You’re Going to be Alright

Years ago, following an art reception, my husband and I were enjoying dinner at a restaurant. As the server set our food on the table, we watched through a window as a car hit a bicyclist who had run a red light.

Go Team Oncology by jparadisi

Go Team Oncology by jparadisi

Immediately, we left our table and went to the woman’s aid. She wasn’t wearing a helmet, and her face was bleeding. She was unconscious, but breathing. Besides a possible neck injury, my concern was that she would stop breathing before the paramedics arrived. Despite my fears, I told her over and over, “You’re going to be alright. Help is on the way.” I don’t know if this mantra helped the woman, but it calmed me.

Nurses tell patients, “You’re going to be alright” all the time, whether or not the situation is as dire as the scenario above.

We tell them they will be alright while we are learning a new EHR documentation system at the same time we are administering their treatment. We tell them they will be alright while we struggle to enter lab orders correctly in the new EHR. Fortunately, EHR experts are readily available to answer questions and help us through this transition. They show us the step we missed, which is the reason the order did not go through.

I slap myself on the forehead, and the EHR specialist kindly reassures me, “You’re going to be alright.”

I think this is one of the most special qualities of nurses: Despite our fears and misgivings about a patient’s condition, or our ability to handle a situation, we tell our patients, “You’re going to be alright.” For the most part they believe us, probably because what other choice do they have? What choice do we have? It is what it is. We must move forward, together.

In Human Resource department lingo, focusing either a patient’s or coworker’s attention on the positive is called “managing up.” For instance, instead of telling a patient you are precepting a nurse who’s giving chemotherapy for the first time, you might introduce yourself by telling them they won the jackpot today — two nurses caring for them instead of one! — and that you are helping Nurse B, who is new to the unit. By doing so, you tell both the patient and Nurse B, “You’re going to be alright.”

In what ways do you manage up at work? What techniques have you adopted to promote a patient’s or coworker’s sense of security during a change of condition or a work-related transition?

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.

Advice for Administering Medications with Narrow Safety Margins

I read the order carefully, looked up the medication, and consulted with a pharmacist before giving it. Signing the medication administration record (MAR), I re-read the order. I did not see the same dose I read the first time.

by jparadisi

by jparadisi

Immediately, the blood rushed up from my feet to my ears, and I was lost in pounding waves of white noise. I made a med error! A serious one! I didn’t say these words out loud. Instead, I placed the patient’s chart and the empty, pre-filled syringe in front of the charge nurse. “I think I just made a med error — a bad one. Look at the order and the syringe. What did I do?” She read the order and examined the syringe. “You gave the right dose. You didn’t make a med error. Now breathe.” The pounding breakers of white noise subsided into the gentle lapping of my breathing.

Medication errors are potentially heart stopping: figuratively for nurses, verily for patients. ICU  and Oncology nurses have the added stress of routinely administering medications with  narrow safety margins to patients willingly offering their venous access. Further, neonatal and pediatric nurses have patients with less tolerance to any medication or fluid error than their adult counterparts.

While all nurses make medication errors, our goal is to develop strategies to avoid them:

  • Always check chemotherapy or any high risk medication orders beyond the five rights of medication administration. Our oncology services have standardized the double check into a checklist developed from the ONS Safe Handling of Chemotherapy and Biotherapies Handbook. It includes monitoring lab values, confirming appropriate regimen, lifetime dose (if applicable), calculating the correct volume of medication in solution, and more.
  • Don’t rely on memory: Look it up. Pharmacists are also a resource.
  • Consult with more experienced nurses, but don’t rely on their memory either. Look it up.
  • Do not allow interruptions during a medication check. This is not a time for multitasking.
  • Maintain current chemotherapy or other applicable education.

Despite precautions, errors will still occur. Owning and learning from them is the quickest way to move past a bad experience. Supporting a culture of safety in the workplace increases rates of both error reporting and prevention. Colleagues should extend support to one another.

Does your institution have a “culture of safety”? What advice would you add about error prevention? What experiences would you share?

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?

Lessons About Medication Errors From Baseball

In the commercial, three guys are standing around a grill, talking about baseball. One of

painting by jparadisi

Baseball Card by jparadisi

them quotes a stat.

Another one says, “Really? Are you sure?”

The first guy says, “I’m 99.9 percent sure.”

The third guy says, “Then you don’t know.”

I don’t remember what product was advertised. I remember the commercial because the question of certainty came up regarding a medication order.

I was reviewing the chemotherapy orders:

  • Patient name and identifiers: √
  •  Orders are dated with today’s date: √
  •  The chemotherapy ordered is appropriate for the patient’s diagnosis: √
  •  The dosage is correct: Uh oh. Wait a minute.

The total dose (in milligrams) did not equal the product of milligrams times meter squared (m2). The reason was easy to spot, however.
The chemotherapy infusion was to be administered as a continuous infusion over two days. The order read:

xxxx mg of chemo drug X m2 = xxxx mg X 48 hours = total dose of chemo drug

The doctor meant to write:

xxxx mg of chemo drug X m2/every 24 hours = xxxx mg X 48 hours = total dose of chemo drug

I was 99.9 percent sure, which means I wasn’t certain. Unlike quoting baseball stats, there is no room for uncertainty in chemotherapy administration. Interestingly, a pharmacist felt 99.9 percent certainty was good enough and mixed the cassette sitting in front of me.

To be fair, this was not the patient’s first infusion. The pharmacist mixed the chemo based on past orders. Using a previous record to predict a result in the future is the definition of betting, which works in baseball, but not so much when administering chemo.

I called the office where the order originated. The nurse on the other end of the phone pulled up a copy of the order. “Oh, he meant to write every 24 hours. If I write that and fax it back to you, will that work?”

“Yes it would,” I said. “Are you certain?”

“I’m 99.9 percent sure.”

“Certain enough to sign your name to an order?” I asked.

There was a pause, and she said, “I’ll have the doctor take a look, sign it, and fax it back to you.”

I thanked her.

The corrected order, signed by the doctor, arrived on the fax machine. The checklist was successfully completed, and the infusion started.

I was 100 percent certain the infusion was correct.

Do you ever feel like the nurse holding everything up? What’s your opinion? Would you trust your familiarity with a patient’s past orders and go ahead with the infusion? Does your work environment support nurses delaying treatment while verifying orders?

Tips for Learning Chemotherapy Administration

I attended a chemotherapy and biotherapy course. Most of the nurses attending had administered chemotherapy for years, but a group of nurses new to oncology sat at the far end of the table. By the end of the first day of class, none of them had spoken a single word after the morning’s introductions.

photo by jparadisi

photo by jparadisi

Concerned, I approached the instructor. She had noticed their lack of participation too and told me these nurses had expressed feeling overwhelmed by the amount of knowledge needed to safely administer chemotherapy.

I can relate. I recall, years ago as a pediatric ICU nurse, admitting a patient in anticipation of tumor lysis syndrome (TLS). Although chemotherapy certified nurses administered the chemo, I was responsible for the patient’s well-being in the ICU. I asked a lot of questions, probably too many. Weary of me, the oncology nurse coordinator remarked, “You worry too much. It’s just chemo.”

Somewhere between this coordinator’s cavalier attitude and the paralyzing fear of a nurse unfamiliar with oncology is the middle ground for teaching chemotherapy and biotherapy administration. Here are some suggestions:

Fear is the nurse’s friend. Fear makes you look up medications and regimens you are unfamiliar with administering. It makes you ask a more experienced coworker for help. It makes you call the oncologist for clarification of orders when you are unsure, but don’t let it paralyze you. Fear is your friend. Embrace it.

Build on what you already know. Safe administration of all medications, including chemotherapy, is founded on the cornerstone of The Five Rights:

  • Right Patient
  • Right Medication: In oncology, this includes becoming familiar with the overarching chemotherapy regimen ordered.
  • Right Dose
  • Right Route
  • Right Time

Right Now is what my husband, a hospital pharmacist, jokingly refers to as the “sixth right,” as in, “the doctor wants the chemotherapy given right now.” While promptness is a virtue, chemotherapy administration is similar to teaching a small child to safely cross a street: “Green means go when safe.” Don’t give the chemo until all the double checks are completed to satisfaction.

Teach evidence-based practice, not your old war stories. None of us older nurses are as entertaining to new nurses as we think we are. As a preceptor, keep your pearls of wisdom short and relevant to the teaching situation.
“Knowledge isn’t knowing everything but knowing where to find it,” said my ninth grade algebra teacher. Teach new oncology nurses the value of looking up medication administration information in your facilities’ policies and up-to-date references. Assuming the information provided by a coworker is reliable instead of looking it up yourself is unprofessional, and won’t hold up as your defense in a sentinel event review.
What helpful advice would you offer new oncology nurses?
What oncology references do you find particularly helpful?

Shift Observations: When It Feels Like Work

Our fatigue is often caused not by work, but by worry, frustration and resentment.

Dale Carnegie

Derail photo by jparadisi 2012

I had one of those patient assignments I couldn’t get control of. The care plan refused to move forward in its time frame, despite fervent pushing. There were unexpected variables: The patient possessed few usable veins; those she had were challenging, and time was lost starting her IV. The infusion wasn’t available when expected. Once it started, the vein blew. No harm occurred to the patient, but another vein had to be found, another IV had to be started, all at the cost of more lost time. It became clear the patient was not going to be on time for a scheduled procedure in another office. This happens once in a while in the ambulatory setting, mostly because the parties doing the scheduling are unaware or overly ambitious about what can be done in a limited amount of time.

I called the RN at the office scheduling the procedure, explaining our patient would be late. Then I returned to my post, watching her IV, willing it to stay open and unobstructed. The expression on my face must have been intense: I didn’t notice our nursing student enter the unit until he came to me and asked, “Tough day?”

This student returned to school to pursue a career in nursing. His commitment, work ethic and accountability are rare. Despite raising a family, and going to school full-time, he finds things to do above and beyond expectations. He’s smart and funny too, with a natural ability to get along with our crusty, all female staff. He’s going to be a great nurse.

“Yeah, it’s a tough day,” I replied. Remembering how hard this nursing student works I realized, instead of whining, I had the opportunity, a choice, to show some professionalism. I explained some of the factors making the assignment difficult. Without thinking, out of my mouth came the words, “Solving the problems is what I do as an RN. This is what I’m paid to do. When things go wrong, that’s when my education kicks in full throttle. I’m here when the work is slow, for the times when things get tough.”

The student smiled and said, “Yeah, that’s what makes it a profession. It’s like when I had my company, the job was easy until there was a problem. That’s when it felt like work.”

He’s going to make a great nurse.

Pain is The 5th Vital Sign, Who Has Control?

Photograph courtesy of Adriana Paradisi, 2011

Recently, two nurses in my blogging community wrote about patients in pain. Joni Watson at Nursetopia posted a link to horrific videos of patients suffering in pain without proper medication, and J. Doe at Those Emergency Blues urges nurses to provide post-op patients with education along with that vial of pain medication at discharge.

Patients who are not in control of their own pain medication often suffer in pain. Here’s a composite story from my Pediatric Intensive Care experience:

I am taking report on a child less than 24 hours post-op open-heart surgery. The night nurse, who is fairly new, tells me that the only pain medication given on her shift was acetaminophen, although the surgeon ordered narcotics too. I say, “WHAT?” The night shift nurse explains she offered narcotics, but the patient’s mother, who was up all night at the bedside, refused them. Like I said, I am familiar with this routine. I have a script for it. I ask the night shift nurse to follow me into the patient’s room so she can learn it too.

In the room, I see a small child sitting rigidly in a hospital bed. An untouched breakfast tray rests across her lap on the bedside table. Above her, the green tracings of the monitor displays tachycardia (heart rate is high). The central venous pressure (CVP) and blood pressure are also high. Barney the Purple Dinosaur is singing about friendship on the blaring TV, and I feel a headache coming on. Mom at the bedside, looks like she hasn’t slept for weeks, and is clearly exhausted. I say “Good morning,” and introduce myself. I say, “So, your daughter’s surgery went very well. How do you think she is doing today, right now?”

The Mom tells me her daughter seems very quiet, and isn’t eating breakfast, which is unusual. I say “Hmmm,” then point out that all of the numbers on the monitor are high, and to me, it looks like her daughter might be painful. “By the way, the night shift nurse mentioned that you prefer your daughter receive only acetaminophen, and she hasn’t had any narcotics. Is there a reason you don’t want her to receive narcotics?”

I am not surprised to find out that someone in the mother’s family recently died of cancer, or another long disease process and at end of life was on a narcotic drip.

The mother equates narcotics with death, and is illogically protecting her daughter by preventing narcotic administration. The patient is too young to speak for herself. I educate the mom on the difference between post-op analgesia and end of life pain control. She allows me to give a little narcotic to her child, and soon the kid is eating breakfast and singing along with Barney. Her vital signs are normal, and the surgeon is very happy with her progress.

Now I work in an ambulatory oncology clinic, and I see another variation of this patient who is not in control of his or her own pain medication administration. Typically, this patient has rapid disease progression, and almost always tumor metastasis to the spine. They are easily identified by their need of mobility assistance, and are painful even lying in bed. They tend to talk to you with their eyes closed. They are too sick to speak for themselves.

A family member always accompanies them, and that person knows the name of all the prescribed medications, the doses, and when they were last given. They give a detailed report of the patient’s diet, stools, and urinary output. The patient is clean, and dressed in clean clothes. They are obviously loved.

I assess for the fifth vital sign: pain. Their body language prepares me for a high number, and I am not surprised when they report an 8 out of 10, or greater. I see on the home medication list that the oncologist has prescribed both long acting pain medication and a short acting one for breakthrough pain.

I ask both the patient and the caregiver when the patient last had pain medication. The caregiver answers, “Last night.” I ask why the patient didn’t have a dose in the morning before this appointment. The answer is something like, “He needs to walk more.” “He doesn’t eat enough when he takes pain meds.” “I didn’t think he needed it,” and a long list more. Apparently, this is a very common problem confronting hospice nurses, and Medscape has a very good article on the topic.

It is my experience when encountering this caregiver and pointing out that their loved one is in pain that they start to cry. They almost always have the vial of long acting pain medication in their purse or pocket. I get an order from the oncologist, and together, the caregiver and I treat our patient for pain.

I explain that the bone pain will not go away; it will worsen. Our patient will need more pain medication, not less.  Then we discuss loss and grief, and how painful they are. The caregiver sees their loved one floating away on a cloud of analgesics, and illogically thinks that withholding narcotics will keep them here longer. I can’t fix this for them. It’s going to happen. I provide a safe environment to talk about grief. I urge them to be brave and declare their love by treating pain. I arrange the appropriate support to protect the patient at home.

And I say a little prayer for all of us.

Advice for Transition From Nursing Student to Professional

Paper Dolls (First Communion diptych) by jparadisi

Last week RealityRN.com asked me to respond to a new nurse’s post about the difficult transition from student to professional nurse. Other nurses also contributed advice and insights. Here’s what I said:

My first six months as a new grad nurse were so painful, I almost quit. More than twenty years later, I can laugh about it enough to post them on my blog, https://jparadisirn.com/. I was lucky to find a great mentor, but don’t wait to see if that happens for you. Accelerate your knowledge base by looking up your patients’ diagnoses in textbooks at home to compare what happened on your shift, and look for information you may have missed in school. Trade work for work with your coworkers by offering to take vitals or other tasks to make up for the time they take to help you. And don’t forget your other non-nursing colleagues as resources: Pharmacists can provide medication administration advice and check your math. Respiratory therapists can offer advice on airway management and options. Buy coffee for the people who often help you and cover their patients when they need a break. Most of all, be patient with yourself. Becoming a nurse is a process, and it takes time. There are no short cuts.

I’ve documented my transition on this blog. The posts are published as The Roz Stories and you can find them in the right-hand column under Categories (Regular Features).

What would you tell new nurses experiencing reality shock?

How I Became a Nurse Part III: It’s An Ongoing Process

The Christening Gown (From Cradle to Grave: The Color White) by jparadisi

One shift, Roz and I worked alone. That night, there were only two patients in the pediatric intensive care unit. Roz was charge nurse. I sat at the console charting, with the hypnotic QRS tracings of sinus rhythm in the background. Roz charted at another desk by the door. The door opened and a man I’d never seen before entered. He walked past Roz, to me. He identified himself as the pediatrician for Roz’s patient, and asked who was the charge nurse.

“Roz is in charge. She’s taking care of your patient.”

He continued addressing his questions to me. “How’s my patient? What’s his blood pressure?” “I don’t know,” I reinforced, “Roz is your patient’s nurse, and she has his chart. She can answer your questions.” I looked quizzically to Roz, who briefly looked up, then put her head down, intent on charting. The doctor continued. “I want to know the I and O. Is the patient getting enough pain medication? Are his parents around?” I didn’t get it. I remained confused until Roz walked over and handed me the chart. Suddenly, I understood. My anger flared then turned into a cold lump in my stomach. I had to control my voice as I answered his questions from the chart.

Roz nursed circles around me. I owed it to her that I was in the PICU and this physician wouldn’t talk to her because of the color of her skin. I only spoke to him because of his patient, a child. He scribbled some orders, gave me the chart, and left. I felt traumatized by his overt racism, and because he directed it towards Roz, my friend. The cold lump in my belly morphed into nausea.

“Roz, I’m so sorry. He’s an ass.” Her eyes betrayed her feelings, but her words were calm.  “Jules, I don’t blame white people for this. That fool is an ornery, nasty soul no matter what color his skin is.”

Decades later, Dr. Racist remains a painful memory. Dr. Racist was never seen again in the PICU. He was a blip on our screen, nothing more. His disappearance prevented Roz and I from doing more than complain to management.

Becoming a nurse is an ongoing process. Certainly, a nurse’s expertise grows through attainment of knowledge and skills, but it is more than that. Becoming a nurse also includes learning when to speak up and when to let something roll off your shoulders. Like everything else she taught me, Roz was better skilled at this than I. I am not a qualified authority on racism in nursing, but the National Black Nurses Association, and minoritynurse.com are two educational resources by people who are.

My treatment by Sister Sebastian was workplace bullying. What happened to Roz is workplace bullying taken to its sinister extreme. It is so universal that the successful TV comedy series The Office uses it for its premise. However, when nurses experience workplace bullying, we are usually in the midst of work requiring responsibility for the safety of others. It’s hard to stand up to rude or disruptive comments when your patient’s condition is rapidly deteriorating or you are in a patient care area. Bullies know this, and use it to their advantage. I think this is what makes workplace bullying particularly demoralizing for nurses:  often, we must choose between defending ourselves and protecting our patients.

I have one strategy, developed over the years, which I find effective. When I overhear a coworker berated by another in either language or tone of voice, I go stand next to that person. Usually my quiet presence is enough to cause the offending person to stop. Occasionally it is not, and the offender asks, “What do you want? Why are you here?” I reply, “I’m just wondering if everything is okay over here. Do you realize everyone can hear you?” So far, this has always stopped the abuse. It’s particularly effective if more than one nurse stands by.

Becoming a nurse is an ongoing process. I am still learning.