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: 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?

Rethinking The Paradigm

A friend and I sat at a wine bar. Over a glass of Pinot Noir, the topic of blogging came up. I

photo by jparadisi

photo by jparadisi

told her I was writing a post about the need to teach nurses how to talk to patients about dying.

She said, “Oh, you can’t talk about that all in one conversation. You have to talk about things like that in short, repeated conversations. It’s too much for someone to take in all at once.”

My friend is a diabetic educator, and she is better prepared to discuss life-changing illness with her clients than most nurses are to talk to theirs. Talking about the life-threatening aspects of diabetes is in her job description. Therefore, she’s been educated to do it.

Unlike clinical educators, nurses are hired for what we do to patients, not for talking to them. Although documenting patient education is part of our job description, it doesn’t carry the same weight of importance as, for instance, administering chemotherapy. Assuring that nurses and physicians are competent to discuss dying with patients is not a priority in health care delivery.

What if nurses and physicians were taught and supported in the necessary skills to bring the process of dying the same respect given to the process of giving birth?

Envision patients, physicians, nurses, social service workers, and spiritual care, working together, creating the same level of compassion and purpose for dying that parents, midwives, nurses, and obstetricians have created for childbirth.

If education about childbirth empowers expectant mothers in labor, might not education about what to expect at death equip dying patients with a sense of control, lessening their fear and pain? What might these patients plan, given small conversations of education, over an adequate amount of time? Would they create personal soundtrack CDs of music? Choose poetry for loved ones to read? Decorate their rooms with art to view as their vision dims? Lie in beds wide enough so loved ones can hold them?

As it stands, we burden hospice nurses with guiding patients and families, who do not know what to expect, through the entire dying process. When there is not enough time, patients go without the necessary knowledge to find personal meaning in this eventual and unavoidable passage.

Diet As Tolerated

by jparadisi

by jparadisi

Sitting in a trendy restaurant sipping a cocktail, I pick Marcona almonds from a small plate set between a blonde woman and myself. We are guests celebrating the birthday of a mutual friend. We grin self-consciously before introducing ourselves.

She asks, “What do you do for a living?”

Do all nurses dread this question at parties? Admitting I’m an oncology nurse is a buzz kill. The dread I anticipate appears in her eyes but not for the expected reason. She says her father is hospitalized in another city and “not doing well.” She can’t visit as often as she’d like.

She asks, “Do you like your patients? Is it hard taking care of them?”

I wonder, how much information can she tolerate? A few morsels or an entrée?

Cancer conjures images of wraiths drinking reconstituted chicken broth from Styrofoam cups or receiving nourishment through tubes. It would be untruthful to say this never happens, however, the social ambience of the clinic where I work surprises newcomers.

Instead of lounge chairs lining the walls of a single, cavernous space, our clinic has private rooms. Long-time patients have favorite ones. It’s not unusual to find Happy Birthday written in Sharpie on a piece of fax paper taped to the sliding glass door of a room of its “regular” occupant. Sometimes there’s birthday cake too. Cancer patients can eat birthday cake, like the rest of us. They eat “diet as tolerated.”

Patients with lengthy appointments are offered lunch, and some choose their infusion day based on the cafeteria’s soup du jour. Many choose to bring food from home, however.

Often, patients make their meals at the infusion clinic a special occasion by bringing utensils from home. I particularly admired a hand-thrown ceramic bowl brought by a special patient. Weekly, it was filled with something new: pillows of wonton, pea pods, and water chestnuts in broth, or brown rice with chicken. On rainy days, it cradled creamy macaroni and cheese, and an heirloom silver fork delivered each small bite to her awaiting mouth.

These meals are prepared with love. Families take pride in the accomplishment of feeding a loved one with cancer. The family table marches onto the foreign field of cancer proclaiming, “We will not surrender our loved one without a fight.”

Back in the restaurant, I see our hostess heading our way. The blonde woman has concerned eyes. There is only enough time to offer her with a small morsel of information.

I consider my answers to her questions, “Do you like your patients? Is working with cancer patients hard?”

“I love them,” I say. “Working with cancer patients is hard work but I can’t imagine a more rewarding job.” Her eyes relax. She takes a sip from her wine glass.

Like a fairy godmother, the birthday girl hugs me, kissing my cheek. Pouf! I am restored to a guest at her party, sipping a cocktail.

*This post was originally published on TheONC website.

Vacation!

At The Pool photo by jparadisi 2013

At The Pool photo by jparadisi 2013

JParadisiRN is on vacation this week. I’ll write a new post soon from a refreshed perspective. Meanwhile, if you haven’t read my oncology blog for TheONC, or latest post for AJN Off The Charts, this is a good week to catch up.

Cheers!

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?

Nature’s Easter Egg

Nature's Easter Egg photo: jparadisi 2013

Nature’s Easter Egg photo: jparadisi 2013

A nurse coworker raises chickens for their eggs. As a spring gift, she brought to work a carton of variously colored eggs to share. None were plain white like the ones in the grocery store. I chose a buff colored egg.

Peeling it this morning for breakfast, I discovered the interior of its shell was a beautiful shade of aqua. I had no idea eggshells existed naturally colored on the inside. This is nature’s Easter Egg.

Happy Easter to JParadisiRN readers!

Doubtful That Art Saves Lives? Evidence Indicates It May Heal

Art Saves Lives,” is a bumper sticker I occasionally see around town, and every time I do  I think, “Maybe, but in an emergency I’d prefer my rescuer know CPR than how to wield a paintbrush.” It’s a conundrum created “where science, humanity, and art converge.”

Girl With Pearl Earring, after Vermeer. watercolor by jparadisi 2012

Girl With Pearl Earring, after Vermeer. watercolor by jparadisi 2012

But what of art’s ability to heal? Most nurses know the benefits of art therapy: self-discovery, personal fulfillment, empowerment, relaxation, and symptom relief. However, can merely looking at art produce similar effects?

This question came to mind while rereading Vermeer in Bosnia¹, an written essay by Lawrence Weschler. Weschler interviewed Antonio Casse, then the presiding judge of the Yugoslav War Crimes Tribunal, during the trial of Dusko Tadic for crimes against humanity.

Weschler asked Judge Casse how he maintained his sanity while listening day after day to horrific accounts of torture, rape, and murder. Casse’s answer: “Ah, you see, as often as possible I make my way over to the Mauritshuis museum, in the center of town [in the Hague], so as to spend a little time with the Vermeers.”

Can looking at art — even a painting as beautiful as Girl With a Pearl Earring — reduce the effects of secondary trauma and compassion fatigue? If so, can nurses and patients benefit from this simplest form of art therapy?

A small study ² conducted by Dr. Marina de Tommaso, a neurologist, found that patients who gazed at and contemplated paintings they considered beautiful felt less pain when subjected to noxious stimuli. The New York Times has reported that museum visits help Alzheimer’s patients experience symptom improvement ³. The mechanism triggering these effects on the brain is not well understood.

Though the jury is out (pun intended) as to whether looking at art has therapeutic power, I think it’s worth a try for patients — and their nurses. Here are a few easy to implement suggestions.

  • Incorporate artwork into waiting rooms and hallways, but be mindful of the patient population. Art with jagged edges or mirrored surfaces (some types of sculpture, for instance) may evoke posttraumatic symptoms in patients who have disfiguring scars, surgical or otherwise.
  • Place something beautiful in the patient’s view from the hospital bed or the infusion clinic lounge chair.
  • Place books featuring artwork in waiting rooms instead of year-old magazines.
  • Hang a beautiful painting in the staff lounge instead of that big, messy corkboard cluttered with safety committee meeting minutes and medication recall notices.
 OK, that last one will never happen, so here are some suggestions to try at home:
  • Find a location with a beautiful view on your route home. Pull over, take a deep breath, and look. We live in a beautiful world.
  • Shop for art at a museum gift shop. Not every budget allows for buying original art. Gift shops offer an assortment of quality reproductions. Have less money to spend than that? Collecting postcards of works by famous painters is an inexpensive alternative. Buy frames from dollar stores or thrift shops, paint them white, and hang them in groups on a bright color- painted wall.
  • Create an art space in your home. I pinned my postcards to an old vanity. Once I added candles, it doubled as a place for meditation and reflection.

Do you think it’s the art or a meditative response to looking that provides relaxation and improves symptoms?

¹ Vermeer in Bosnia, Lawrence Weschler,The New Yorker, Nov. 20, 1995
² ITALY: Beautiful Art Eases Pain, Monica Dobie05 October 2008 Issue No:47
³ The Pablo Picasso Alzheimer’s Therapy, Randy Kennedy, October 30, 2005, The New York Times

Poll: The White That Binds Ornament

Readers, I’m doing some marketing research, and I need your input.

Last week during my interview on RNFMRadio, Keith, Kevin and I discussed creating an ornament with the image of my painting, The White That Binds (Pinning Ceremony).  I believe Kevin’s suggested I consider doing this in time for Nurses’ Day, in May, and June graduations. The ornaments would be available to buy on-line. What do you think? You can leave further suggestions in comments. Thanks for your help!

The White That binds (Pinning Ceremony) mixed media by jparadisi. )

The White That binds (Pinning Ceremony) mixed media by jparadisi.

If You Can’t See It, You Aren’t Living It: How To Visualize Your Best Life

After cancer treatment, my hair grew back in wild curls that I dyed platinum blonde, symbolizing my pursuit of a more creative life. “Now what?” I asked. How does one pursue a creative life?

photo by jparadisi

photo by jparadisi

The same way nurses create a patient care plan: with a focused goal.

“Huh?” I hear you say.

Nurses ignore hunger. We rationalize it’s OK we haven’t peed for 12 hours, because we haven’t had anything to drink either. Is anyone surprised we’re numb in the creativity department? If you need a Doppler to find your dreams, take heart! There are tools for restoring creative perfusion.

The first tool is rediscovery

For me, it was drawing, riding horses, writing, collecting seashells, cooking, and hiking. I made greeting cards. Not much about nursing. I wasn’t particularly athletic, but maybe you were. What did your childhood self dream of doing? Write it down.

Make a scrapbook of images 

  • This exercise clears clutter: Tear pictures from old magazines of everything that catches your eye.

    photo by jparadisi

    photo by jparadisi

Using a glue stick, randomly paste the pictures into an inexpensive scrapbook. Don’t worry what it looks like. This is an exercise in free association. Do it over several weeks, compiling enough images to spot trends.

Pay attention: Your subconscious is talking! I discovered myself clipping pictures of lofts with contemporary furniture, a far cry from my country-style living room. Pictures of clothing were elegant, urban fashions, not my uniform of jeans and comfort footwear.

Maybe your pictures depict people, not things. In that case, what are they doing: traveling, creating something, dancing, or playing a musical instrument? Are they back in school for that BSN or advanced degree? If a picture is worth a thousand words, what are yours saying?

This project can be accomplished using Pinterest. However, the paper version provides privacy, perhaps fostering candid responses. If Pinterest works for you, go ahead.

Create a vision board

  • Our brains are trainable. Vision boards are a visualization tool. Training your brain to “see” the life you want helps achieve it.

Using the information you gathered from the previous two exercises, glue pictures from magazines representing the life you want on a large piece of poster board. A single mother at the time, my pictures represented falling in love and a happy relationship, along with pictures of an art studio, places I wanted to visit, learning Rieki, and living into old age. I made mine during cancer treatment — your patients might enjoy making this project too.

Through these exercises, I discovered I was cleaning a rarely used guest room. My dining room sat empty because I preferred impromptu dinners with girlfriends served on the coffee table while watching a movie from the couch. Clearly, I dreamt of a lifestyle very different from the one I maintained. I changed that.

Are you living the life of your dreams or simply the one you find yourself living? If you are, how did you find it?