I Wish I’d Said It

Tact is the art of making a point without making an enemy.

Attributed to Issac Newton

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.

You’re a Nurse. Don’t You Have to Do What The Doctor Says?

“You’re a nurse. Don’t you have to do what the doctor says?”

Pulcinella (Punch & Judy) oil on canvas by jparadisi 2011

I check my iPhone to be sure the year is still 2012. I have not magically transported to a nursing station in the past, say 30 years ago, because it’s been 30 years since someone has asked me this question. I can’t believe the woman on the other end of the phone asks it now.

She answers phones at a doctor’s office. I want to say, “You have to do what the doctor says, because you’re his employee, not me,” but I don’t. She isn’t being rude.  She doesn’t understand the role of a Registered Nurse.

“This is an opportunity to educate,” I says to myself. So I give it a go:

“Nurses work with doctors, administering the medications they order to patients. However, it is my job to also prevent patients from harm as a result of their medications. I am calling to tell the doctor I cannot give this patient her medication today, because of her lab values. We have to reschedule the medication, when the lab results improve.”

“But the doctor wants the patient to get the medication today.”

“I know. Giving it today may harm the patient. I’m not calling to ask the doctor if I can give the medication. I’m calling to tell the doctor the infusion will be rescheduled.”

You do not understand! The doctor wants the patient to get it today.”

“I do understand. It is not safe for the patient.”

“You’re a nurse. Don’t you have to do what the doctor says?”

Sigh. “Is the doctor available? May I speak with him, please?”

It May Help Someone

US West Communications photo: jparadisi

I apologize to my friends and family members who are reading about my current health issue for the first time on this blog. Finding out about what’s happening in the lives of the people you love through social media is akin to a HIPPA violation, but there you have it. It’s not that I don’t care, or don’t miss communicating with you directly, it’s that when an unexpected health problem occurs, hours of time are spent on the phone navigating the system for appointments, waiting for return calls, requesting diagnostic information, notifying work, canceling or rescheduling activities previously planned, and fulfilling as many other commitments as possible before surgery. I did call my mother first, because Mom finding this stuff out on the blog is a HIPPA violation where I come from. At times, I wonder if I should blog about this at all, but from the beginning I’ve felt that these posts may help someone.

One of the phone calls I made led to a strange encounter. I was prepared for most of the questions the woman asked, but a few seemed odd. For instance, when she found out that my implants have ruptured, she asked if it’s a common occurrence. I wasn’t sure what she meant. Common for me? Common for breast cancer survivors, or for implants in general? I told her implants have an expected lifespan of ten years, but I don’t have actual statistical data. She asked if it hurts. No, not now, just uncomfortable. There was a pause on her end of the line, then she asked the most outrageous question: “Is there a nicer word to use than ‘explode’?” Offended by her insensitivity, I sharpened a smart-ass remark and aimed it at her carotid. Then I thought better of it. In my best teaching voice, I said, “Use the word ‘rupture’; if you say ‘explode’ to a breast cancer survivor, you might make her cry.”

I was unprepared for the woman’s response: “I know, I’m going through it myself.” Incredulous, I asked her, “You have breast cancer?” She said, “Yes.” She told me she finished chemo and is going through reconstruction.

I dismounted my moral high horse. I considered the anxiety my story would have triggered in me when I was going through reconstruction, or cause someone else who is experiencing it now. She has a difficult job.

With genuine concern, I told her I am sorry she had breast cancer too. I told her that despite my current predicament, I am glad I chose reconstruction. I told her that being alive makes this problem entirely worth it.

And I mean it.

Let Me Tell You One More Thing You Already Know

Intubated (Baby with a Breathing Machine) mixed media on vellum by JParadisi

Maybe it happened because I was tired after working a string of long, busy shifts.

Maybe Mercury, the communication planet, went retrograde last week.

Last week I wasn’t as good of a communicator as I would like to be.

I am one of those nurses who learned something in the Therapeutic Communication module of nursing school. Before you judge me as the nerd I kinda am, I do not go around repeating, “What I hear you saying is…” Such phrases are not what someone wants regurgitated back at them. The phrase is a tool, not a mantra. Instead, I learned to carefully listen to the words a patient uses and watch for any mismatch of those words in their body language. Then I speak to the body language. As a visual artist I first think in images, then put the ideas represented by the images into words, like a songwriter fitting lyrics to a melody. For me, the pictures come first, then the words.

Here’s what happened:

A colleague introduced me to a nursing student whose next clinical rotation is pediatrics. She told her I was once a pediatric intensive care nurse, and the student asked if I had any pearls of wisdom to share. While I am not so vain to believe my words possess a cure for the deep wounds of a human soul, I am vain enough to believe I occasionally have something insightful to say. So I offered this advice:

  • Always consider the parent-child unit as your patient
  • Even if a parent doesn’t know pathophysiology, they know their child better than you do.
  • The smaller the patient, the more important it is that you get it right the first time.
  • If you are unsure of what you are doing, find a nurse who does know. Stick close to your preceptor.

I finished and saw the glazed look on the student’s face. Her shoulders already turned away from me. She didn’t really want my advice; she was only being polite. David tells me when he sees this look in the eyes of the pharmacy students he precepts, he adds, “Let me tell you one more thing you already know.” She was not my student, however, so I shrugged it off.

A few days later, I was starting an IV in a patient. I had started IV’s in this patient before, and this particular day, while I did so, she told me about a bad experience she had as a child when a nurse started her IV. As before, her body language was the picture of calm while she talked. I inserted the IV easily. As soon as the patient saw the blood flash, confirming the IV was in the vein, she passed out, just like that. I yelled for help, but by the time my coworkers arrived, she was already coming to. With the innocent expression of a child she looked up into my face, and said, “Oh, it’s you.”

I disappointed myself. Her words had not matched her body language, and I missed it. I didn’t know how much courage it took for her to come in for treatment. I gave her some juice, and a little time to herself. When it was clear that her inner child had safely returned to her soul’s play room, I told her I was sorry. She apologized for not telling me how she really felt. She didn’t want to be a difficult patient. We talked about her fear of needles, and came up with a plan. She decided to finish her IV treatment, and I learned one more thing I already knew.

Code Oink: An RN Considers the H1N1 Vaccine.

    The other day I was walking through a hallway at the hospital, when one of the staff began coughing. He looked embarrassed, and I told him he’d better cut it out, or someone may call a Code Oink, which is:  he gets tackled to the floor, has a cotton swab pushed up his nose, a vaccination shot into his arm, and a mask thrown over his head before he’s booted out of the hospital and into the street. We both laughed, but neither of us was sure it wouldn’t actually happen.

     I’ll probably get the H1N1 vaccination this flu season. I’ve had MMR (measles, mumps, rubella), tetanus shots, and the hepatitis B series, all without damage.

    Personally, I’m still waiting for SARS, West Nile Virus, Bird flu, and killer bees, each of which were predicted as the next pandemic of their time. 

     Cynical as I am, it’s logical to admit that eventually the epidemiologists will be right, and we’ll have a pandemic of something;  maybe it will be the Swine Flu.

     What puzzles me is my aversion to taking the vaccine. As mentioned, I’ve been vaccinated for almost everything else. Why am I dragging my feet over this?

     The answer is: I resent the insinuation that I am not considering my patients’  or coworkers’ safety  if I refuse the vaccination.

     Nurses work twelve hour shifts, often without breaks of any substance. We stay over time because of late admissions, coding patients and short staffing. We come in on our days off for education and staff meetings. We miss family birthdays and holidays. We fly in small aircraft through bad weather transporting sick patients from one hospital to another so that they receive the care they need. We admit patients with contagious diseases we aren’t aware that they have. We continue to take care of them once we know what terrible, contagious disease they have.  We are exposed to second hand smoke from our patients and their visitors. We are exposed to violent patients. Still, we return for our next shift.

        I cannot speak for any nurse other than myself, but attempts to make me feel guilty do not motivate me; they make me feel manipulated. 

        Just tell us what I perceive to be the truth:  Health care administrators are afraid that this time, there really is going to be a pandemic, and if health care professionals don’t get the H1N1 vaccine, there may not be enough available staff to take care of all of the sick patients. Just say “please get the vaccination. We can’t afford for all of you to get sick.”  Admit it: you need us, all of us.

     We’ve known it all along.