Tag Archives: nurses

Applying Nursing Process and Knowing When to Quit

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

It was several more days since 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.

New Year’s Eve 2016: Hospital Staff Style

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Since I left oncology infusion nursing to become an oncology nurse navigator, I’m no

Sushi platter with chopsticks photo by Julianna Paradisi 2016

Sushi platter with chopsticks photo by Julianna Paradisi 2016

longer required to work holidays, as I did the previous 28 years.  My husband, however, is a hospital pharmacist, and this year New Year’s Eve and New Year’s Day fall on his weekend on. There will be no staying up to MIdnight for us, because he has to be up at 5 am to provide the medications administered to critically ill patients by nurses who will also celebrate a quiet New Year’s Eve at home.

We’ve created a tradition for the New Year’s Eves that mandate we get a good night’s sleep because of our work. This year, it’s my turn to get take out sushi from the Japanese restaurant down the street. A bottle of champagne chills in our fridge. When David gets home from work, we’ll enjoy the sushi and champagne while watching a movie, reflecting on how good our life is, despite 2016 being one of the more challenging years in recent memory.

It’s not glamorous, but we enjoy it.

Wishing you and yours happiness, good health, and prosperity in 2017.

 

 

 

 

Found Time for Creativity and Mindfulness: Make The Most of Waiting

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Around the beginning of the year, I wrote about setting a timer for 15 minutes each day and during that time write or make something. Although the product of that commitment hasn’t been evident on this blog, I am honoring it, by continuing to write and illustrate posts for Off the Charts, paint, and an unusual way to use found time.

Part of my job as an oncology nurse navigator is meeting or checking in with patients during their course of treatment. These face to face meetings often occur before, during, or after one of their oncology appointments.

Cancer treatment involves doctor appointments, and doctor appointments involve waiting. As a ONN, I wait my turn to see the patient, although not usually in the  patient waiting room. Sometimes I’m in a MOB lobby. Often I’m invited in the back office area. If it’s a lengthy wait I go back to my office cubicle, and try to connect with the patient later.

But when the wait is about 15 minutes, sometimes I use the time drawing. Actually, it’s more like advanced doodling. Nothing fancy: I use the simple, lined notepad I bring to appointments, and a cheap, ball-point pen used to write notes. I select a random object. Flower arrangements and office plants are common subjects, but capturing enough details to visually describe a piece of medical equipment is a fun favorite. Rarely is a sketch completed before I’m called back to work.

Drawing without pressure to create product is a delightful form of mindfulness I’m fortunate to merge into my work day on occasion. The illustrations above are examples from my notebook.

The Red Thread of Nursing Experience

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An invisible red thread connects those destined to meet, regardless of time, place, or circumstances. The thread may stretch or tangle, but will never break. ~ Chinese Proverb

Calligraphy by Julianna ParadisiI’m headed for Seattle. Making the experience surreal is that I’m traveling without David for first time since we married. I’m attending the West Coast Regional Meeting of the AONN (Academy of Oncology Nurse Navigators). It’s been years since I’ve attended an out of town nursing conference. Truth be told, I’m pretty much a homebody. Home is my happy place. Yazzie (detail) by Julianna Paradisi

Yesterday, in preparation for this trip I had a mani/pedi, and Bree, my manicurist, mentioned the Chinese proverb above. I hadn’t heard of it before, but it immediately resonated. I’m sure there’s a red thread connecting David and me, and he agrees. I believe I’m bound in a similar way to my family, and a few friends too.

This trip is about forming connections. In my new role of oncology nurse navigator, it’s important not only to close gaps in my knowledge base, but to form relationships with other nurse and patient navigators. Textbooks and continuing education can only advance a nurse’s education so far: Experience is vital to competent decisions, and critical thinking. The fastest way to gain experience is from other nurses. Conferences are about nurses creating red threads of connection between ourselves by collectively sharing our knowledge and experiences.

My hope for this conference is to learn to be a better nurse navigator, and maybe find some nurse red threads.

The Adventures of Nurse Niki: Nurse Characters Doing Nurses’ Work

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This post was originally published on RNFM Radio‘s blog October 2013

JParadisiRN

JParadisiRN

I’m one of those nurses other people hate watching TV medical dramas with. I shout out: “Intubate her now!” or congratulate myself on guessing a diagnosis from a minimal amount of script information. People watching these programs with me say, “It’s just a TV show.”

But the truth is, it’s not.

When the same nurse characters are recreated over and over for public consumption by the entertainment industry they become woven into public awareness, and accepted as fact. I wrote about this in a previous post for RNFM Radio.

After my appearance on RNFM Radio earlier this year, I realized I want to create nurse characters closer to the truth, struggling with feelings of social isolation caused by intimate association to the trauma of others, and the accountability to act on it.

Nurses do not only witness the suffering of others, nor do we only hold the hands of patients in pain, or their hair out of their faces while they puke. We assess their needs, get them the treatment needed to alleviate their symptoms, and administer it. Other times, we cover their profuse bleeding with our gloved hands, yell for help, and initiate the ministrations designed to help them hang on.

Except on TV. On TV, physicians do all of this work. In real life, I have had the pleasure of working with doctors who actually did hold the basin while a patient puked, and I’ve even had one assist with cleaning a code brown. These are special people, performing outside of the work doctors are usually expected to do, not because doctors wouldn’t necessarily do so, so much as because doctors are not usually present when these things happen, and nurses usually are.

Anyway, in The Adventures of Nurse Niki, nurses do the work of nurses. Physician characters appear proportionately to how they normally do in real hospital units: during rounds, when summoned from the call room, during codes, procedures, and for admissions and discharges. Doctors are not constantly at the hospital coordinating and administering patient care, because that is not their job. It’s the job of nurses.

None of this information is new to either nurses or anyone who has spent a lengthy time hospitalized, but it appears to be new information for producers and TV writers who continue to populate TV hospitals with doctors doing patient care, while the nurses stand by waiting to, or asking for, help. Some TV nurse characters enter medical school, I suspect, so they too can get a starring role.

The Adventures of Nurse Niki is an attempt to make a 3-dimensional main character whose life is interesting because she is a nurse, not because she works in the proximity of doctors.

 

The Nursing Dilemma of Medical Marijuana

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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?

 

All Deaths Are a Great Loss

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When I was in nursing school, an “elderly” instructor (she must have been at least 60)

Bones (Redivivus) by jparadisi

Bones (Redivivus) oil on canvas by jparadisi

asked our class,

“Is the death of a young person a greater loss than the death of an old person?”

The oldest student was maybe 30. Unanimously, we agreed that the death of a young person is the greater loss. The instructor’s expression let us know she did not agree,

“All deaths are a great loss. No one wants to die. As nurses, you’ll do well to remember this.”

My first nursing job was in pediatrics. I remained in pediatrics for 15 years, and my student perception of the death of a young person being a greater loss than the death of an old person was never challenged. However, now that I am an adult oncology nurse, I have a better understanding of what our nursing instructor was trying to teach us that day.

Few people would argue that the death of an older person is sadder than that of a young person, but that’s not what my nursing instructor had asked. She asked, “Which is the greater loss?” The losses are equal, but for different reasons.

The death of a young person is a great loss because the world loses a potential Picasso, Hemingway, or Madame Curie. The parents of the youth lose the legacy of grandchildren who may have been born to their child. If grandchildren are already born, they lose a parent. The dying youth loses a full lifetime of experiences, love, joy, and sadness — the bittersweet fruit of a ripe old age. A piece of hope dies with them.

When an old person dies, the world loses a Gandhi, Rosa Parks, or Mother Theresa. More commonly suffered are the loss of a spouse, a parent, a close friend, or confidant. We lose someone with whom we share common history and memories. Upon death, an old person takes a piece of life from those left behind. With this understanding, I sit at the bedside of elderly patients, holding their hands as they grieve out loud their cancer diagnosis and impending deaths. I grieve their loss as greatly as I did the loss of my pediatric patients.

Nurses know that every passing life is a loss and there’s peace in knowing there’s no need to judge.

Nurses Work in Tight Spaces Under Intense Circumstances

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I’m standing in the patient nutrition nook, eating a mid-morning snack of yogurt with a plastic fork, because I can’t find the plastic spoons. Twelve feet away, a patient can see me from her infusion chair. She smiles and waves at me.

At the same time, another nurse joins me in the nook, which is so tiny we stand nearly shoulder-to-shoulder as she responds to a text from her kids. This doesn’t bother me; she’s just looking for a private moment, same as me.

Under Oregon law, farmers selling eggs are required to make changes in how their chickens are raised by 2026.

watercolor painting by jparadisi

watercolor painting by jparadisi

According to the article, egg farmers must increase the personal space of each chicken from 67 square inches to 116.3 square inches. I’m trying to visualize what this would translate to proportionately in private space for nurses.

I don’t know very much about chickens, but I do know a little about nurses. We work in tight spaces under intense circumstances.

Finding a private spot from which to make a phone call or even to enjoy a quiet half hour during a lunch break is nearly impossible for nurses. A staff lounge for breaks provides respite from direct contact with patients, but since it’s a common area, not only nurses you work with, but people from ancillary departments, usually share it too.

Here’s the thing about people — we’re all different. For some, a break means eating a lunch brought from home, catching up with friends’ updates on Facebook, or reading a book or magazine. Other nurses, however, are re-energized by using their breaks for socializing. There’s not a right way or wrong way to take a break from patient care; it’s a matter of personal diversity.

Regardless of either style, it’s not likely that hospital units or clinics will increase private space for nurses. While it’s acceptable for hens to be less productive when privacy needs are not met, it is not acceptable for nurses to be less productive or deliver unsafe care because of a lack of personal space.

How can nurses support each other’s privacy needs?

  • Respect each other’s different break styles by moderating the volume of conversation in the break room.
  • Exercise patience with coworkers who re-energize through socialization.
  • Text rather than talk on the phone whenever possible.
  • Be sensitive to signals the person you’re on break with may not want to talk, such as reading a book or magazine.

What is your personal privacy style at work? Does your institution provide a quiet space for nurses? What are your tips for finding moments of private time at work?

Nursing The Unexpected Job Change

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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.

Close Encounters at The Grocery Store: Thanksgiving

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It’s the weekend before Thanksgiving, and I’m grocery shopping. Pushing a cart through throngs of people looking for that special can of yams, I wish I’d pinned a sign reading, “Don’t follow, Makes frequent stops,” to my rear, so people might stop running into me.

photo: jparadisi 2012

photo: jparadisi 2012

Surprisingly, most of the shoppers are in good moods. I hear the words, “Excuse me,” “After you,” over and over. Only the very young adults, shopping for holiday meal preparations for the first time, I presume, express out loud their bewilderment at the crowds. Suddenly, their attention to space and time is required. This means they have to get out of the way while text messaging, instead of stopping abruptly in the middle of an aisle where more seasoned shoppers will trample them.

In the produce section I pull a thin plastic bag from a dwindling roll to fill with Brussels sprouts. Another woman poises to do the same. I’m sure she’s a nurse, like me, although I will never know. Simultaneously, we pause at the large bin of loose sprouts, realizing we have to gather them with our bare hands, because there is not even a rudimentary tool for the task. We eye each other, smile, then I say, “Wow, how many pairs of dirty hands have been in this bin before mine?”

She laughs. “I know,” she says, “I’m thinking the same thing. I’m going to have to scrub these well, and remove the outer leaves.”

“Me too,” I say.

I’m sure she’s a nurse.

Happy Thanksgiving from JParadisiRN

*This post was originally published on JParadisiRN in November 2012.