Normal Is a Cycle on the Washing Machine

In my mind, as long as the weather is good, summer isn’t over. However, the beginning of the new school year, and the return of football indicates that ritual outweighs my imagination.

Sigh.

It’s good to let an imagination run free from time to time, so I took the summer mostly off from blogging.

Preparing paintings for display. Image and paintings by jparadisi 2014

Preparing paintings for display. Image and paintings by jparadisi 2014

I’m back.

I think there’s a tendency to view creative work as less taxing, dare I say less challenging, than nursing. I wouldn’t say less, so much as different: Different types of knowledge, different sets of skills. The biggest difference, I think, lies in accountability. Harsh criticism of their work can damage an artist’s psyche.Missing a deadline for a post or art exhibition is unprofessional and negatively affects the editors and curators writers and artists work with. It leaves them in the lurch, which in turn negatively impacts the artist’s career.

In nursing, however, medication errors can seriously impact a patient’s health, with potential life-changing consequences for patient and nurse.

I discovered something this summer: Taking time off from creative projects creates a vacuum into which other projects, out of nowhere, are sucked in, filling the “free” time I worked so hard to create. I see this phenomenon in the lives of the retired too. In fact, I often tell my Mom, “You’re scaring me; retirement looks twice as busy as working life, without the paycheck.”

Mom just smiles, and says, “Remember, ‘normal’ is a cycle on the washing machine. Don’t wait for things to slow down. They won’t.”

She’s right.

An unexpected project close to my heart this summer was the opportunity to hang my paintings and monotype (one of a kind) prints in a health care setting. It is a very satisfying experience to work with a design team to select and hang art with the intention of improving patient experience. In the past, I’ve sat on selection committees choosing artists for hospital art commissions, but this was my first experience as the selected artist.

For me, it came together when a patient, unaware that I am the artist, made this remark about the art, “It makes me think of other things than why I’m here.”

Bingo. That’s exactly the result I was looking for.

The Adventures of Nurse Niki is back too. The latest episode, At The Raleigh, posted Monday.

Summer vacation brought fresh insights, generating posts for AJN’s Off the Charts. In a drop-in life drawing studio I drew a connection between art and nursing. A road trip with my husband inspired this post. And a close call with danger inspired yet another.

Normal is just a cycle on the washing machine.

 

 

 

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.

 

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!

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!