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!

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.

Switching to Oncology From Another Nursing Specialty

illustration by julianna paradisi

illustration by julianna paradisi

One of the most enjoyable aspects of my recent job transition is meeting new colleagues. Not only are they a great group of nurses, but for the opportunity to exchange information.

During one such discussion, the topic was how we learned oncology. Unlike myself, a former PICU nurse, some had started out in oncology as new grads. We all agreed that nursing school does not provide much preparation for oncology nursing. The conversation then turned to “how I became an oncology nurse.” 

It occurred to me that other nurses might be seeking information about how to break into oncology nursing.

I offer this advice:

  • If you want to transition from another nursing specialty into oncology, do some research about the skills the two have in common. For instance, skills carrying over from the ICU to an oncology unit are the use and maintenance of central lines (although you’ll probably need to learn accessing implanted ports), and whole body assessments. The interpretation of lab values, and acting on them is as important in oncology as the ICU. Conditions such as SIAH, SVC syndrome, and more are common to both specialties, as is pain management. Highlight these similar skills during a job interview.
  • Consider outpatient oncology. Much of cancer treatment is now done on an outpatient basis. While outpatient nursing is very different than inpatient, it is as rewarding and challenging.
  • In the beginning, focus on one or two common cancers (breast cancer and colon cancer for instance). Develop a familiarity with their treatments, particularly the chemo regimens. From there, expand your knowledge base while gaining experience.
  • Earn oncology CE. This provides two benefits: First, it guides your focus on one or two cancers. Second, it provides certificates you can add to a resume for an oncology job interview. You can find oncology related CE at the Oncology Nursing Society (ONS.org) and The Oncology Nurse Community (TheONC.org) website offers a library tab, which is a great resource for nurses seeking oncology CE.
  • Immerse yourself in oncology culture. Become a national member of the ONS. Sign up for electronic newsletters.
  • Cultivated local networking. Join the local ONS chapter, and participate. I meet nurses seeking oncology positions all the time at these meetings, which are often attended by oncology unit managers too. Sign up as a member of a cancer department’s team for fundraising events, another way to meet and network with oncology nurses and managers while helping others.

What advice do you have for nurses, new or experienced, desiring to break into oncology nursing?

Nurses: Keeping Your New Job From Feeling Like The Titanic

Complaining about being overwhelmed by a job in this economy is a little like complaining about too much sunshine. It’s a complaint of the fortunate, particularly when the work involves caring for cancer patients: Certainly the grass is not greener on their side of the infusion chair.

by jparadisi

by jparadisi

Nevertheless, the reality for those of us fortunate enough to have jobs is that everyone works harder, for longer hours compared to when the economy was robust.

I’ve thought about this a lot during my job transition to a new employer. Learning new expectations is overwhelming for everyone involved, not only for my previous coworkers and myself, but for the new coworkers too. For instance, it takes a lot of trust to cosign chemotherapy administration with a nurse you’ve never met before. Both new and previous colleagues are confronted with this. Physicians I’ve never met have been welcoming, and willing to learn that I know what I’m doing. I am a new face for the patients too, earning their trust as well.

I’m relearning skills I’m already good at using new equipment. An example of this occurred when a new colleague asked me to start an IV. “I got this,” I thought, until opening the IV catheter package. In it, I found an over-the-needle system I’d never seen before. I asked my coworker how the safety gizmo worked, feeling a bit dull-witted. I practiced with it once on a tissue box, all the while thinking of that scene from the movie Titanic, where Jack makes Rose practice swinging the axe a couple of times before letting her take a swing at the handcuffs binding his wrists to a pole while the ocean water rapidly rises. Like Rose, I was successful on the first attempt. Whew!

For those of you making a job change in the clinical setting, here are some tips for managing new job-related stress:

  • Allow extra time. Something as simple as changing a PICC line dressing can take twice the expected time if you can’t find the special wrap the patient wants to secure his PICC in an unfamiliar storeroom.
  • Bring a water bottle, and keep hydrated. Have a packaged protein snack handy for low blood sugar.
  • Go to bed early. Stress often interrupts sleep in the form of processing thoughts during the night. Allow for extra rest.
  • Minimize outside obligations. Spend leisure time with your family or significant others. They benefit from your job, and will support you when the going is tough.
  • Remind yourself that you know how to be a nurse. You may not know where to find gauze or tape, but you know how to keep patients safe. Rely on those skills.

What other suggestions are helpful when starting a new job?

All Deaths Are a Great Loss

When I was in nursing school, an “elderly” instructor (she must have been at least 60)

Bones (Redivivus) by jparadisi

Bones (Redivivus) oil on canvas by jparadisi

asked our class,

“Is the death of a young person a greater loss than the death of an old person?”

The oldest student was maybe 30. Unanimously, we agreed that the death of a young person is the greater loss. The instructor’s expression let us know she did not agree,

“All deaths are a great loss. No one wants to die. As nurses, you’ll do well to remember this.”

My first nursing job was in pediatrics. I remained in pediatrics for 15 years, and my student perception of the death of a young person being a greater loss than the death of an old person was never challenged. However, now that I am an adult oncology nurse, I have a better understanding of what our nursing instructor was trying to teach us that day.

Few people would argue that the death of an older person is sadder than that of a young person, but that’s not what my nursing instructor had asked. She asked, “Which is the greater loss?” The losses are equal, but for different reasons.

The death of a young person is a great loss because the world loses a potential Picasso, Hemingway, or Madame Curie. The parents of the youth lose the legacy of grandchildren who may have been born to their child. If grandchildren are already born, they lose a parent. The dying youth loses a full lifetime of experiences, love, joy, and sadness — the bittersweet fruit of a ripe old age. A piece of hope dies with them.

When an old person dies, the world loses a Gandhi, Rosa Parks, or Mother Theresa. More commonly suffered are the loss of a spouse, a parent, a close friend, or confidant. We lose someone with whom we share common history and memories. Upon death, an old person takes a piece of life from those left behind. With this understanding, I sit at the bedside of elderly patients, holding their hands as they grieve out loud their cancer diagnosis and impending deaths. I grieve their loss as greatly as I did the loss of my pediatric patients.

Nurses know that every passing life is a loss and there’s peace in knowing there’s no need to judge.

Surviving The Realities of Nursing

Adriamycin by jparadisi

Adriamycin by jparadisi

One of the things I love about blogging is conversation through comments on posts with people I may not otherwise meet. I learn as much from the comments as I do writing the posts.

I received a comment from a nursing student, quoted in part:

I am finishing up my RN degree and so want to go into oncology, but I fear that it will turn into nothing more than a loosing battle. A battle that I lose almost every day. Do you ever feel this way and do you ever wonder if the chemo is worth the pain your patients suffer through sometimes?

I think this sensitivity makes her an excellent candidate for oncology nursing. I wanted to answer her honestly. After taking a few days to consider, I responded:

You must have done some clinical rotations in oncology if you have interest in it. I’m wondering what experiences led you to believe it will turn into a losing battle? As a cancer survivor, and a nurse, I would answer, “Yes, the chemo was worth it.”
I suspect the question you might really be asking is,
“When should curative treatment be withheld or stopped?” and that is the big question in any nursing or medical specialty. I’m sure you are aware that some chemo, surgery, and radiation are done to control cancer symptoms when cure is not possible, and that is different.
Doctors and nurses do not have crystal balls. The best we can do is listen to our patients, offer advice when asked, and respect the decisions they make. Nurses are patient advocates. We cannot control outcomes, only do our best for each. Every nurse must find a way to reconcile this.

Perhaps I could have/should have added at the end, “in order to survive our profession.”

I thought about this nursing student’s question while sitting on the rolly stool gently pushing chemotherapy into the side arm of IV tubing connected to a patient. She asked how long it would be before her hair fell out.

There and then, I wanted to apologize for being the nurse dealing this blow to her self-image, but I did not. Instead, I reminded myself that the chemo might very well save her life. The blow I administered was to her tumor. Her hair will grow back.

This is how I have to look at oncology nursing for my patient’s survivorship — and my own.

Do you feel nurses face a losing battle? How have you reconciled the harsh realities of treatment with your desire to help others? How would you advise this student?