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?

Are Nurses Attracted to Gardening Because We Work in Close Proximity to Death?

On a beautiful late spring morning, I sat in my favorite chair, sipping coffee and writing. Through the window, I watched a hummingbird sip from the newly-potted salvia on our tiny deck. He is so at home that he actually perched on the railing while drinking from the tubular blossoms.

Hummingbird by jparadisi

Hummingbird by jparadisi

It was satisfying to watch. The hummingbird’s presence deepened my enjoyment of our small container garden.

Years ago, before changing course to make time for painting and writing, I had a huge garden. The limitations of container gardening make me miss my ambitious gardens of the past. As I write, I imagine a larger garden after I retire from nursing, whenever that may be.

What is the connection between nurses and gardens? I don’t think I know a nurse who doesn’t grow something, if only a lowly houseplant on a windowsill. Every spring, it’s common to find potted plant starts in the staff room from one nurse’s garden brought for another nurse to plant. I know nurses who raise prize-winning orchids. Another farms trees in his spare time.

Are we attracted to gardening because we work in close proximity to death? Does placing a dormant seed into carefully prepared soil, waiting for it to burst forth and blossom, satisfy something in our souls, deeper than merely beautifying our homes?

Nurses wear gloves to prevent soil from staining our fingers, keeping them from seeming unsightly as we palpate a patient’s vein to start an IV. Still, garden soil often seems cleaner, more wholesome, than the invisible bacteria populating the skin of human beings.

At work I overheard nurses giving one another advice on killing garden slugs. I was horrified when one said she snips them in half with garden shears. However, a few days later, when I found one in my container garden, I didn’t think twice about dowsing the poor creature in salt. Encrusted, he reared up, pillar-like, then moved no more. Was my action any less cruel because it evokes the Biblical image of Lot’s Wife? Are my coworkers and I applying oncology principles to gardening: both tumors and slugs must be removed, either through cutting (surgery) or by chemo?

My final observation about nurses and gardening is this: how little nurturing we are inclined to lend a plant for its survival. Universally, I hear, “If it doesn’t live, it’s not meant to be,” and I share this sentiment about plants. I wonder if nurses have such low tolerance for a plant’s inability to thrive because we give so much of our hearts to our patients?

Managing Patient Anger

Recently, I received an invitation to submit jpegs of my paintings to a juried art exhibition. While looking over the gallery’s past exhibits on their website, I wondered why they invited me.

Punch & Judy (detail) by jparadisi

Punch & Judy (detail) by jparadisi

The paintings I make don’t reflect the style of work this particular gallery exhibits. The mismatch started me thinking about the concept of curation, and how it applies not only to art, but also to nursing.

The definition of curate is:

Verb [with obj.] select, organize, and look after the items in a collection or exhibition.

Nurses curate insofar as we organize the care, and advocate for, a random collection of patients during our shifts. Usually, we do not select (jury in) these patients. Instead they are admitted by a physician or nurse practitioner, and assigned by a charge nurse, or whoever makes assignments on the unit.

The bedside nurse takes this collection of patients and curates (organizes) the mêlée. Most  shifts it works, but occasionally, a mismatch of personalities occurs.

I’m talking about those times when a patient doesn’t like me. If I don’t take immediate steps towards alleviating the situation, they become patients I don’t like either, and I am never pleased with this outcome.

Not every patient is a nice person. Disease and trauma are kind of blind in that regard. However, most patients are so kind, and patient, that it always catches me off guard when one is downright rude.

Here’s a list of things I’ve observed about angry patients:

  • No one is a voluntary patient. Anger is a normal response to an unexpected trauma or diagnosis.
  • No matter how personal their words, they are mad at their predicament, or at life in general, not you. Don’t take or make it personal.
  • Often anger expresses helplessness. For example, many elderly patients are also caring for a spouse or adult child with disabilities. Their anger often expresses anxiety that they are now unable to provide for that family member’s welfare.
  • Transportation to and from appointments contributes to the anxiety of patients dependent on other people for transportation. This may be expressed as anger if follow up appointments or ongoing treatment are prescribed.

Here are a few suggestions for coping with patient anger:

  • Often, simply arranging for the needs of the patient’s disabled charge diffuses the situation.
  • Call in spiritual care and social services to counsel the patient, and help arrange transportation needs.
  • Effective communication requires a clear message. Evaluate your approach. If a patient reacts during their assessment, consider re-wording the questions. You may be using words or a tone of voice they consider offensive, and are reacting to that. They actually may not understand, and are not trying to be difficult. The patient doesn’t know you’ve worked three 12-hour shifts in a row, and haven’t had a meal break yet. The reality is, that’s not a patient’s responsibility.
  • Frame disagreements regarding an angry patient’s care on the foundation of their safety. By keep this perspective and remaining professional, it is easier for your manager to support and defend you from unreasonable patient complaints.
  • Do not placate angry patients by promising special treatment outside of patient safety or professional boundaries. This sets up the next nurse for trouble. Care plans for any patient need to be sustainable for everyone providing care.
  • Never start an IV or access a port on a patient when you are angry.
  • If all else fails, request another assignment. Some clashes can’t be settled rationally.

What suggestions do you have for managing personality conflicts with patients?

Nurses Can Offer Reassurance When Cancer Changes Relationship Roles

Many relationships thrive after cancer, but how?

painting by jparadisi

Self Portrait by jparadisi

I think they transcend.

In a way, a patient is lost to loved ones during cancer treatment. Roles within the relationship change. The big, powerful husband adored by his wife of many years is now too weak to get in or out of their car without assistance, let alone do his longtime chores around the house. The wife and mother who makes Martha Stewart look like an amateur has not only stopped preparing gourmet meals, but can’t tolerate the smell of cooking food either, forcing Dad to pick up deli stuff, or order pizza to feed their hungry children.

Everyone has to adjust when a family member has cancer. The roles have changed.

  • There’s a new chapter in the family medical history. The cancer patient is the unwilling author of a family cancer history. Genetic counseling is an option, but family members may not want to know the results. It depends on their comfort level with the sword of Damocles dangling above them.
  • Partners become caregivers. Suddenly, there are extra duties around the house. Some learn to help with ostomy appliances or continuous infusion pumps. It’s common to teach spouses to flush PICCs. I often assess my patient’s status by the level of distress expressed by the spouse.
  • There is an uninvited guest who never leaves: fear of recurrence. David and I married after my cancer treatment. It’s a cute story; maybe I’ll post it one day. A few years ago, my surveillance labs came back with abnormal liver function results. My doctor ordered an ultrasound. Watching the monitor while the tech swabbed my belly with a wand, I said to David, “Look, Honey, I’m not pregnant!” I laughed, the tech laughed, but I will never forget the look of pain in my husband’s eyes as he uncharacteristically admonished me, “This isn’t funny.” I felt guilty for his fear, for letting someone fall in love with me when the cancer could come back. It turned out, an antibiotic I had taken a few weeks before caused the elevated LFT results. There was no cancer, but our uninvited guest remains.

Nurses cannot make these things disappear for our patients. We can, however, be sensitive to their needs, and reassure that they’re on a well-traveled path. Remind them that the most important thing they can do to help themselves is to talk about the pressures they feel as the cancer patient, or as the partner with increased responsibilities. We can also encourage them to develop strategies against their common enemy as a couple. Finally, we can be prepared to provide information about community resources available to support them.

And hope for the best.

How do you help patients and their families adapt to changing roles during cancer treatment?

A Nurse’s Guide to The Art Of Rescue

Image

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?

  • Enlist the help of nurse navigators, social services, and spiritual care. Some patients will refuse or sabotage this help, but ensure that it’s offered. These experts have experience dealing with these situations. Enlist their help.
  • Resist triangulating yourself between the patient and family, or patient and oncologist. Encourage the patient to interact with caregivers directly by scheduling her own appointments, rides, and prescription refills.
  • Using input from the nurse navigators, social services and spiritual care, create a care plan for this patient. Through consensus, gain buy-in from staff caring for him or her. Some patients benefit from consistent staff assignment — however, beware of establishing “favorite nurses.”
  • A characteristic of dysfunctional grief/anger is playing people (especially nurses) against each other. Ensure the care plan is ethically sustainable for the nursing unit. Other patients know when another receives “special” treatment. Keep things fair.

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?

 

Cheap, Fast, Or Good

Last week I was on vacation, the centerpiece being a small family reunion of sorts at the

The View is Clear From Here.

home of my mother and stepfather. My sister and her husband flew in for the weekend from out of state. They booked a flight on one of those new airlines offering cheap tickets with a la carte prices, charging you for every little thing beyond a seat on the plane. My sister joked that even the seats were cheap: they did not recline. Passengers sat in full upright position the entire flight.

On Sunday afternoon, we dropped them off at the airport.

An hour later, my sister calls saying their flight is delayed two hours. Soon it was delayed two more. This went on for six hours. Finally they were told their plane was delayed due to mechanical problems in Las Vegas. The passengers asked for the flight to be cancelled, and their money refunded so they could make other arrangements. They were told the flight would never be cancelled. Flights were only cancelled due to weather conditions, not for the lack of a jet. They were not allowed to leave the security area. They were not provided with dinner vouchers. Glasses of wine cost $15.

Sky Law had been declared.

What, you ask, is Sky Law? It’s a reference from the TV show 30 Rock, spoken by Matt Damon playing Airline Pilot Carol:

“Sky law, it’s when I turn on the fasten seat belt light and nobody’s allowed to talk until I get ten minutes of silence. I made it up, but people are stupid.”

Eventually my sister and her husband made it home, but not until 2 am the next day. Between the food tab, and missed time at work, any savings from the inexpensive airline tickets was forfeit.

You can get it cheap, or you can get it good.

After vacation, I returned to work to find my coworkers complaining about how another department’s lagging is causing treatment delays, appointments to overlap, and general dissatisfaction among the nurses, and patients. These complaints from nurses and patients seem sucked up into the Bermuda Triangle of hospital administration.

You can get it fast, or you can get it good.

The airline industry has been cutting back services and raising their prices for a while now. Pop up airlines offer lower prices at the expense of customer service: fewer flights, possibly less crew. Perhaps it takes longer to access a new plane and flight crew when the unexpected occurs, creating long flight delays.

I suspect the delay in service to our patients may be connected to recent layoffs. Although I’m not aware they directly affected this department, layoffs mean that those of us remaining with jobs that impact patient care are doing more work with fewer resources. It takes longer to provide services when a department is unexpectedly short staffed, or hospital census rises unexpectedly.

Once again health care imitates the airline industry. You can get it cheap, or you can get it fast. It’s still possible to get it good, but you can’t have all three.

What Drawing Has in Common With Nursing

Self-Portrait. Pencil on paper 2001 by jparadisi

Telling Our Stories to Benefit Others is my latest blog post for TheONC; the online community for oncology care teams. Registering for TheONC is free for oncology nurses.

Having the opportunity to write about creativity and its place in the oncology setting allows me to blog out loud the internal dialogues about painting, writing, and nursing I’ve had ever since I came out of the closet as an artist over a decade ago.  I have found these words of Goethe’s true:

“Whatever you do, or dream you can, begin it. Boldness has genius and power and magic in it.”

In my pursuit of living creatively, I frequently find magic in the convergence of science, humanity, and art. For instance, take this passage written by Peter Steinhart:

To draw anything you have to find a connection with it. You have to turn off the noise that keeps you from focusing. You have to let the object stir you to empathy or ennoblement or joy or compassion-even to fear. You must see that things are a part of your world in some special way before you can attend to them.

Now re-read the same passage, with a few simple changes:

To be a nurse, you have to find a connection with people. You have to turn off the noise that keeps you from focusing. You have to let patient care stir you to empathy or ennoblement or joy or compassion-even to fear. You must see that your patients are a part of your world in some special way before you can attend to them.

When making art, or practicing the art of nursing, it all boils down to focus and connection. Whichever you are doing today, find that focus and connection. Someone’s life will be better, because you did.

Never Stop Developing Your Curiosity: New Post This Week for TheONC

This week, I’ve written a new post for TheONC titled, Never Stop Developing Your Curiosity.  I discuss the role curiosity plays, not only in creativity, but also in patient care, such as helping a patient deal with chemo induced alopecia.

TheONC is an online community for cancer care teams with blogs and discussions covering a variety of oncology topics. Recent posts discuss palliative pain control, stem cell transplant, cancer risk after solid organ transplant, music therapy, and more. Individuals involved in the care of cancer patients can register for a site login, and join the conversation. Follow on Twitter @The_ONC.

Living With Our Mistakes & Holes in Our Socks

Knitting Two Socks at a Time on a Pair of Circular Needles. photo: jparadisi 2012

I’m learning to knit socks. If you read this blog regularly, you’ll recall learning to knit socks is one of my New Year’s Resolutions for 2012.  Since I don’t know what I’m doing anyway, I decided to learn the new method of knitting two socks at one time on a pair of circular needles, instead of one sock at a time on a single circular needle. Never mind only a few years ago I defined knitting as: making a tangled mess with yarn and sticks. Hey, I’m a girl who loves a challenge.  My audacity stems from years of the “see one, do one, teach one” on- the- job- training mentality most nurses rely on.

Fortunately, learning to knit socks two at a time is accompanied by patterns with clear diagrams and photographic illustrations. I found mine in Knitting Circles Around Socks by Antje Gillingham (Martingale & Company, publishers).

I’m happy to report I have successfully turned both heels. The most vexing problem has been confusing which of the four needle tips to use, then having to rip out and knit again previous rows after doing it wrong. I found one dropped stitch too, which is so far back at the beginning there is no way in hell I will rip out my work to redo it. I’ll simply learn to live with it.

If only nursing mistakes were as inconsequential. Who wouldn’t go back in time and fix the med error, rephrase the statement that made you sound dumb in front of coworkers, or treat differently the symptom, which turned out more significant than you realized at the time? Wouldn’t it be great if we could rip out our mistakes and knit them again like stitches dropped from a pair of needles?

We can’t.

Instead, I am aware of the importance my words carry when patients come to me with concerns or fears. I answer the same questions multiple times over the years of my career, but for the patient, their fears are new.  For everyone, I hope to get it right the first time: the right amount of compassion, the right understanding of the meaning of their words, the right kind of wisdom needed for a particular moment. If I get it wrong, coming across as abrupt, disinterested or intensifying fear rather than calming it, there is no going back to rip out stitches from the fabric created by my words and actions. They hang in our memories like dropped stitches; leaving an unsightly hole.

Nursing is more complex than knitting two socks with four needles. Often, there’s no way to go back and fix our mistakes. Sometimes the best we can do is learning from errors, acquire the necessary grace, and live with the resulting holes in our socks.

*Update: I finished knitting my first pair of socks last night.  See photo.

My First Pair of Knitted Socks! photo: jparadisi 2012


This Ghoul Will be Your Nurse Tonight: Should Nurses Wear Halloween Costumes to Work?

This IS My Costume. photo: jparadisi 2011

I dodged a bullet this week. My coworkers are wearing costumes to work on Halloween. I was scheduled to work that day, but on Friday a nurse asked to trade shifts, so I don’t have to decide whether or not to wear a costume. This year I won’t feel like the spoilsport among my coworkers. Don’t get me wrong, I like Halloween, costumes, jack o’lanterns, and all that. I just wonder if they are appropriate in patient care areas?

Nurses wearing costumes to work on Halloween aren’t limited to my unit. The entire hospital celebrates with costume contests (individual and department categories), decorations, and special treats. It’s intended to build enthusiasm and rapport among employees. There are written guidelines about what sort of costumes and decorations are not appropriate. Respect for gender, race, political, and religious beliefs is emphasized. Costumes and decorations cannot be gory or represent death. They cannot interfere with patient care either.

Earlier this month, Buckman elementary school principal Brian Anderson, in Portland, Oregon was included in an article in The Huffington Post because he banned costumes at the school. He took heat from parents, and sparked a national controversy on whether he was being fair.  The Portland Mercury quotes Anderson as saying:

For many reasons, the celebration of Halloween at school can lead to student exclusion. There are social, financial and cultural differences among our families that we must respect. The spirit of equity has led most PPS (Portland Public Schools) schools, including most elementary schools, to deemphasize the celebration of Halloween at school.

He has a point. Critics argue that banning Halloween costumes from schools is taking political correctness too far.

But what about hospitals and nurses?

Halloween costumes are allowed in every hospital I’ve worked for, however, I never wore one to work. In the PICU, there were so many painful situations that, for me, costumes felt out of place, yet I don’t recall a single patient or parent expressing disapproval of nurses dressed as witches or scarecrows. Now that I am an outpatient adult oncology nurse, I still don’t wear costumes to work. I have not heard complaints from our patients about the nurses who do.

What do other nurses and health care providers think about this? I also wonder what patients and people from other walks of life have to say.