Tag Archives: nursing process

Down the Rabbit Hole

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Down the Rabbit Hole, collage, 2017 by Julianna Paradisi

Why is it 2018 feels more like “2017, The Sequel,“ and not an actual New Year?

While I have one or two friends who’ve had an immediate change of luck, many more of us are experiencing 2018 as a poorly constructed, run-on sentence (or rambling blog post) with little progress or clear goals for the future.

Progress requires a release of perceived limitations, and expectations. The process of releasing creates tension similar to a snake shedding its skin, or a butterfly breaking forth from its chrysalis. Things become too tight and uncomfortable before breakthrough occurs.

Nearing the end of January, the growing and stretching feels more intense than in previous years, and I find myself sympathizing with Alice for choosing to follow a rather strange rabbit down a hole, without thought of where it would lead, or how she would return. “Don’t over think it, just do it.”

Choosing to go down the rabbit hole is not a characteristic of most nurses. Nurses like clear goals, something to steer towards, whether it’s gaining a patient’s trust by managing her pain, meeting discharge goals, or simply relieving a fever.

Measurable goals work in nursing. They’re admirable, and create safety.

* * *

Safety. What is safe?

As an oncology nurse navigator, and a cancer survivor, my patients and I grapple with this question daily: How to balance cancer prevention (safety) with an enjoyable and fulfilling life?

If you believe the answer is easily found in NCCN guidelines, and AJCC recommendations, you are most likely not a cancer survivor. Being a cancer survivor is “going down the rabbit hole.”

* * *

Being an artist and writer demands a willingness to go down the rabbit hole; a comfort level with uncertainty.

The challenge of life is learning to live somewhere on the continuum between safety, and recklessness.

Hank Stamper, the burly central character in Ken Kesey’s epic novel, Sometimes a Great Notion, about Oregon’s logging industry, argues towards recklessness:

“Hank would have been hard put to supply a reason himself, though he knew it to be true that Lee’s presence at the Snag tonight was important to him…maybe because the kid needed to see first-hand what kind of world was going on around his head all the time without him ever seeing it, the real world with real hassles, not his fairy book world of his that him and his kind’d made up to scare theirselfs with.”

* * *

Progress begins by asking questions.

What is safe? What is reckless? Should a predictable outcome dictate the beginning of a new enterprise?

An explorer would answer, “No.”

Alice returned from Wonderland, having viewed strange, new perspectives, and with a bunch of great puns. I assume she counted it a good experience, because she went back for a second trip Through the Looking Glass.

Here’s to going down the rabbit hole, and leaving 2017 behind.

 

 

 

 

 

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.

Drawing Lessons: Sideways Perspective,Dishwashers & Forks III

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Forks Sideways (2009) JParadisi

Fork Sideways (2009) JParadisi

        A  doctor mentioned that if health care reform occurs, he will not make enough money to pay off his student loans. If this is true, he has a valid concern.

     I heard that 62% of personal bankruptcies in the United States are caused by debt incurred from a medical crisis. If this is true, it is also a valid concern.

    Everyone has a reason to be for or against Health Care Reform.  Fork tines upwards, or fork tines downwards.  We know that forks can also be placed in the dishwasher sideways, keeping the tines clean and free of entanglement in the basket. 

     Forks have to be washed after use. Health Care Reform is going to occur, one way or another, because our society can not afford the current system.  Some people fear  Health Care Reform will take away their Medicare benefits. At the current rate that health care costs are increasing, Medicare benefits may need to be cut. Why not change the system, and create a Medicare for all who need it? Medicare for everyone.

        The yelling and pictures of President Obama sporting a Hitler mustache at town hall meetings feels similar to the nurses venting their frustration, anger and distrust at each other and the administration during the intial phases of transition to nurse governance at a hospital, which I posted about on September 3rd. The force of opposition displayed at these meetings on the evening news is reminiscent of the energy surrounding the civil rights movement in the 1960’s and early 70’s. Historically, social change in our country occurs with dramatic labor pains. 

           Health Care Reform is a civil rights issue.

          Maybe, when all of the yelling has stopped, honest, respectful and productive conversation will begin at town hall meetings on the evening news.

Drawing Lessons: Problems in Perspective, Dishwashers & Forks II

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Tines Upwards (2009) photo:JParadisi

Tines Upwards (2009) photo:JParadisi

      Garrison Keillor says that you don’t really know what you think until you start writing.

       This morning, while the coffee was brewing, I unloaded the dishwasher. Imagine my surprise to see that all of the forks were placed tines upward. 

       I asked my husband about this fork/dishwasher thing. He has an opinion: tines upward. 

      I can live with it. But what if I find tines upward to be unacceptable?

     A hospital I worked for decided to implement nurse governance as a tool for making decisions within nursing units.  The process was painful in the beginning. We would attend meetings facilitated by a representative from Human Resources  with our nurse manager present, and for awhile, some doctors too. For an hour at a time we  would vent our hurt, frustration, anger and distrust towards all of the factors we blamed for making our work difficult. This process went on for several meetings. Most of the time I wanted to bail, because I felt we weren’t making any progress. Because attendance was mandatory, I stayed. 

     Then something happened:  one meeting, the arguing and the yelling stopped. The strong emotions had run their course, and now we were ready to talk calmly to each other. We were able to begin the work of conflict resolution.

      Each of us was asked to make a list of the top five problems we wanted fixed in our unit. The lists were compiled, and an overarching list was posted on a wall in large letters for all to see. This list was the starting point from which we selected the six most important problems by group consensus.  The rest of the list items were saved in a “parking lot”,  meaning that once the first top priority problems were resolved, the rest of the list would be revisited in the next wave.

      Six committees were formed. Participation on a committee was mandatory. We were paid for our time. It was understood that some of the problems were resolvable, and the lifespan of some of the committees was self-limited. Committees dealing with issues like communication, staffing, and education, were longstanding in nature, and members made a time commitment to those.

     Things improved. For me, the most important thing gained from this model of conflict resolution was learning how to talk to my colleagues, our manager, doctors, and administrators in a manner that was honest, respectful, and productive. Is it perfect? Did we create a nursing Utopia? Please, we’re adults here, of course not. But I learned a lot about listening and respecting the perspectives of others, and a way to resolve differences.

     Just in case I change my mind about forks and dishwashers.

Drawing Lessons: Dishwashers and Forks in Perspective I

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Tines Downward (2009) photo: JParadisi

Tines Downward (2009) photo: JParadisi

     The other day at the nurses’ desk, my colleagues had a conversation about which direction to put forks into the dishwasher.

     I’d never given the topic any thought before. Hmmmm. Should I have a position on this?  Why has this question never occurred to me in the twenty years I’ve owned a dishwasher? Do other people think about forks and dishwashers, or  just nurses? Our one male nurse was not working that day, so I couldn’t ask him if this is a gender issue. 

     There were two opposing views. Some of the nurses feel that forks should be loaded into the dishwasher tines downward, because this prevents the tines from coming in contact with the fingers of the person unloading the dishwasher after they’d been washed.

     The second group feels forks should be placed tines upward in the dishwasher. That way the tines don’t get stuck down in the plastic basket holding them, making removal of the fork from the basket easier and more efficient. These nurses also feel that debris is better removed from the tines in this position.

     Hmmmm. I wonder if there are any studies on this? Are there best practice benchmarks for dishwasher use?

     Puzzling over this, it occurs to me that there is at least a third way to place forks into a dishwasher. They can be laid on their side in the tray in the top shelf of the dishwasher. They get clean that way, they don’t get tangled in the basket, and the handle is easily accessed to prevent touching the clean tines when removing the forks. 

   I am reminded that when I am presented with a problem, rarely are there only two answers to it.

Meditation on Luer Locks and Legos

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It All Fits Together (2009) photo: JParadisi

It All Fits Together (2009) photo: JParadisi

     If I’d known I was going to be a nurse, I would have played with Legos more as a child.

     I say this to myself while snapping together the various plastic pieces needed to start an IV: valve cap, connector tubing, luer lock syringe. This tiny medical sculpture will connect to the angiocath once it is successfully introduced into my patient’s vein. On the other end, I connect the infusion tubing dangling from the bag of solution for the patient’s treatment.

     The pieces fit together in such a way to make needles unnecessary. The needless system is a safety measure  preventing staff from poking ourselves with contaminated needles.  On second thought, the system is more like those Habit Trail environments for hamsters, only it’s molecules of blood, medications, and normal saline running through the tubing, instead of a small, furry rodent.

     It’s easy to feel like a hamster running through its Habit Trail on days when the tasks that need to be accomplished are unending.  I remember this while I carefully connect the pieces I need to start an IV one by one, mindful of keeping the ends sterile. I imagine myself stringing beads. I think of a rosary or prayer beads as I make each connection. I focus my thoughts on the task at hand: placing an angiocath into the vein of my patient. I remember to breathe. I am ready to begin.

Nursing Process & Process Art

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This butterfly photo has nothing to do with this post. I just like it. photo: J.Paradisi

This butterfly photo has nothing to do with this post. I just like it. photo: J.Paradisi

      I have an adulterous relationship with the word “process” and I am unashamed.

       The word process has several meanings, but I only cheat with two of its definitions.

     The first definition (according to Encarta) is a “series of actions: a series of actions directed towards a specific goal. ” This is the definition I am faithful to when nursing is my focus. I use nursing process and evidence based care in the clinical setting. While there’s room for the occasional “reasonable man” approach, most of the time the answers I need for safe and effective patient care are found in nursing policies and procedures. This issue comes up from time to time when someone wants to try something new (usually after reading an obscure study in “the literature”), before the treatment has been evaluated by the policy and procedure committee and approved.

      I know, I know, some times it feels like there’s too many rules getting in the way of what feels like good patient care. But the longer I practice nursing, the more I value  evidence based practice as a structure to build sound clinical skills upon, much like an armature for a sculpture. It ensures patients get consistent and proven treatment.  Occasionally, I have heard of nurses “cutting corners” during busy or emergent situations that can lead to more harm than good, like giving a medication that one is unfamiliar with incorrectly, instead of reading the drug information or calling the pharmacist for advice. Performing a procedure without familiarity with the hospital policy, is another example.  I know, I know, our nurse work loads are heavier by the minute, and we are busy. Taking the extra time to look up a procedure or a drug indication slows us down, but offers our patients an extra measure of safety. Becoming an Oncology Certified Nurse (OCN) this year was driven by my belief in evidence based practice, patient safety, and applying both to my clinical practice.

     When my focus is art, I give another shout out to Encarta for the second definition of process, “series of natural occurrences: a series of natural occurrences that produce change or development.” I am a process painter. Unlike a nurse working to achieve a specific patient outcome, process painters may or may not have an idea of a finished image in their heads. It’s pretty vague. A surface and medium are chosen, and the artist begins to make marks, scraping and adding until an image emerges. There’s freedom in art to let an image declare itself, without putting a lot of rules or limitations on it. It’s a lovely foil to my need as a nurse to follow procedure.

     In either vocation, nursing or artist, creative use of resources is a valuable skill, but I’ll reserve my artful risk-taking for the studio.