Rethinking The Paradigm

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

photo by jparadisi

photo by jparadisi

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

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

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

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

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

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

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

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

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?

Of Med Errors and Brain Farts

I read the physician’s order carefully, looked up the medication in the nurses’ drug book, and consulted with our pharmacist before I gave it.  While signing the medication administration record (MAR), I read the order again, and I did not see the same dose I had read the first time.

Immediately the blood in my feet rushed up to my ears and I was lost in pounding waves of white noise. Fuck, fuck, fuck, I made a med error, and it’s a serious one. Of course, I didn’t say these words out loud. Instead, I carried the patient’s chart and the empty, pre-filled syringe to the nurses’ station. Putting them in front of the charge nurse I said, “I think I just made a med error, a bad one. Look at the order and the syringe label. Tell me what I’ve done.” She stopped what she was doing. 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 in my ears subsided into the gentle lapping of my breathing. Another nurse came to my side saying, “I know exactly what you’re feeling.”

I felt relief. My patient was safe. It was a medication I am not very familiar with. That’s why I read the order carefully, looked it up, and consulted with our pharmacist. All I can determine about my confusion after giving the dose is that I had a brain fart. Somehow my eyes and my brain disconnected after I gave the medication, and the order unexplainably failed to make sense. That’s the best I can come up with: a brain fart.

Later, my coworkers told me their stories of making med errors. We all make them. I didn’t know that when I was a new grad.

It is unbelievable to me as I type this, but it is true: in nursing school  I had an instructor who told our class that she had never in her thirty year career, ever made a medication error. Never. And I was young, and shiny, and idealistic enough to believe her. Seriously, I did. So when I made a medication error during the first couple months of my new-grad job, I was sure that I was not cut out for nursing. At that time, my coworkers didn’t gather around offering support like they did recently. No, I was written up, and had to call the pediatrician and tell him that I had forgotten to hang a dose of ampicillin. He was more sympathetic than the day shift charge nurse back then. I made other medication errors too, nothing serious, but enough to consider quitting nursing during my first six months of practice.

Then I met one of the best nurses I have had the pleasure to work with. For some reason, she decided to mentor me. I confided to her that I considered quitting nursing, because I made med errors, and that my instructor never had.  She laughed.”If that instructor of yours never made a med error, then I’m thinking she’s too dumb to catch them. You are so crazy. Let me tell you about med errors…” She was a great nurse, not a perfect one.

She showed me how to string nursing tasks together like a pearl necklace, and eventually I gained the confidence needed to stay in nursing these past twenty-four years. I still make mistakes from time to time. I take responsibility for them. I learn from them. I am compassionate towards my coworkers when it happens to them. Nursing is not a risk-free profession.

And sometimes I have brain farts.