Applying Nursing Process and Knowing When to Quit

The Queen of Cups II
Collage 6.5″ x 4.75″ by Julianna Paradisi 2017

It was several more days later   before I ripped out the knitted sleeve I wrote of in my last post. I blame part of my reluctance on nursing process: Nurses are trained (to the point of reflex) when confronted with a problem or undesirable outcome to devise further interventions to create the desired outcome. Likewise, I attempted to apply nursing process to the problem of the knitting mistake.

I measured the sleeves of my favorite sweaters, discovering I habitually wear sleeves an inch or so longer than the pattern I’m using prescribes. Then I did some math, and calculated I could still make all the required increase stitches, if I were willing to accept a longer sleeve, but it would be a very close call between longer and too long. As an artist, and nurse, I felt compelled to take the challenge. Artists like to work with process too.

The hard part about nursing process, however, is knowing when to call it quits: How far backwards is one willing to bend to make something work? This can also apply to dysfunctional relationships or work environments. Carrying out interventions beyond the limits of healthy boundaries quickly becomes denial and co-dependence.

In the end, I conceded the sleeve was too long. I ripped out every stitch, turning my head away so I didn’t have to look, the way a patient undergoing a procedure with only local anesthetic does while the doctor takes a scalpel to their skin.

The deed is done. There’s no more anxiety about the outcome. I did what I had to do.

Sometimes a Cigar Isn’t a Cigar

Dreaded Bathroom Mirror photo: jparadisi 2011

The painter Lucian Freud died last week at the age of 88. The grandson of Sigmund Freud, he was a portraitist, making images of friends, family, the famous and the not so much, splayed naked on ruined couches, chairs or ottomans; sometimes draped with animals, mostly dogs. I first learned of Freud in art school, during a figure painting class in which an instructor commented something to the effect of:

“He breaks a lot of rules of painting, but somehow it works.”

I like Freud’s portraits, and was a little shocked after he died to read that many art critics strongly dislike them. Jerry Saltz writes about Freud for NYMag:

“Which brings me to my personal taste. While I don’t particularly like Freud’s work (just last week I saw the Met’s current Freud show and thought, “Meh”). Yet then as now, I admire him greatly. I look at Freud’s intensely worked, eternally noodling oozey surfaces, the incessantly teeming little paint-brush strokes, the Morandi-like limited palette of flesh tones, and his claustrophobic vision of naked models forever posing in his famously dilapidated London studio, and am often struck by how the life of his art seems to drain away. Mostly what I see is nearly maniacal painterly control. Yet Freud is an important touchstone for the many of us who secretly fear that we are not naturally gifted; we who are not precocious geniuses, we non-Picassos who are always unsure that we even are what we say we are.”

Ouch! Those are some harsh words. Good thing I’m not thin skinned.

The opinion that best challenges my own comes from someone whose art critique I hold with regard. He wrote about Freud:

“I hated his work with a passion. Certainly, like everyone else, I could see the penetrating psychological deconstruction he was going for and nailing…his drab palette and ethos of anti-romanticism encapsulated everything I am against.”

(Note:  Romanticism refers to a philosophical movement within art history, not romance, as in sharing a good Oregon Pinot Noir and gourmet chocolates naked on the deck by moonlight…Hmmm. Hey, David.….?)

My friend’s words touched on something for me, and I’ll tell you what it is. I agree, Freud’s portraits are “penetrating, psychological deconstructions” of his subjects. They are disturbing because they coldly render the sitter into gobs of painted flesh, not pretty flesh, but swollen, loose, pale, sweaty flesh. Freud took months to a year to finish a portrait, literally “deconstructing” the sitter through the physically punishing act of posing for hours, days, weeks, and months.

Sometimes, he painted people we think we know, like pregnant super model, Kate Moss. I only know the painting is of her, because he told us it is. Through Lucian Freud’s eyes, I do not recognize her famous face. At times, his portraits remind me of the shock I feel seeing the reflection of my imperfect body emerge from the shower in the in the steamy bathroom mirror, or watching David’s unguarded face in the repose of sleep; in both instances wondering, “who is that person?” This feeling of astonished wonder, this anti-romanticism, is the price of intimacy.

Freud looked at people through the eyes of a clinician, reducing them to bluish veins under discolored flesh. I think that’s why I like his paintings. I am a nurse, and often, the first vision nurses have of a naked patient is similar to one of his portraits. The sensation brings a bit of shock to both nurse and patient. Part of nursing is gaining the ability to navigate within the intimate personal space of another human being. We use a clinician’s eye to assess problems readable in the naked flesh of our patients. However, it is inherent in nursing to turn off the clinical eye and relate to the person residing inside the ailing flesh, with the understanding that they come before us deconstructed by their disease process.

Our decaying flesh is the price we pay for being mortal.

Chickens, Nurses, and Personal Space

photo: jparadisi 2011

It’s a busy morning at work and the schedule is full. IV pumps keep alarming and the phone never stops ringing. Eventually it’s lunchtime. Besides food, I crave a half hour of quiet.

While eating lunch in the staff lounge, I read an article in our local paper about a new Oregon law requiring farmers selling eggs to make changes in how their chickens are raised by 2026. Another nurse, also on her lunch break, chats animatedly on her cell phone. The lounge is small, affording neither of us privacy. To me, a break is a time for quiet. For her it’s for socializing and catching up with the people she loves. People are wired differently, and neither of us is wrong. At least we have a nice place to sit and eat our lunches, even if the room is small.

The article I’m reading says the changes egg farmers must make under the new law include increasing the personal space of each chicken from 67 square inches to 116.3 square inches, which means less chickens per cage, therefore less eggs. Opponents of the law argue that a dozen eggs may cost $8 in order for the farmers to make a profit once all the changes go into effect.

As on egg farms, space is at a premium in hospitals too. Not only for patient beds, but also for storing equipment needed to care for patients (big things like ventilators and wheel chairs), examination and procedure rooms, storage of office supplies…it goes on and on.  Nurses’ break rooms do not earn revenue, just like increased personal space for chickens means less profit for the egg farmer who employs people trying to make a living. Perhaps happier chickens lay more eggs than crowded ones; I don’t know very much about chickens.

But I do know a little about nurses. We work in tight spaces under intense circumstances.  Sometimes we gather to vent or laugh a little at the nurse’s station. Often, we get too loud. It’s not right, but it’s human. Maybe we need more personal space too.

Maybe dampening the sound of voices with three-quarter Plexiglas partitions at the nurses’ station is an option. I saw this in a hospital in California, where my father was a patient. Initially, I was put off that I couldn’t talk to a nurse at the desk. However, if I called for a nurse from his room, someone answered my call within minutes every time. Because I was in his room, and not wandering the halls looking for a nurse, I had no idea what occurred in other patient rooms. Privacy prevailed. Partitions make sense when discussing patient information over the phone. Patients and their families wouldn’t hear that either.

Plexiglas partitions are not a good idea in an ICU, where they might block rapid response to a patient’s critical turn of events. An effective alternative I’ve seen is a small alcove where a nurse can sit with a direct view of patient and monitors when not administering care. Every two rooms shared an alcove containing a computer and two phones. This discourages nurses from congregating at the nurses’ station, and perhaps lessens the risk of falling prey to alarm fatigue.

Nurses often need reminders to quiet down in patient care areas, but thoughtful workspace design and consideration of a nurse’s personal space may offer a more consistent solution.

Welcome Back

Welcome Back photo: jparadisi

Reluctantly, I sit at my computer writing this post. Tomorrow I will spend eight hours at a training computer learning the electronic medical record system, Epic. The following day, I will spend another eight hours doing the same thing. I previously posted that our hospital converted from paper charts to EMR last week while I was on medical leave. I am making up the classes that my colleagues took last month. Although I’m not thrilled about spending so much time at a computer, I am looking forward to participating in patient care again.

I provided precious little help to my coworkers during the two shifts I worked last week, since besides having limits on lifting, I won’t have a computer sign on until I complete the two classes mentioned above. Instead, I spent much of my time following coworkers who kindly taught me as much as they could about Epic in a live patient care setting.

The hardest thing about those two shifts was my feeling of incompetence, because nothing in our unit operates the way it did before EMR. I can’t even open a patient’s chart, look up the name of their doctor, or find an order without a sign on. I’m used to being nursing muscle, not a helpless bystander. I felt uncomfortable, and I have to admit, mildly anxious.

The funny thing was, because Epic is still so new, my coworkers are struggling too. In that way, we remain on level ground, although at least they can access charts, and record the care they gave. However, I could see how learning to navigate the new system slows them down. One way that I helped was to listen thoughtfully as they described the frustrations of providing patient care while simultaneously learning a new system. I let them vent, and I learned from their experiences.

Week by week, things will improve. I hope so, because EMR isn’t going away.

Did I mention that despite all of the controlled chaos at work, I brought a cake to work for my coworkers on my first day back? And that one of them found time to bring in flowers for me?

Remember: be nice to one another.

10 Things to Do On Time-Limited Medical Leave

Three Horses oil & graphite on canvas by jparadisi

I expected to return to work today, but a temporary administrative glitch changed those plans. Rather than languish at home, I’ll write about things to do while on a time-limited medical leave, derived from my own experience.

  1. Finally read Middlemarch, by George Eliot. Okay, I haven’t actually read it yet, but I downloaded the free version to my Kindle this morning. Free is a very good price on disability wages.
  2. Make new friends on Facebook, also free.
  3. Ask my daughter, the hairstylist to give me a cute new haircut. She gave this service as a gift.
  4. Call my mother more often and realize how much I enjoy our leisurely conversations.
  5. Spend time with my favorite eleven year-old. Unfortunately, his toddler sister weighs more than I’m currently allowed to lift. Sigh.
  6. Learn how to apply make up like a pro. By way of charming and entertaining videos, Marlena at Makeup Geek teaches how to create a smoky eye, and wear red lipstick without it making you look clownish. She explains which brushes you need and how to use them. She offers alternative products to more the expensive department store brands. This is a fun site to watch with your teenage daughter if either of you want to bump up your everyday look once in a while.
  7. Walk alternative routes in the neighborhood and see what’s new.
  8. Earn continuing education units. In order to maintain my OCN certification, I’m required to complete 100 units of CE every four years. CE is expensive at $10-$20 per unit. Medscape offers CE in 0.5-2 unit increments free and provides a convenient on-line CE tracker.
  9. Thoughtfully consider my direction as an artist and writer, and plan new goals.
  10. Send a platter of cookies to my colleagues at work, because I’m sorry I’m not there to pick up my part.

Equine Group Show at The Froelick Gallery for June First Thursday

Last night was the opening reception for the Froelick Gallery group show, Equine. I am fortune that my painting Twenty-Oneis included among the work of many accomplished artists. Tonight is First Thursday, and there is a reception for the show from 5:00 pm until 8:00 pm. The show runs all of June, through July 16, 2011.

The Froelick Gallery is located at 714 NW Davis Street, Portland Oregon, 97209.

Artist Statement for Twenty-One

The painting Twenty-One is inspired by the prehistoric drawings found on the walls of the Chauvet-Pont-d’Arc Cave in France. These drawings, made before humans possessed written language, are the earliest known record of primordial expression, and they are images of horses. Later, humans learned to use symbols instead of pictures to create words. Inspired by the transition of pictorial language into words, the repetitive form of grazing horses in Twenty-One suggests ancient cuneiform. Impressed by stylus into clay tablets, cuneiform script marks the abstraction of pictorial expression into symbolic characters. It is the precursor of the modern  alphabet.

Twenty-One by jparadisi

Advice for Transition From Nursing Student to Professional

Paper Dolls (First Communion diptych) by jparadisi

Last week 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, 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?

The Fragrance of Caring

Cupcakes! photo: jparadisi

Hospitals are not known for their fragrance, and recent shifts in particular have lacked delicate bouquet. It comes with the territory, and if I wanted a perfumed environment, I should have chosen a profession that doesn’t include the collection and measurement of body fluids. People with sensitive stomachs should think twice before becoming nurses. Whining about poop and vomit belongs in the “Well What Were You Thinking It Would be Like?” file.

If you require regular and predictable hours for happiness, nursing is not the career for you either. Shifts are unexpectedly extended because of late admissions, acute changes in patient conditions (read EMERGENCIES!!!), short staffing, etc.  In the past weeks, I have left work late for these reasons. Poop, vomit, EMERGENCY! I’m not complaining. This is what I am educated to do. I am proud to be a nurse with the necessary skills to lead patients through their dark moments.

Recently, I came home from a particularly long, smelly shift to find a UPS slip stuck to my door, informing me that a package required my signature IN-PERSON for delivery. The package was my birthday gift from David. I worked the following few days, so I called the UPS customer service number and arranged package pick-up. There was enough time left to pick up the package that evening. Since the gift was from David, he wanted to go get it, even though he’d also worked a longer than expected shift that day. We changed out of our smelly work clothes, and hopped into the car to get the package.

Traffic was horrendous. It was raining, and getting dark. I told David it wasn’t important; we could pick up the package the next day, but he was on a mission. When we finally arrived, it was twenty minutes past the office’s closing time. Surprisingly, the light was on, and the door unlocked. A smiling woman stood at the counter, holding my package. “Are you Paradisi?” she asked. “Yes, I am. Are you waiting for me?” “Yes,” the woman said. “I didn’t want you to drive all this way and find us closed, not in the traffic and weather.”  She extended her shift to take care of me, as I had done during my shift to take care of someone else. It is the essence of excellent customer service: the fragrance of caring, and the gift of time.

JParadisi RN Painting Featured in March Issue of AJN ‘Art of Nursing’

The March 2011 issue of the American Journal of Nursing features my painting Mean Girls (First Communion II). (Click on link, then click on “article as PDF” tab on the right side of the page).

Mean Girls (First Communion II) is part of From Cradle to Grave: The Color White, a series of paintings about the symbolism of the color white in western culture, and in nursing in particular. The entire series of paintings can be viewed on my other blog, Die

From Cradle to Grave: The Color White was exhibited at the Anka Gallery, in Portland, Oregon in October 2010.

Senior editor Sylvia Foley coordinates The Art of Nursing.

Hoarding and The Meaning of *My* Things

photo by jparadisi

You know how when you were in nursing school reading about pathology, and you thought you had symptoms of every disease you studied? You knew you weren’t really sick, but still…it gave you pause. This common phenomenon is called hypochondriasis of medical students, or nosophobia.

Well, I kinda had déjà vu of that last week.

It began with an innocent enough tweet from the American Journal of Nursing. The tweet read: AmJNurs AJN Got to get this book! RT @sciam: MIND Reviews: Stuff: Compulsive Hoarding and the Meaning of Things (emphasis mine).

To the right of the desk where I am writing this post, sits a pile of stuff. The pile of stuff is made of washed, empty yogurt containers, flat, plastic lids, old bed sheets, pages torn from magazines, glass jars of varying sizes, and the disembodied heads, arms, and legs of dolls. And that’s just the stuff I can see sitting here at my desk, without actually going through the pile. I mention this to David, who says, “Yeah, everyday I want to throw this stuff out, but I remind myself it’s Julianna’s stuff, not mine.” I had no idea.  OH SNAP!  I am a compulsive hoarder!

Well, not really. I am an artist. This pile of stuff is awaiting transfer to my studio, where the real hoarding takes place. Unlike the homes of pathological hoarders, however, my studio lacks floor to ceiling piles of accumulated stuff and “goat paths.” The containers, lids, jars, sheets, and doll parts are stored in their respective places. They also have purpose. The containers and lids are recycled into paint holders and palettes. The sheets are torn into rags, a necessary artist’s tool. The jars hold dirty brushes and solvent. The magazine pages are pasted into scrapbooks of images. The doll heads and limbs…well, you’ll find out later.

Anyway, I read the article linked in the tweet above, and am relieved to know I am not a pathological hoarder. Still, I think I’ll clean out a cupboard or something after I post this piece.