A Nurse’s Sketch Book

 

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Nearly a year ago, I wrote a post about mindfulness and found time for creativity, in which I described how I used downtime spent in waiting rooms to draw, or more accurately, for advanced doodling.

The practice continues. This year, I purchased an inexpensive set of crayons, which I keep in a desk drawer. During my lunch break, I take a minute or two to add a splash of color to the ballpoint pen ink drawings. None took longer than 15 minutes to sketch, usually much less.

These rough sketches don’t take the place of painting in my studio, but, there’s a certain satisfaction that comes with adapting to challenges of managing time, learning to juggle purpose and passion. Nursing provides purpose rooted in service, and passion (or a reasonable facsimile of art) blossoms from its branches. Like spring flowers following a severe winter, it will not be denied.

 

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!

Switching to Oncology From Another Nursing Specialty

illustration by julianna paradisi

illustration by julianna paradisi

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

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

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

I offer this advice:

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

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

Nurses: Keeping Your New Job From Feeling Like The Titanic

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

by jparadisi

by jparadisi

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

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

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

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

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

What other suggestions are helpful when starting a new job?

All Deaths Are a Great Loss

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

Bones (Redivivus) by jparadisi

Bones (Redivivus) oil on canvas by jparadisi

asked our class,

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

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

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

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

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

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

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

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

Surviving The Realities of Nursing

Adriamycin by jparadisi

Adriamycin by jparadisi

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

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

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

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

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

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

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

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

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

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

Vascular Air Embolism: Explaining Tiny Bubbles to Patients

It happens almost every shift — I hang an IV infusion, and no matter how carefully the tubing is primed, at least one tiny bubble passes the pump’s electronic air detector, and floats its way towards my patient. The patient reacts with a tense expression, visually following the tiny bubble’s journey to the IV site. “Is it okay to have an air bubble in the tubing?”

Tiny Bubbles by jparadisi

Tiny Bubbles by jparadisi

I know they are thinking of the TV medical dramas of the 70s and 80s, shows like Mannix, or Quincy, in which a murderer sneaks into a hospital room and carefully injects the tiniest of bubbles into the IV tubing of the sleeping victim, who suddenly codes while the murderer, dressed in scrubs, slinks away unnoticed.

The question remains, however: How much air is too much in venous access? The answer is — the amount that makes a patient symptomatic.

Minor cases of air embolism are common and cause minimal or no symptoms. Severe cases are characterized by hemodynamic collapse and/or acute insufficiency of certain organs, including the lungs, brain, and spinal cord.¹

This is not new information for experienced nurses, but it is for most patients. Nearly all VAE (venous air embolism) occurs in conjunction with venous access devices. In fact,

60-90 percent are caused by “fractures or detachment of catheter connections.”¹

Other factors include:

  • Failure to occlude the needle hub and catheter while inserting or discontinuing an IV site
  • Self-sealing valve failure
  • A tract that remains after central venous catheter removal
  • Positioning the patient upright during central venous catheter removal

Oncology nurses use venous access devices regularly. VAE prevention includes:

  • Priming IV infusion tubing and needle hubs
  • Testing nurse inserted catheters for patency before insertion
  • Securing all IV and central line connectors
  • Instructing patients to perform a Valsalva Maneuver during central line removal
  • Placing patients in supine position during central venous catheter removal
  • Covering the removal sites of central venous catheters with an occlusive dressing

Symptoms of air embolism include:

  • Dyspnea
  • Chest pain
  • Sense of impending doom
  • Lightheadedness
  • Tachypnea
  • Tachycardia
  • Hypotension
  • Wheezing
  • Change in mental status

Severe air embolism is a medical emergency. If you suspect air embolus:

  • Call the Rapid Response Team or Code Team
  • Place the patient in left decubitus position
  • Begin supplemental O2

Prevention is the best treatment for an air embolus. All oncology nurses should demonstrate infusion therapy competency in the patient care setting.

Have you witnessed a patient experiencing VAE? What recommendations for preventing VAE would you add? What policies have your workplace initiated?

References:

  1. Air Embolism, 2013 UpToDate Authors: Liza C O’Dowd, MD, Mark A Kelley, MD, Section Editor: Jess Mandel, MD, Deputy Geraldine Finlay, MD

How to Give Good Phone

by jparadisi

painting by jparadisi 2013

Nurses spend lots of time on the telephone. So much, that I believe How to Give Good Phone should be taught in nursing school as a subtopic of therapeutic communication. For the rest of us, here’s a crash course developed over the years.

We all remember that communication has three components: sender, receiver, and a message:

Sender. Nurses call other departments for a variety of reasons. We call material supplies requesting special bio-occlusive dressings for patients with adhesive allergies. We call the pharmacist with questions about unfamiliar medications. We call physicians requesting new orders when a patient isn’t doing so well.

Receiver. Nurses also receive phone calls. Physicians call to admit patients. The lab calls, announcing we didn’t send the blood tests in the right colored tubes, and they need to be redrawn.

Someone we don’t know calls, asking if his mother, who we also don’t know because she is not one of our patients, is done with her appointment. When we ask him for more information to find her, the caller misconstrued this to mean we’ve misplaced his mother, which brings me to…

Message. Clarity begins with the sender. Intuitively, message should be the simplest part of the communication process, but in fact it is often the most difficult, especially over the phone, where visual information is lost to the sender, the receiver, or both. This loss of visual information is what makes reading back a telephone order by a nurse to a physician a critical component of that type of communication.

Here’s another example: you’re calling in a hemoglobin value to the physician. If the lab value indicates borderline for anemia, but you strongly feel the patient would benefit from a transfusion, you would want to include the subjective symptoms you see at the patient’s bedside: headache, shortness of breath on exertion, and increased fatigue. Knowing that you are going to suggest a transfusion for this patient based his clinical assessment before pushing the phone number keeps the message on track and focused on the patient.

I’ve been the sender of a message to a receiver (not a physician), who appeared confused about our roles. She did all the talking.  This obstructed my message. Perhaps anxiety caused her to blurt out lengthy commentary irrelevant to the subject of the call, I don’t know. I let her talk until she needed to take a breath, then interjected, “May I give you more information?” each time this occurred, until finally my message was delivered, and we got to work on the real problem.

Why would I devote so much time to this phone call? Because I needed the services of the receiver on the other end of the phone. Interrupting her abruptly to tell her how busy I am, using a smug tone of voice, or getting angry would simply slow down progress, and patient care. Giving good phone requires a purpose, an intended outcome, and patience.

What is your biggest peeve about telephones at work? How does your unit help patients seeking information by telephone?

A version of this post was previously published on TheONC.org.

Nurses & Doctors: Make Appreciation Reciprocal

artist: jparadisi

artist: jparadisi

Few life-threatening or terminal diseases present themselves in otherwise healthy, alert, and charming hosts the way cancer does.

From the get-go, oncologists are not only captain of the ship; they hoist life preservers in the form of treatment to patients drowning in waves of shock after a cancer diagnosis.

In my opinion, oncologists’ hearts closely resemble those of nurses. This is attributed to the fact that although oncologists do not spend the same quantity of time with patients as nurses do, the quality of the time they spend is intense. They often form relationships with patients over years. It’s common for an oncologist to know close members of their patient’s family, also like nurses.

During my last episode of possible (it wasn’t) recurrence, I experienced this truth.

My oncologist and I share a professional relationship. One of the reasons he’s my oncologist is because I know he’s good at what he does. My husband likes him, too. They share an easy communication, which is another reason for my choice. If/when cancer recurs, I know they will cooperate on my care, freeing me to be the patient, not the nurse. This arrangement brings me peace of mind.

Anyway, I had suspicious symptoms, which landed me face down in an MRI. My appointment to receive the MRI results was scheduled at end of a workday for my oncologist.

David accompanied me. Dr. My Choice entered the exam room holding the films, clipping them to the light box.

“I haven’t looked at these yet,” he explained. “I thought we could see them at the same time.”

It hit me in a flash: Dr. My Choice likes us too. He is about to find out if he will tell a nurse he enjoys working with, and her husband, whether or not her cancer has recurred.

Snap! What have I done to him?

Fortunately, the films revealed I am still cancer free. The look of relief on Dr. My Choice’s face nearly equaled David’s.

Oncologists, (doctors) have feelings, too. This knowledge affects the professional relationships of nursing practice in the following ways:

  • When questioning an order, assume the doctor has good intentions toward his or her patient, same as you.
  • Avoid framing questions to a doctor with your personal inferences, such as opinions of whether or not the physician is “good” or “bad.”
  • Consider that doctors suffer from work overload, and burn out, as do nurses.
  • Remember: Being part of a team is catching one another when we fall. No one is on top of his or her game every time.
  • Protect the Rock Star Doctor (every unit has one) by double-checking their orders the same as you do for any other physician. Don’t let them fall to earth because you were not diligent in providing a safety net for their patients.

Education is the tool of our trade. It is our demeanor, which makes us professionals.

Using Perspective As a Tool Against Nursing Burnout

The death rate for humans on the planet Earth is currently 100 percent. I know this is not a pleasant thing to read while enjoying your first cup of coffee this morning, or perhaps you’re enjoying a calming glass of wine later this evening. It’s unpleasant enough that perhaps you will not finish reading this post, but it’s true nonetheless.

Ravens by jparadisi

Ravens by jparadisi

Running parallel to our fear of dying is our pursuit of eternal youth. Cosmetic surgery and procedures are a billion dollar industry. Many men and women consider regular treatments for balding, teeth whitening, the prevention and removal of wrinkles, and coloring gray hair part of normal maintenance. Some choose to have  the evidence of time wiped from their faces by a surgeon’s scalpel.

The struggle nurses face in striking the right balance between hope and realistic outcomes for our patients is in part due to society’s mythical belief that death is preventable, when in fact, it’s inevitable. As humans, nurses buy into the myth to some extent also.

Discussing this, a nurse friend and I joked about gray hairs and wrinkles. She remarked, “Getting old is terrible.”

“No,” I said, “It’s not. It’s what nurses do for a living. We help people stay alive so they can grow old.”

See? It’s a matter of perspective.

Whenever someone asks, “Is it hard being a cancer nurse working with dying patients?” the above thoughts come to mind. The answer is, “I don’t see oncology nursing from that perspective.”

Yes, oncology nurses work with the dying, but I perceive our practice as helping people live to their fullest capacity.

Nurses cannot guarantee patients a cure or how long they’ll live, but by promoting prevention, treatment, and providing tools for managing chronic disease, we encourage them to pursue their best life possible as things stand. If nurses lose this perspective, how can we hope to share it with our patients?

There is balance in the realization that death is part of life. Death and loss cause grief, a normal response. Grief and loss are painful. We fear death and loss, but they are a natural occurrence of living. Maintaining a realistic perspective is a tool for burn out prevention among nurses.

All people die. Nurses are here to help patients live until that day.

I grieve their loss, and mine, because I glimpse my mortality too in the faces of the dying.

Thank you for reading this entire post.