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.

 

The Stars of Our Lives

Mixed Media on Paper 2016 by Julianna Paradisi

The air temperature was below freezing, and because of all of the rain earlier in the week, the streets were frozen. Lots of car accidents were reported on the roads.

Because I walked to work I didn’t think too much about it, but as I progressed closer to the hospital the sidewalks, and particularly the asphalt streets became more slick with ice. I was wearing the wrong sort of boots and had to tread carefully to avoid slipping and falling.

Most interesting about the experience was that when I came to an intersection I waited to let the cars go first:

1. Because I had to walk gingerly, and slowly, and

2. Because the cars could slide too, and I didn’t want to be struck if they did.

Surprisingly, some drivers were annoyed when I refused to go first after they waved me on. One was so upset he shouted, “I was just trying to be polite to you!” from his vehicle as he passed. Intending to be thoughtful I had affronted him by not accepting his gesture of kindness, as though we were characters in an O. Henry story.

It made me think about how we are the stars of our own lives, and as such, often interpret the actions and motives of others through the lens of their effect on us. The driver didn’t understand I was being considerate too (and concerned for my safety). It didn’t occur to him that the road was as icy and slick for pedestrians as it was for those behind the wheel of a car.

I don’t know who originated it, but before reacting to someone’s words or actions it’s helpful to remember the meme, “People are not against you, they are for themselves.” I know I do it too, judge others’ actions by the effect they have on me. I hope I can become more mindful of doing it, and less self-focused.

 

Nurses Make Birthdays, One Year at a Time

by jparadisi

by jparadisi

Part of our institution’s medication administration policy is asking patients to state their name and birth date, scrutinizing the information against the medication label. Patients of a certain age, more women than men, customarily wince while saying the year in which they were born. Often they say, “I’m getting so old.”

Perhaps it’s none of my business to respond, but as a cancer survivor and an oncology nurse, I can’t seem to help it. This reply escapes my mouth with hardly a thought in between: “That’s what we do here. We help you grow old, one birthday at a time. That’s why you and I are here.”

It always gets a laugh, and more often than not a, “Well, I suppose you’re right. That is what we’re doing here, isn’t it?”

Like many things in life, the ability to enjoy growing old is a matter of perspective.

It’s a funny world we live in. People bemoan their birthdays and growing old; yet endure chemotherapy and procedures, fighting to add years to lives threatened by disease.

I don’t love the effects of aging on my body. I color my hair to hide the gray. I exercise and eat right, and avoid over indulging in things that destroy a body’s ability to maintain its health. But these things enhance life, they do not prevent the inevitable. I know my days are limited. I know some day I will cease to exist in the manner I do now.

You may feel depressed by reading this post, but I say to you, knowing that life is finite is the most freeing of all thoughts. It bestows the gift of living everyday to the fullest, to make choices honoring integrity, and loving relationships. Life is too short to dwell in unhappiness. This is the least that nurses can do to honor the memory of the patients we have known and lost: live life as if each day were the last.

And, yes, I will take another slice of that birthday cake.

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!

The Nursing Dilemma of Medical Marijuana

Medical marijuana is legal in Oregon, where I practice. In one sense, this seems to be an enlightened act of legislation for patients who cannot tolerate conventional medications or simply prefer an herbal approach to managing pain and/or nausea. Its use is particularly prevalent in among oncology patients, and those with chronic pain.

Still, it’s a nursing conundrum. The issue is that marijuana remains illegal at the federal level. Because of this, many hospitals are reluctant to allow prescription marijuana on their campuses. Although a 2009 Justice Department memo recommends that drug enforcement agents focus their investigations away from “clear and unambiguous” use of prescription marijuana, it also says users claiming legal use but not adhering to regulations may be prosecuted.

In light of this, hospitals take the conservative approach: Attending licensed medical practitioners are prevented from prescribing medical marijuana for hospitalized patients, and create policies prohibiting the use of medical marijuana on their campuses.

For pharmacists and nurses the problem is this:

  • Pharmacists can only dispense medications prescribed by licensed medical practitioners. The federal government classifies marijuana as a Schedule I drug, which means licensed medical practitioners cannot prescribe it.
  • Nurses administer medications only with an order obtained from licensed medical practitioners.

Nurses may have run-ins with patients and caregivers unfamiliar with this policy, and a patient’s home medication routine may be disrupted.

Though it does not happen often, I had the experience of treating a chemotherapy patient expecting to smoke marijuana between infusions to control nausea and vomiting. Initially caught off guard, I struggled to find a way to manage the situation.

The campus did not permit smoking, tobacco or otherwise. When I reviewed the hospital policy, it confirmed that the medical marijuana was not an exception. I explained this to the patient, who was understanding, but skeptical.

Reviewing the premedication orders, the oncologist had done a good job of covering nausea and vomiting with conventional medications. I asked the patient to give it a try. Always having a plan B, I promised that if the medications didn’t work, I’d call the oncologist and, if necessary, the department manager.

Fortunately, the conventional medications worked. The patient enjoyed a hearty lunch and held it down. For the future, I recommended the patient smoke marijuana at home before appointments, and afterwards if indicated.

Several states have enacted medical marijuana laws. Do you work in one of them? How does this affect your nursing practice?

 

Managing The Moderately Unstable Patient: The Challenge of Ambulatory Care Nursing

When a nurse educator makes the bold statement, “The moderately unstable patient is at the highest risk,” I’m interested in knowing why. I’ve thought about this statement ever since.

Wild Card by jparadisi

Wild Card by jparadisi

She explained that the task-oriented nature of ambulatory care units (ACU) is a contributing factor. While patients in the ACU are assessed by their physician or nurse practitioner for treatment readiness, and again assessed by the infusion RN during treatment, the primary goal of these appointments for patients and providers is to administer treatment, complete the appointment, and, for the providers, to move on to the next patient. The ACU patient then goes home to fend for his or herself until the next appointment.

If you spend only a small length of time at the triage nurse’s desk answering phones, the high risks faced by these moderately unstable patients are clear:

Pain
Chemotherapy-induced nausea and vomiting (CINV)
Blood clots
Febrile neutropenia
Depression
Herpes zoster shingles
Malnutrition
This list is not comprehensive. Individual risk factors such as living alone or comorbidities also play a role in overall risk factors.

Some risk factors that might occur during the ACU appointment:

Patient falls
Adverse drug reactions
Syncope
Patient and nurse are unaware that patient is unexpectedly unfit to drive after the appointment
The above factors often occur because the nurse caring for a particular patient is unfamiliar with that patient’s baseline functioning. This puts first-time patients, and nurses new to an established patient, at an increased risk for an unfortunate event.

So, how can ACU nurses protect patients and their nursing license in this fast paced, and rapidly expanding nursing specialty?

First, stop calling your place of work a clinic. The ACU is a specialty care area requiring its own unique set of nursing skills, and should be recognized as such.

Maintain a high level of suspicion. Asking the right question is more important than having all the answers. What you don’t know will harm your patient. One of the most common examples is explaining to a patient how to care for their back pain, only to later discover that the pain is shingles, which were missed because no one asked to see the patient’s back. Other important questions are: “When did you take your (fill in the blank) medication last?” If they haven’t recently, ask, “Why?” because the answer may surprise you. Asking the right questions is an essential part of a solid assessment.

Continuing education is critical to quality patient care. While ACU nursing may seem less demanding than inpatient nursing, it requires the same level of skill and vigilance.

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?

Nursing The Unexpected Job Change

Besides reimbursement changes, The Affordable Care Act (ACA) calls for the formation of Accountable Care Organizations (ACOs): joint ventures coordinated by hospitals and providers in communities in which they stop competing and create coordinated services for patients, thereby reducing the cost of care.

I said NEO, not Nemo by jparadisi

I said NEO, not Nemo by jparadisi

In this vein, the hospital I worked for has undertaken collaboration with another hospital to provide outpatient oncology care for patients. As a result, after working for the same healthcare system for nearly 20 years, I have become an employee of the other hospital. Though my job is basically the same, I unexpectedly find myself working for a new healthcare system.

In many ways this change is actually beneficial. However, it has also created turmoil for my coworkers and me.

For instance, there is the expectation that we occasionally float to locations other than our home unit, involving commutes for some. Vacation plans beyond the new hire date are uncertain; we’ve been asked not to request vacations until after the end of the year (2013). New benefits packages require reading, new retirement options must be considered, and there is a different pay scale than what we were accustomed to. I want to reiterate, none of this is a bad thing, but when a job change is unexpected it creates disruption. Here are some coping skills I learned, in case it happens to you:

  • Get your vacation plans approved by your manager as soon as you are aware of the job change. Merging two staffs means some people won’t get the time slots they desire.
  • Polish your resumé. Find the addresses of the schools you attended, remember the names of past managers, and assemble reference contacts. Even if you are automatically offered a job with the new employer, you will have to fill out a job application.
  • Anticipate drug testing as part of the hiring process. This was my first time ever!
  • Make dental, vision, and medical appointments, and renew your prescriptions before the new hire date, in case your new insurance coverage makes it necessary to seek new providers.
  • If you can’t rollover your sick leave or vacation time, consider using as much of it as you can before the job change. It might be taxed at a lower rate that way.
  • Remain calm, and avoid the rumor mill. Find out who is authorized to answer your questions, and get as many answers in writing as possible.
  • Be patient. ACOs are new for everyone. Administrators and human resources personnel are also learning facts as the project develops. They are not necessarily purposely vague. They really may not know the answers to your questions yet.

Finally, remember this: Regardless of the changes, patient care and safety are pretty much the same everywhere. Your employer may change, but you still know how to be a nurse.

A Blue Mason Jar Full of Post-It Notes Goals for The New Year

Note from JParadisiRN: This post was originally published on this blog in 2011. As it remains one of my most popular, I dusted it off for you to read today. Happy New Year 2014!

Every year I write my New Year’s resolutions on Post-It notes, filling a blue, vintageMason jar with them after reviewing the ones from the year before. I write the date on each Post-It note.  If a previous year’s resolution wasn’t met, and still holds merit, it remains in the Mason jar with the new ones.

Blue Mason Jar of Dreams photo: jparadisi 2011

Blue Mason Jar of Dreams photo: jparadisi 2011

Previous years’ resolutions in the jar:

  • “My health: that I may remain cancer-free” (1999)
  • “The continued good health of our families” (1999) I updated this one to “our families” in 2004, the year David and I married.
  • “David’s and my continued good health and happy marriage” (2008)
  • “To show a financial profit as an artist.” (2008)
  • “Gallery representation”(2008)
  • “Publish more stories in 2011” (2010)
  • “A book deal for my manuscript” (2010)
  • “The blog will have more than 1,000 visitors/month (2010)
  • “Lose ten pounds” (2011)

Most striking about the hopes and dreams on this list is that none of them are actually resolvable. They are ongoing. Sure, publishing The Adventures of Nurse Niki into a book, (or better yet, a TV series) would be great, however, knowing me, the next year I would resolve to write another book, one that won an award or topped the charts, or something like that. Artists are rarely satisfied with any level of achievement. We are always looking up the ladder at the next rung:

  • Gallery representation leads to the desire for critical recognition, increased sales, collectors, fame.
  • Publishing stories leads to writing more stories, longer ones, for larger audiences.

In general, human nature is much the same:

  • Health and happiness leads to the expectation for more of the same.
  • I lost ten pounds last year. For 2012 I expect to keep them off.

Resolution is the wrong choice of word. For me, setting New Year’s Goals is better phraseology. Most of the improvements I wish for in life take time and perseverance to achieve, and more hard work to maintain. To my way of thinking, New Year’s is a time to review the larger goals of my life, and see if they are still worth steering towards. If so, then I ask myself what small adjustments can I make this year to further them? These adjustments are written as goals on the Post-It notes, dated, and placed in the jar.

The most important part of opening the Mason jar each year is reading the hand written Post-It notes, and saying a small prayer of thanks or another expression of gratitude for the advances, which occurred over the past year towards each goal. There is no lasting joy in achievement without gratitude. This year, I am thankful for:

  • A clean bill of health when we were afraid my cancer had returned.
  • Editors who published my paintingsessays, and blog posts.
  • David and I lost weight. He avoided a prescription for blood pressure medication.
  • I was represented by Anka Gallery. I met wonderful people there and made lasting friendships.
  • I sold some paintings.
  • JParadisi RN blog has grown beyond my previous goals.

So what’s on Post-It notes this year? What goals am I steering my life towards in 2012?

  •  Remain cancer free
  • The continued good health of our families
  • David’s and my continued good health and happy marriage
  •  A financial profit as an artist
  • Finish the series of paintings and drawings begun in 2013
  • Gallery representation
  • Write and publish more stories in 2014
  • Increased writing income
  • The blogs, especially The Adventures of Nurse Niki will grow increased readership
  • Keep off those ten pounds

Here’s the cool thing about writing down goals: The Examined Life (Socrates). Today I see  each goal I’ve written down is focused on an unknown future. I haven’t written a single one, which applies to my present reality. So, until my dreams come true:

  • I will continue to develop my skills as a nurse so my patients remain safe in my care.
  • I will strive to be a better team player at work.
  • I will phrase criticism in a constructive manner.
  • I will remember that everyone has a difficult job. That’s why they call it work.
  • I will say Thank You at least once daily. It’s wrong to wait an entire year to give thanks for everything that is good in my life.

I wish to thank my family and friends (new and old) for your support of JParadisi RN blog. May your New Year be filled with Health, Love, Happiness, and Prosperity.