Envision patients, physicians, nurses, social service workers, and spiritual care, working together, creating the same level of compassion and purpose for dying that parents, midwives, nurses, and obstetricians have created for childbirth.
If education about childbirth empowers expectant mothers in labor, might not education about what to expect at death equip dying patients with a sense of control, lessening their fear and pain? What might these patients plan, given small conversations of education, over an adequate amount of time? Would they create personal soundtrack CDs of music? Choose poetry for loved ones to read? Decorate their rooms with art to view as their vision dims? Lie in beds wide enough so loved ones can hold them?
As it stands, we burden hospice nurses with guiding patients and families, who do not know what to expect, through the entire dying process. When there is not enough time, patients go without the necessary knowledge to find personal meaning in this eventual and unavoidable passage.
by jparadisi
Sitting in a trendy restaurant sipping a cocktail, I pick Marcona almonds from a small plate set between a blonde woman and myself. We are guests celebrating the birthday of a mutual friend. We grin self-consciously before introducing ourselves.
She asks, “What do you do for a living?”
Do all nurses dread this question at parties? Admitting I’m an oncology nurse is a buzz kill. The dread I anticipate appears in her eyes but not for the expected reason. She says her father is hospitalized in another city and “not doing well.” She can’t visit as often as she’d like.
She asks, “Do you like your patients? Is it hard taking care of them?”
I wonder, how much information can she tolerate? A few morsels or an entrée?
Cancer conjures images of wraiths drinking reconstituted chicken broth from Styrofoam cups or receiving nourishment through tubes. It would be untruthful to say this never happens, however, the social ambience of the clinic where I work surprises newcomers.
Instead of lounge chairs lining the walls of a single, cavernous space, our clinic has private rooms. Long-time patients have favorite ones. It’s not unusual to find Happy Birthday written in Sharpie on a piece of fax paper taped to the sliding glass door of a room of its “regular” occupant. Sometimes there’s birthday cake too. Cancer patients can eat birthday cake, like the rest of us. They eat “diet as tolerated.”
Patients with lengthy appointments are offered lunch, and some choose their infusion day based on the cafeteria’s soup du jour. Many choose to bring food from home, however.
Often, patients make their meals at the infusion clinic a special occasion by bringing utensils from home. I particularly admired a hand-thrown ceramic bowl brought by a special patient. Weekly, it was filled with something new: pillows of wonton, pea pods, and water chestnuts in broth, or brown rice with chicken. On rainy days, it cradled creamy macaroni and cheese, and an heirloom silver fork delivered each small bite to her awaiting mouth.
These meals are prepared with love. Families take pride in the accomplishment of feeding a loved one with cancer. The family table marches onto the foreign field of cancer proclaiming, “We will not surrender our loved one without a fight.”
Back in the restaurant, I see our hostess heading our way. The blonde woman has concerned eyes. There is only enough time to offer her with a small morsel of information.
I consider my answers to her questions, “Do you like your patients? Is working with cancer patients hard?”
“I love them,” I say. “Working with cancer patients is hard work but I can’t imagine a more rewarding job.” Her eyes relax. She takes a sip from her wine glass.
Like a fairy godmother, the birthday girl hugs me, kissing my cheek. Pouf! I am restored to a guest at her party, sipping a cocktail.
*This post was originally published on TheONC website.
In the commercial, three guys are standing around a grill, talking about baseball. One of
Baseball Card by jparadisi
them quotes a stat.
Another one says, “Really? Are you sure?”
The first guy says, “I’m 99.9 percent sure.”
The third guy says, “Then you don’t know.”
I don’t remember what product was advertised. I remember the commercial because the question of certainty came up regarding a medication order.
I was reviewing the chemotherapy orders:
The total dose (in milligrams) did not equal the product of milligrams times meter squared (m2). The reason was easy to spot, however.
The chemotherapy infusion was to be administered as a continuous infusion over two days. The order read:
xxxx mg of chemo drug X m2 = xxxx mg X 48 hours = total dose of chemo drug
The doctor meant to write:
xxxx mg of chemo drug X m2/every 24 hours = xxxx mg X 48 hours = total dose of chemo drug
I was 99.9 percent sure, which means I wasn’t certain. Unlike quoting baseball stats, there is no room for uncertainty in chemotherapy administration. Interestingly, a pharmacist felt 99.9 percent certainty was good enough and mixed the cassette sitting in front of me.
To be fair, this was not the patient’s first infusion. The pharmacist mixed the chemo based on past orders. Using a previous record to predict a result in the future is the definition of betting, which works in baseball, but not so much when administering chemo.
I called the office where the order originated. The nurse on the other end of the phone pulled up a copy of the order. “Oh, he meant to write every 24 hours. If I write that and fax it back to you, will that work?”
“Yes it would,” I said. “Are you certain?”
“I’m 99.9 percent sure.”
“Certain enough to sign your name to an order?” I asked.
There was a pause, and she said, “I’ll have the doctor take a look, sign it, and fax it back to you.”
I thanked her.
The corrected order, signed by the doctor, arrived on the fax machine. The checklist was successfully completed, and the infusion started.
I was 100 percent certain the infusion was correct.
Do you ever feel like the nurse holding everything up? What’s your opinion? Would you trust your familiarity with a patient’s past orders and go ahead with the infusion? Does your work environment support nurses delaying treatment while verifying orders?
At The Pool photo by jparadisi 2013
JParadisiRN is on vacation this week. I’ll write a new post soon from a refreshed perspective. Meanwhile, if you haven’t read my oncology blog for TheONC, or latest post for AJN Off The Charts, this is a good week to catch up.
Cheers!
When I hear the word inertia, the meaning I think of is actually paralysis:
The loss of the ability to move (and sometimes to feel anything) in part or most of the body, typically as a result of
Take One Daily by jparadisi
illness, poison, or injury; inability to act or function in a person, organization, or place.
The actual definition of inertia is:
A property of matter by which it continues in its existing state of rest or uniform motion in a straight line, unless that state is changed by an external force. Inertia is the inability to change course.
Nurses experience inertia when we are unable to switch gears from the high emotional output of our jobs to the more “normal” activities of our personal lives.
I wrote about my difficulty changing course in “The Hostess With The Mostest.” In that post, I describe struggling to transform from on-duty nurse into a party guest at the end of a shift. The difficulty is not only in physically changing from work clothes to party wear. It’s also in retooling my brain for party talk. I have to remember how to talk about favorite restaurants, or the latest film I have not yet seen, instead of cancer nursing, blogging about nursing, or the other related things I spend large amounts of my time doing, casting a shadow over a perfectly good cocktail party.
I think about this while observing people who are not nurses enjoying themselves by taking funny pictures with their cellphones while I avoid being caught in any photographs I wouldn’t want an employer to find on Facebook. Do I worry too much, or is it this a characteristic that makes me a nurse?
It’s healthy for nurses, like myself, to avoid inertia and change course through external activities after leaving our places of work. I find it easier said than done, however, not because I can’t relax, but because “normal” life sometimes fails to hold my attention.
I suspect other nurses find normal life less interesting than their nursing roles, too. If we aren’t over-scheduling ourselves with committee meetings, working overtime, all the while being the World’s Best Soccer Mom, we don’t feel busy enough.
This point was brought home to me by a friend who commented that I seemed tired after I said I was going for a run after getting off a 12-hour shift early. I told her, “No, I’m not tired. I only worked eight hours today.” She replied, “For most people, eight hours is a full day’s work. Go home and get some rest.”
I didn’t. I went for the run. I do my best thinking while running, not meditating on a yoga mat. It’s hard to walk when you’re born to run.
Do you think preferring a busy and sometimes-hectic lifestyle is a characteristic of nurses?
Like the rest of us, I grieve for the victims of the Boston Marathon bombings, and am thankful for the rapid response of the health care providers who were suddenly thrust into a scenario resembling a war zone.
I found out about the attack moments after the bombs went off, by turning on the TV. I had come home early from the clinic, because our census was low. Earlier in the morning, I told my coworkers that my cousin was running the Boston Marathon. Now I wondered where was he? Were he and his partner safe?
You can imagine my relief when he quickly responded to my text, “I’m ok.”
I called my Mom, to let her know too.
Soon afterwards, my cousin posted the same message on Facebook. Dozens of friends and family expressed relief.
I am grateful for the safety of my family. My heart breaks for those who were not as fortunate, and are suffering still. My thoughts and prayers go out to the victims, their families, and the teams responding to this senseless emergency.
I attended a chemotherapy and biotherapy course. Most of the nurses attending had administered chemotherapy for years, but a group of nurses new to oncology sat at the far end of the table. By the end of the first day of class, none of them had spoken a single word after the morning’s introductions.
photo by jparadisi
Concerned, I approached the instructor. She had noticed their lack of participation too and told me these nurses had expressed feeling overwhelmed by the amount of knowledge needed to safely administer chemotherapy.
I can relate. I recall, years ago as a pediatric ICU nurse, admitting a patient in anticipation of tumor lysis syndrome (TLS). Although chemotherapy certified nurses administered the chemo, I was responsible for the patient’s well-being in the ICU. I asked a lot of questions, probably too many. Weary of me, the oncology nurse coordinator remarked, “You worry too much. It’s just chemo.”
Somewhere between this coordinator’s cavalier attitude and the paralyzing fear of a nurse unfamiliar with oncology is the middle ground for teaching chemotherapy and biotherapy administration. Here are some suggestions:
Fear is the nurse’s friend. Fear makes you look up medications and regimens you are unfamiliar with administering. It makes you ask a more experienced coworker for help. It makes you call the oncologist for clarification of orders when you are unsure, but don’t let it paralyze you. Fear is your friend. Embrace it.
Build on what you already know. Safe administration of all medications, including chemotherapy, is founded on the cornerstone of The Five Rights:
Right Now is what my husband, a hospital pharmacist, jokingly refers to as the “sixth right,” as in, “the doctor wants the chemotherapy given right now.” While promptness is a virtue, chemotherapy administration is similar to teaching a small child to safely cross a street: “Green means go when safe.” Don’t give the chemo until all the double checks are completed to satisfaction.
The first thing people usually say to me when they find out I’m an artist is, “Gosh, I can’t even draw a straight line.” My response to that statement is, “Nobody can. That’s what straight edges are for.”
Detail of oil painting by jparadisi
When these same people discover I am also an oncology nurse, the second thing they say is, “Painting must be so therapeutic, after dealing with so much death.” My response to this statement is more complex than the first.
First, there’s not really “so much death” in oncology, as treatments improve and many cancers are managed as chronic conditions, which is great. There is still sad sorrow, however. Ironically, when I’m most engaged in a real life human drama, that’s when I find it the most difficult to unleash my creativity. On those days, I’m more likely to calm myself by going for a long run, or knitting, which I consider hobbies.
For me, the creative act of painting is often as uncomfortable as a difficult day of patient care. This is because, I believe the difference between art as therapy, and art as art, is that art as art usually begins with a question or inquiry, and most importantly, results in an insight. Art as therapy requires neither. However, if art as therapy results in an insight, it can also meet the status of art as art. Simply speaking, strong works of art, like strong nursing, involves critical thinking, not simply performing rote skills.
Attaining insight is the reason I believe it is so important for nurses to open up to creativity. Insight leads to an understanding of motivation, our own, and that of others. When we understand our motivations, we are better able to communicate with others. In this dynamic time of The Affordable Health Care Act, nurses need to publicly communicate our role in health care now more than ever.
For instance, the nurse blogosphere is full of posts championing Advanced Practice Nurses as primary care providers. Proponents focus on filling the gap created by a shortage of Family Practice physicians, and reducing the cost of care. While these goals are admirable, the time is now to take creative control of the Nurse Practitioner image by promoting the characteristics differentiating medical science from nursing science: an emphasis on preventive care, in-depth patient teaching, and patient-centered care, which are in some ways superior to that offered by medical science. By creating an image, or branding, if you will, for APRNs, they are appreciated as a unique profession, not as a watered down brand of medicine, or “doctor lite.”
Unflattering, and inaccurate images of nurses are created through tradition, novelists, and outside observers, but rarely by nurses themselves. In order to dispel the nursing stereotypes we despise, nurses will need to rise up and create new ones through visual art, novels, screenplays, and films of such quality that our vision of ourselves transcends into mainstream culture.
Note: This post originally appeared in March 14 2013 on RNFM Radio: Nursing Unleashed!
Horrified, I watched helplessly on the esplanade as a fuzzy, yellow gosling struggled to right itself from his back in the high water of Oregon’s Willamette River. Four feet away, his mother placidly treaded water, making no attempt to help.
The Willamette River runs swift and cold, with a notorious undertow. Impulsively, I considered jumping in to save the gosling, but the imaginary headline on the evening news played inside my head:
Crazy Nurse Drowns in Failed Attempt to Rescue Gosling. Pictures at Eleven.
Luckily, the gosling righted itself and swam away with its mom and siblings.
I feel a similar sense of helplessness caring for the occasional patient (and sometimes a family), drowning in profound grief expressed as anger.
They present at each appointment with unending lists of complaints. They antagonize their families, find fault with every caregiver, and disparage the home cooked meals generously provided by neighbors. They complain until you contact the oncologist on their behalf, only to find this patient refuses the prescription you are requesting every time his doctor offers it.
Your co-workers snigger when you tell them; they’ve made the same phone call for this patient. You believe your patient is stuck in the grief process at anger, expressing it by making everyone around him crazy. These patients are not violent, nor verbally abusive to nurses. The problem is the amount of energy they require, without solution or resolution. Eventually this may cause nurses to emotionally shun them, like the goose watching her gosling drown.
How can you help these patients without drowning along with them?
I think about the goose watching her gosling struggle helplessly, accepting that he may drown. It’s difficult to reconcile this image with the role of a nurse. Not every patient will die a good death, but with a little help, some, like the gosling, may right themselves.
What suggestions do you have for nurses with patients stuck in the grief process?
