Nurses and Holiday Stress

Painting by jparadisi

Painting by jparadisi

Nursing potentiates normal holiday stressors. For many nurses, the beauty of the winter holidays is diminished by feelings of stress.

Staffing woes contribute: Who knows why every year during the holidays, patient census randomly explodes abundantly or trickles down to near nothing, resulting in too much overtime or hours-deficient paychecks?

We go home to enjoy the glow of Christmas tree lights knowing our patients spend their holidays in a hospital or hospice bed, their rooms lit by overhead fluorescent lights, and this knowledge dampens a nurse’s ability to fully enjoy celebrations of bounty. We may experience feelings of guilt that our income is dependent on the misfortune of others, in this case, illness or trauma.

Mismatched schedules, especially those of night-shift nurses, complicate holiday arrangements with family. Gift giving weighs heavily on sensitive souls: Instead of buying gifts, shouldn’t the money be given to those in need? Or are our expressions of love for family and friends, the creation of memories and traditions left after our own health fails, equally important? Someday, we will become the ones missing from the family dinner table of Christmas’s future.

Here are suggestions for handling holiday stress:

  • Reduce expectations. Holiday preparations and gifts are expressions of love, not declarations of wealth. Stay within your physical and fiscal boundaries.
  • Plan quick, easy, and low-calorie meals in between holiday parties. You’ll feel better.
  • Enlist the help of children with holiday baking and food preparation. This is an opportunity to teach them to cook while spending time together.
  • Lighten your housework load by asking children to help with age-appropriate tasks like dusting, folding clothes, drying dishes, etc. Work out a payment incentive with them. Encourage them to use the money for Christmas shopping, to buy a toy for a less fortunate child, or donate to a food bank.
  • Plan downtime and use it for activities with personal meaning. Don’t skip yoga class or your morning run. Take a break from wrapping gifts for a cup of fragrant hot tea or cocoa with marshmallows. Spend an hour at church, take a long walk, or meditate to regain your sense of grounding.
  • Remember the gifts you give. Nurses give to their patients throughout the year gifts that cannot be remunerated on a paycheck. Although we do not have magic wands to cure disease, taking time to listen and help patients with their needs goes a long way. The best way to feel better is to help someone else feel better. This is the gift of nursing.

Does your nursing job ever affect your ability to enjoy the holidays? What steps do you take to reduce holiday stress?

For The Nurse on Your Holiday List: A “Shift From Hell” Emergency Kit

As if the onslaught of commercials isn’t enough to remind us, the winter holiday season has begun. For nurses, whose patients always seem to worsen, or expire, around the holidays, jumbled feelings of anxiety and guilt may arise.

‘Tis the season to practice extra strength self-care and creative gift giving!

If you need an idea for an inexpensive holiday gift for a preceptor, mentor, student, or that special nurse buddy who always has your back, here’s an idea: Give him or her a Shift From Hell emergency kit for their locker or fanny pack. The contents will vary with your own creative ideas, but here are some suggestions gleaned from my 25 + years of bedside nursing:

  • Nail clippers: for fixing a broken or snagged nail
  • An emery board: see above
  • A pair of tweezers — for wayward eyebrow or nasal hairs
  • A package of toothpicks: Does anyone share my irrational fear of food stuck in my teeth?
  • A small package of antacids: They can mean the difference between leaving a shift early or staying to finish it
  • A travel-size package of ibuprofen or acetaminophen for unexpected headaches and minor pain
  • A laundry detergent pen or wipes to remove betadine, coffee, or blood stains from scrubs and lab coats before they set.
  • Lip balm — For those shifts when you don’t have time to drink enough fluids
  • Change for the vending machine — particularly useful on the night shift
  • Gum or breath mints
  • A hair tie as back-up for the one you wore to work that broke
  • A cheap pair of reading glasses: because who can read that tiny print on single dose medication vials?
  • Packages of fancy instant coffee, a fragrant tea, or cocoa — for when you finally get a moment to sit down
  • Chocolate

Remember to keep the supplies miniature. Collect them into a cloth drawstring bag, coffee mug, or Mason jar. Those cosmetic bags you get as a “gift with purchase” from department stores work, too. Add a bow and gift tag: voilà!

If you prefer a gift for your unit while maintaining a budget, consider buying larger amounts of the supplies, and place them in a basket lined with tissue paper or gift straw, as a group gift available in the staff lounge.

What items do you consider essential items for a nurse’s Shift From Hell?

Simon’s Turn: The Adventures of Nurse Niki Chapter 21

The Adventures of Nurse Niki
The Adventures of Nurse Niki

The Adventures of Nurse Niki Chapter 21 is posted! In this week’s episode, Simon’s Turn, Niki experiences a life-changing moment.

The Adventures of Nurse Niki is a work of serial fiction. The blog is formatted so the most recent episodes appear at the top. New readers not wanting spoilers of The Adventures of Nurse Niki may begin at Chapter 1 and scroll up from there.  Chapters are archived by month (click on the lined square icon on the home page). New chapters post weekly on Thursdays.

Off the Charts has this to say about The Adventures of Nurse Niki:

This blog is made up entirely of first-person episodes told by a fictional nurse named Niki. Each episode is short, detailed, and engaging, and it’s easy to keep up with it on a regular basis, or quickly catch up if you haven’t yet read any episodes. Jacob Molyneux, AJN senior editor/blog editor

Kevin Ross, aka @InnovativeNurse wrote a review of The Adventures of Nurse Niki, with this highlight:

Julianna has embarked on something special for the nursing community. The Adventures Of Nurse Niki is one of the most intelligent perspectives of life as a nurse. These are the experiences of a “real nurse” if you ask me. Nurse Niki is a smart and dynamic character who works night shift in the PICU at a California hospital. A good television show or fiction novel could certainly draw out the sexiness of working in the ICU, but with Niki’s story we quickly discover that this dynamic character is also struggling to cope with life at the bedside, and as a mother and wife. Hidden within each chapter the discovery is that Nurse Niki is in fact you. She’s me. Well that is of course if I was a woman.

You can 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 not only Like Nurse Niki’s Facebook Fan Page. The support is very much appreciated!

Rolling Out Changes So Nurses Aren’t Under a Rock

I was about to administer a chemotherapy infusion. The carboplatin dose was double-checked by a co-worker. First, she calculated the patient’s GFR and then the AUC (area under the curve). 

Area Under the Curve by jparadisirn

Area Under the Curve by jparadisirn

Independently, I calculated the GFR and then calculated the AUC using the carboplatin dose calculator I found on the hospital’s online resource. Following those directions, I plugged in the patient’s GFR, serum creatinine, weight, height, etc. My coworker and I came up with the same answer. Whew.

When the IV bag of carboplatin arrived from pharmacy, we reviewed the bag’s label against our calculations, completing the double check. Holy moley! The dose in the IV bag was different from our calculation. The process stopped while I made a phone call to the pharmacist. Here’s what I learned:

“We cap the serum creatinine value at 0.8 and the GFR at 125. Your patient’s creatinine is 0.6, which increases the GFR above the cap. The dose is based on the capped values.”

“Oh,” I replied.

This is what the FDA says about carboplatin dosing:

Based on preliminary communications with the National Cancer Institute/Cancer Therapy Evaluation Program, a potential safety issue with carboplatin dosing has been identified. By the end of 2010, all clinical laboratories in the US will use the new standardized Isotope Dilution Mass Spectrometry (IDMS) method to measure serum creatinine. The IDMS method appears to underestimate serum creatinine values compared to older methods when the serum creatinine values are relatively low (e.g., ~0.7 mg/dL). Measurement of serum creatinine by the IDMS-method could result in an overestimation of the Glomerular Filtration Rate (GFR) in some patients with normal renal function. If the total carboplatin dose is calculated based on IDMS-measured serum creatinine using the Calvert formula, carboplatin dosing couldbe higher than desired and could result in increased drug-related toxicity.

I must have been under a rock when this happened. Using the capped values, we recalculated the same dose as in the IV bag. I administered the carboplatin. Problem solved — or is it?

Afterward, I vaguely recalled an email from pharmacy sometime last year (or maybe it was a few months ago?) explaining the change in carboplatin dosing. That was the entire rollout of this information. Did in-patient nurses receive more information or an in-service? I don’t know.

I applaud pharmacy for initiating a best-practice in medication dosing. I also feel that a significant change such as this requires more than an informal email, and I suspect this happens often to nurses working in hospitals.

Nurses are expected to assess a patient’s understanding of the education we provide. Likewise, significant changes in clinical practice should be coordinated across departments, using nurse educators and managers to assess their nurses’ awareness and understanding.

Have you had similar experiences missing crucial information that was informally communicated?

Nurses: Do You Carry Liability Insurance?

When I was fresh out of nursing school, all bright and shiny, I bought a personal liability insurance policy, because I saw right away how easy it is to make a serious nursing mistake. As years passed, however, I let the policy lapse. At various new employee orientations throughout my career, hospital administrators told us forthrightly,

Umbrella of Safety by jparadisi

Umbrella of Safety by jparadisi

Nurses do not need liability insurance. Nurses are covered under the umbrella of this hospital’s insurance policy. The hospital is the financial deep pocket. No one sues individual nurses.

For years, this made sense. Lately, however, I’ve been rethinking this stance, for multiple reasons:

Stories of hospitals firing a nurse after he or she made a serious (often fatal) mistake are more frequent in the news. Perhaps this occurs because of the terms of the settlement. Perhaps the hospital promises a patient’s family that it will no longer employ the nurse. Or perhaps the nurse violated a hospital policy or protocol, and the hospital agrees not to disclose against the nurse in exchange for laying him or her off. Either way, the public never knows why. Does the umbrella of a hospital’s insurance cover a nurse they fired?

Commercially, the argument for purchasing personal liability insurance, even if the nurse is not fired, is this:

When a serious event occurs, the hospital’s legal department works on behalf of the hospital, not the nurses involved. A nurse’s legal rights and reputation are not the legal department’s priority. In such a scenario, an attorney hired by the nurse, working on her behalf and covered by her liability insurance, is a good investment.

Some insurance policies cover the costs incurred when a nurse is called to stand before their state board of nursing for complaints or misunderstandings filed against them.

Those who feel liability insurance is unnecessary argue that it cuts individual nurses “out of the group,” implying that being sued collectively offers more security.

Patient acuity is increasing, as are patient care loads. Many medications bear similar names, but cause very different results. As technology advances, nurses are required to maintain higher levels of vigilance. In the meantime, I’m getting older and acutely of how easy it is to make a serious nursing mistake.

Do you carry nurse liability insurance? Why or why not?

Hand

 “All nurses are different. Some just jab the needle into you, and it hurts.”

-A patient

White Gloves by jparadisi

White Gloves by jparadisi

Few things make me feel more successful as a nurse than when a patient says, “That was the most painless port access, (IV start, or injection) I’ve ever had.” I can never promise a patient I won’t hurt them, but when I don’t, it makes my day. I strive for a gentle hand. 

In art the term “hand” describes the workmanship of an artist, and nurses often tell patients going to surgery, “You’re in good hands,” referring to a surgeon’s skill with a scalpel. But “hand” refers to the way we treat people too.

Whether educating patients about chemotherapy and radiation regimens, explaining home medication administration, or simply discussing current events, it’s important to remember that even the most optimistic patient is emotionally fragile. Tone of voice, the abruptness of an encounter, and our choice of words all contribute to the “hand” we touch them with emotionally. Too heavy of a conversational hand can pierce a patient’s soul as painfully as any needle or scalpel.

I forgot this during a shift memorable for both the number and acuity of its patients. Everyone had complex questions about their care. I enjoy patient education; however, this shift I was doing so much that I began pulling information from my knowledge base as if it were files from a computer. By this, I mean remotely. I wasn’t paying attention to hand, my personal touch.

During the course of an assessment, a patient revealed she wasn’t taking a prescribed home medication because of its side effects. The patient also reported a symptom, which I recognized was caused by the discontinuation of the home medication she’d just mentioned, and I just sort of blurted out my observation. Immediately, I regretted my heavy-handedness as I saw this otherwise optimistic patient crumble nearly to the point of tears. I had carelessly broken a tender reed.

Needing to make amends, I sat on the rolly stool, and I apologized. I complimented her involvement in her care, and her ability to sense changes in her body. I also apologized for abruptly responding to the discontinuation of her medication. I regained my gently touch, she forgave me, and we devised with a care plan.

I hope I made up careless hand. I had hurt her as if I’d jabbed her with a needle.

Innovative Nurse (Kevin Ross) Reviews The Adventures of Nurse Niki

Last week, I had the pleasure of being a guest of nurse bloggers Keith Carlson and Kevin Ross (or, as I refer to them, ) on RNFM Radio. We spent a fast hour discussing the lifestyle of nurses, and The Adventures of Nurse Niki. I had a fabulous time, and one of the take-homes I went away with is the idea to hash tag forthcoming episodes of The Adventures of Nurse Niki on Twitter #NurseNiki, so regulars readers can discuss them on Twitter. Great idea, Kevin & Keith, thanks!

The Adventures of Nurse Niki

The Adventures of Nurse Niki

Following the interview, Kevin (who turns out is a huge Nurse Niki fan) wrote this awesome essay The Adventures of Nurse Niki: The Daytime Drama You’re Not Reading. The title doesn’t reflect Kevin’s wonderful review of Nurse Niki, or his thoughtful expose of the life of nurses, which is actually the most important part of the review. Here’s an excerpt from Kevin’s post:

Julianna has embarked on something special for the nursing community. The Adventures Of Nurse Niki is one of the most intelligent perspectives of life as a nurse. These are the experiences of a “real nurse” if you ask me. Nurse Niki is a smart and dynamic character who works night shift in the PICU at a California hospital. A good television show or fiction novel could certainly draw out the sexiness of working in the ICU, but with Niki’s story we quickly discover that this dynamic character is also struggling to cope with life at the bedside, and as a mother and wife. Hidden within each chapter the discovery is that Nurse Niki is in fact you. She’s me. Well that is of course if I was a woman.

Niki’s struggles are really no different than yours. She’s trying to find work-life balance and has the same inner turbulence that never seems to allow for the seat belt sign to be turned off. Niki’s hope was to work for awhile as a nurse and then be able to stay home with her daughter when she was born. She so desperately wants to feel that same connection with her husband that she had with him in college, but how can she possibly put her day in perspective for someone who isn’t exposed to the same emotional trauma that a nurse endures day in and day out? Sound familiar?

Our well laid out plans rarely seem to work out in the way we picture them, and so far it certainly hasn’t for Niki as she deals with the conflict of the same characters we all try to play each day in our own lives. What we believe work-life balance should be is really what I like to call controlled chaos. With a house full of boys around here we often find ourselves having to put up barricades and call in the crowd control teams to herd what seems like a bunch of cats out the door for their next soccer practice or school performance.

Just like many of us either currently or in the past, it’s never just a 12-hour shift and only 3 days a week. Nursing is not a part-time job by any stretch. When you work in high acuity settings like these it seems as if you never leave, even with a couple of days off in between your shifts. It’s really a constant you can depend on. Your co-workers become your family. The frightening difference is that they are the ones who understand you the best, and so the plot thickens.

In case you missed it, The Adventures of Nurse Niki Chapter 16 posted last Thursday. I don’t want to spoil it for new readers, but this is a chapter you’ve waited for.

If you haven’t discovered The Adventures of Nurse Niki, the blog is formatted with the most recent episodes first. However, you can conveniently begin at Chapter One by clicking here. Previous episodes are also archived by month on the main menu.

Don’t forget to Like The Adventures of Nurse Niki on Facebook, and follow her on Twitter @NurseNikiAdven #NurseNiki. Let’s do this!

The Difference Between Nursing and Journalism

Nurse's Note by jparadisi

Nurse’s Note by jparadisi

On any given shift, nurses witness the drama of life and death. This aspect of our work is unlikely to change. We witness patients taking in the bad news of their diagnosis, holding basins up to their faces while they vomit, and transfusing blood products before they exsanguinate. Although oncology is not an actual war, nurses and patients alike use military terms to describe it, such as battling cancer, or attacking tumor cells. We see ourselves as comrades in the fight against this devastating enemy.

Louisa May Alcott, author of Little Women, was a nurse during the Civil War. In her memoir, Hospital Sketches, she describes witnessing the death of a young soldier in detail so vividly the scene rings true for any nurse who has attended the bedside of the dying.

Whether we record our experiences in words to share with others, or keep them to ourselves, as nurses we bear witness to the suffering of our patients. Sometimes this secondary trauma leads to compassion fatigue, if not real disease or injury.

Watching people suffer is difficult, but at least I am not watching helplessly. I am grateful to be an oncology nurse now, when advancements in cancer treatment and its side effects occur regularly. Armed with these tools, oncology nurses bring knowledge and skill to the care and comfort of their patients. For me the ability to give aid makes witnessing the suffering bearable. I think being a news journalist or photographer sent to bear witness of the stories of conflicts in the world would be more difficult. Or filming a devastating natural disaster while people perish. Journalism requires a story, and pictures. Granted, at their best, these stories and pictures alert the world to action, serving a valuable purpose. Still, emotional trauma occurs among journalists, as in nurses.

Even Alcott experienced trauma from her military service when she contracted typhoid fever. She suffered lifelong chronic pain, a side effect of the mercury-based medication used to treat her. This is not unlike secondary cancers suffered by oncology patients from the chemotherapy administered to save them from their primary cancer.

Have you ever felt helpless in a patient care setting? Do your nursing skills offset the emotional trauma you experience or have little impact? What tools do you use to prevent compassion fatigue for yourself?

Clutter Be Gone! Mental Clutter Off Switch at TheONC & AJN Releases iPad App Tomorrow

Shutting down the mental clutter of work after your shift is over is the topic of my post for TheONC this week. Included are Ideas for creating a “mental clutter shut-off switch,” and readers are responding with their own methods too. You can follow TheONC on Twitter @The_ONC and Facebook.

Going digital cuts down on physical clutter, and I am excited the American Journal of Nursing releases its iPad app tomorrow on iTunes. Tomorrow only, April 28, the app is free!

Hospitals Are Not Restaurants

A Blank List photo: jparadisi 2012

My horoscope says today is a good day for diversion, but I disagree. This is one of those mornings I wake up with a to do list forming in my head, which means I am already behind. One of the things on the list is writing this post. Be charitable as you read it; I haven’t finished my coffee yet.

This feeling of being behind before the day begins is familiar in our home. David, a hospital pharmacist, and I work the same weekends, and this weekend we both worked the Saturday, Sunday, Monday stretch. For some reason, all hospitals I’m familiar with staff units lighter on weekends: no unit secretary, linens are not delivered, IT support is unavailable. Pharmacy has less support, meaning nursing waits for medications to arrive; everything slows down.

This mindset is puzzlement. Why would weekends be more or less busy in a hospital than any other day of the week as if they are restaurants?  I’ve worked in food service. For restaurants, happy hours and dinners are consistently busier on Fridays and Saturdays than weekdays. Restaurants catering to the business lunch crowd are understandably busier Monday through Fridays.

People do not schedule how sick they are going to be according to the day of the week.

Granted, most doctors’ offices are closed, and surgeries are usually not scheduled on weekends. I get that. However, this leads to the proviso that people who are admitted for hospitalization are too critical to wait until Monday for surgery or treatment. Trauma and sepsis do not wait until the doctor is in. They keep the weekend health care team pretty damn busy.

I’m not complaining, just pointing out a reality of life in health care, by way of explaining today, our first day off, both David and I are feeling a little frazzled. The evidence of this is on our dining room table. Rather than a place for a leisurely, home cooked meal, over the weekend it has become a catchall for the implements of our trades: his messenger bag, my tote. Both of our notebooks charge quietly, their green LED lights reflected in the luster of the table’s finish. Valentine’s Day cards, still without a permanent home, remain on the table.  Although our home is a disorganized mess, there is love.

We’re out of food though. Add a grocery store run to the to do list.