You’re Going to be Alright

Years ago, following an art reception, my husband and I were enjoying dinner at a restaurant. As the server set our food on the table, we watched through a window as a car hit a bicyclist who had run a red light.

Go Team Oncology by jparadisi

Go Team Oncology by jparadisi

Immediately, we left our table and went to the woman’s aid. She wasn’t wearing a helmet, and her face was bleeding. She was unconscious, but breathing. Besides a possible neck injury, my concern was that she would stop breathing before the paramedics arrived. Despite my fears, I told her over and over, “You’re going to be alright. Help is on the way.” I don’t know if this mantra helped the woman, but it calmed me.

Nurses tell patients, “You’re going to be alright” all the time, whether or not the situation is as dire as the scenario above.

We tell them they will be alright while we are learning a new EHR documentation system at the same time we are administering their treatment. We tell them they will be alright while we struggle to enter lab orders correctly in the new EHR. Fortunately, EHR experts are readily available to answer questions and help us through this transition. They show us the step we missed, which is the reason the order did not go through.

I slap myself on the forehead, and the EHR specialist kindly reassures me, “You’re going to be alright.”

I think this is one of the most special qualities of nurses: Despite our fears and misgivings about a patient’s condition, or our ability to handle a situation, we tell our patients, “You’re going to be alright.” For the most part they believe us, probably because what other choice do they have? What choice do we have? It is what it is. We must move forward, together.

In Human Resource department lingo, focusing either a patient’s or coworker’s attention on the positive is called “managing up.” For instance, instead of telling a patient you are precepting a nurse who’s giving chemotherapy for the first time, you might introduce yourself by telling them they won the jackpot today — two nurses caring for them instead of one! — and that you are helping Nurse B, who is new to the unit. By doing so, you tell both the patient and Nurse B, “You’re going to be alright.”

In what ways do you manage up at work? What techniques have you adopted to promote a patient’s or coworker’s sense of security during a change of condition or a work-related transition?

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?

Advice for Transition From Nursing Student to Professional

Paper Dolls (First Communion diptych) by jparadisi

Last week RealityRN.com 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, https://jparadisirn.com/. 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?

How I Became a Nurse Part III: It’s An Ongoing Process

The Christening Gown (From Cradle to Grave: The Color White) by jparadisi

One shift, Roz and I worked alone. That night, there were only two patients in the pediatric intensive care unit. Roz was charge nurse. I sat at the console charting, with the hypnotic QRS tracings of sinus rhythm in the background. Roz charted at another desk by the door. The door opened and a man I’d never seen before entered. He walked past Roz, to me. He identified himself as the pediatrician for Roz’s patient, and asked who was the charge nurse.

“Roz is in charge. She’s taking care of your patient.”

He continued addressing his questions to me. “How’s my patient? What’s his blood pressure?” “I don’t know,” I reinforced, “Roz is your patient’s nurse, and she has his chart. She can answer your questions.” I looked quizzically to Roz, who briefly looked up, then put her head down, intent on charting. The doctor continued. “I want to know the I and O. Is the patient getting enough pain medication? Are his parents around?” I didn’t get it. I remained confused until Roz walked over and handed me the chart. Suddenly, I understood. My anger flared then turned into a cold lump in my stomach. I had to control my voice as I answered his questions from the chart.

Roz nursed circles around me. I owed it to her that I was in the PICU and this physician wouldn’t talk to her because of the color of her skin. I only spoke to him because of his patient, a child. He scribbled some orders, gave me the chart, and left. I felt traumatized by his overt racism, and because he directed it towards Roz, my friend. The cold lump in my belly morphed into nausea.

“Roz, I’m so sorry. He’s an ass.” Her eyes betrayed her feelings, but her words were calm.  “Jules, I don’t blame white people for this. That fool is an ornery, nasty soul no matter what color his skin is.”

Decades later, Dr. Racist remains a painful memory. Dr. Racist was never seen again in the PICU. He was a blip on our screen, nothing more. His disappearance prevented Roz and I from doing more than complain to management.

Becoming a nurse is an ongoing process. Certainly, a nurse’s expertise grows through attainment of knowledge and skills, but it is more than that. Becoming a nurse also includes learning when to speak up and when to let something roll off your shoulders. Like everything else she taught me, Roz was better skilled at this than I. I am not a qualified authority on racism in nursing, but the National Black Nurses Association, and minoritynurse.com are two educational resources by people who are.

My treatment by Sister Sebastian was workplace bullying. What happened to Roz is workplace bullying taken to its sinister extreme. It is so universal that the successful TV comedy series The Office uses it for its premise. However, when nurses experience workplace bullying, we are usually in the midst of work requiring responsibility for the safety of others. It’s hard to stand up to rude or disruptive comments when your patient’s condition is rapidly deteriorating or you are in a patient care area. Bullies know this, and use it to their advantage. I think this is what makes workplace bullying particularly demoralizing for nurses:  often, we must choose between defending ourselves and protecting our patients.

I have one strategy, developed over the years, which I find effective. When I overhear a coworker berated by another in either language or tone of voice, I go stand next to that person. Usually my quiet presence is enough to cause the offending person to stop. Occasionally it is not, and the offender asks, “What do you want? Why are you here?” I reply, “I’m just wondering if everything is okay over here. Do you realize everyone can hear you?” So far, this has always stopped the abuse. It’s particularly effective if more than one nurse stands by.

Becoming a nurse is an ongoing process. I am still learning.

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.

I Wish I’d Said It

“As a nurse, I am the patient’s last line of defense.”

-Lee S. Shulman, President Emeritus, The Carnegie Foundation for the Advancement of Teaching

From the foreword of Educating Nurses: A Call for Radical Transformation by Patricia Benner, Molly Surphen, Victoria Leonard, and Lisa Day

Learning to Observe, Observing to Learn

Street Art, unknown artist. photo: jparadisi

Here’s a collection of loose observations I made last week:

  • People who lie or cheat believe that everyone else in the world does too.
  • People who feel paralyzing guilt over a mistake they made believe they are the only one in the world who’s made one.
  • Nursing students and new grads still believe in patient centered care and patient advocacy (Thanks Nurse2be for writing about one of my posts. I feel relevant).
  • Precepting is an opportunity to develop a colleague I love to work with.
  • I am a preceptor even when I don’t have an orientee. What do I teach coworkers about nursing culture through my nursing practice and behavior?
  • A patient and I commiserated over frustrations with health care. I said, “I’d like to change it, but they won’t let me be queen.” He touched the ring on my left hand under the nitrile glove I wore, and said, “You have this ring; you’re somebody’s queen.”
  • Nursing is my profession, but it does not define my entire life. Good shifts, bad shifts, when I leave the clinic I return to the life I create.
  • It’s all about choices.

Let Me Tell You One More Thing You Already Know

Intubated (Baby with a Breathing Machine) mixed media on vellum by JParadisi

Maybe it happened because I was tired after working a string of long, busy shifts.

Maybe Mercury, the communication planet, went retrograde last week.

Last week I wasn’t as good of a communicator as I would like to be.

I am one of those nurses who learned something in the Therapeutic Communication module of nursing school. Before you judge me as the nerd I kinda am, I do not go around repeating, “What I hear you saying is…” Such phrases are not what someone wants regurgitated back at them. The phrase is a tool, not a mantra. Instead, I learned to carefully listen to the words a patient uses and watch for any mismatch of those words in their body language. Then I speak to the body language. As a visual artist I first think in images, then put the ideas represented by the images into words, like a songwriter fitting lyrics to a melody. For me, the pictures come first, then the words.

Here’s what happened:

A colleague introduced me to a nursing student whose next clinical rotation is pediatrics. She told her I was once a pediatric intensive care nurse, and the student asked if I had any pearls of wisdom to share. While I am not so vain to believe my words possess a cure for the deep wounds of a human soul, I am vain enough to believe I occasionally have something insightful to say. So I offered this advice:

  • Always consider the parent-child unit as your patient
  • Even if a parent doesn’t know pathophysiology, they know their child better than you do.
  • The smaller the patient, the more important it is that you get it right the first time.
  • If you are unsure of what you are doing, find a nurse who does know. Stick close to your preceptor.

I finished and saw the glazed look on the student’s face. Her shoulders already turned away from me. She didn’t really want my advice; she was only being polite. David tells me when he sees this look in the eyes of the pharmacy students he precepts, he adds, “Let me tell you one more thing you already know.” She was not my student, however, so I shrugged it off.

A few days later, I was starting an IV in a patient. I had started IV’s in this patient before, and this particular day, while I did so, she told me about a bad experience she had as a child when a nurse started her IV. As before, her body language was the picture of calm while she talked. I inserted the IV easily. As soon as the patient saw the blood flash, confirming the IV was in the vein, she passed out, just like that. I yelled for help, but by the time my coworkers arrived, she was already coming to. With the innocent expression of a child she looked up into my face, and said, “Oh, it’s you.”

I disappointed myself. Her words had not matched her body language, and I missed it. I didn’t know how much courage it took for her to come in for treatment. I gave her some juice, and a little time to herself. When it was clear that her inner child had safely returned to her soul’s play room, I told her I was sorry. She apologized for not telling me how she really felt. She didn’t want to be a difficult patient. We talked about her fear of needles, and came up with a plan. She decided to finish her IV treatment, and I learned one more thing I already knew.

Whistle Blowers & Patient Advocates: When the Nurse Stands Alone

oil on unstreched canvas (detail) 2009 JParadisi

A colleague and I discussed the Winkler County Whistle Blowers case and our admiration for Registered Nurses Vicki Galle and Anne Mitchell. They brought the nurse’s role of patient safety advocate into the national spotlight.

My colleague is also a force to reckon with when it comes to patient advocacy. During our conversation she grew quiet and told me once, she had advocated for a patient without the support of her peers or administration.

The event occurred early in her nursing career, before she gained the skill and knowledge, which now empower her ability to act confidently as an advocate. In the end, she followed orders, even though they conflicted with her ethics. Decades later, she still regrets her choice.

I listened to her story, and tried to imagine her as a young nurse, uncertain and faced with a situation nursing school had not prepared her for. I imagined her alone and isolated, the only one in a nursing unit who felt, or more likely, spoke out loud the feeling that what was happening might not be best for the patient.

The Winkler County Whistle Blower case demonstrates that this kind of moral isolation still happens to nurses. However, it also demonstrates that nurses have developed resources for themselves and learned how to access them. These days, many hospitals have ethics committees and safety committees for reporting unsafe systems and behavior. Many hospitals have policies protecting nurses who refuse to administer treatments that conflict with their moral beliefs. Winkler County Memorial hospital fired Anne Mitchell and Vicki Galle when they used the hospital’s safety chain of command to protect patients, but the hospital and the doctor bringing charges against them found out this kind of punitive behavior is no longer tolerated by the court system or a majority of health care professionals. The Texas Nurses Association and the American Nurses Association said, “We are watching,” as did the Texas Medical Board. I’ve heard the conversations of doctors who ask why Dr. Arafile’s colleagues didn’t report his behavior. Why was the responsibility left to nurses? If any of these resources were available for my nurse colleague when she faced her dilemma decades ago, I would be surprised.

My heart breaks for that young nurse, facing an ethical dilemma alone and unsupported, with nowhere to turn. I told my colleague I hope she has forgiven that young, inexperienced, and frightened version of herself, with  her older, more experienced self’s compassion. I suggested that what she learned from that episode long ago has forged her into the warrior nurse advocate she is today, benefiting hundreds of patients during her long career as their advocate.

Advanced Precepting, Part II

In my last post, I promised to tell the story of another preceptee who didn’t remain in the PICU after orientation.

A new grad, this preceptee showed lots of promise. She was smart, detail oriented, and learned quickly. She was also independent. So independent, that fresh out of school, she would assess her patient, decide what was needed, and call the intensivist for orders without discussing anything with her preceptor first. Sometimes, she was right. Sometimes, she focused on a symptom without looking at the larger picture of the patient’s overall status. And that would lead to another phone call  to the intensivist, in which the preceptor had to explain why the previous order needed revision. You can imagine how well that went over, when it became a pattern. Her tendency to act without notifying her preceptor also precluded the opportunity to group questions for the intensivist, and asking the other nurses on the shift if they needed to call with questions too. In our unit, we worked effectively with the intensivists by grouping questions together as often as possible, facilitating work flow between medicine and nursing. In return, the physicians agreed not to call with new orders or questions during change of shift report, unless it was necessary. Suddenly, nursing wasn’t holding up its end of the bargain.

Because I was a mentor in our unit, my colleagues came to me with their complaints about this preceptee. Her behavior was interpreted as contrary to a team approach, and it was. I had trouble getting nurses to precept her. She was aware of the growing hostility of the other nurses towards her, and in turn, became withdrawn, acting out with more Lone Ranger behavior and creating a vicious circle for herself.  She tried, really she did, but it was difficult for her. She was intelligent and competent enough, but her inability to work with a team hindered her success.

The difference between  problems and  dilemmas is:  problems have a resolution; dilemmas are ongoing and unresolvable. I was beginning to think I had a dilemma on my hands.

I took over her orientation. Each shift I outlined what our goals were, and reinforced the expectation I be notified before every phone call to the intensivist. If I was in the bathroom, momentarily unavailable, and she thought there was an emergency, she was to notify the charge nurse first.  It was difficult for her, but she tried. Conversely, I included her in every discussion I had with the intensivist, explained the rationale for changes in the care plan, and took lunch breaks with her. I reinforced I respected her as a colleague and friend. She needed to trust me too. It didn’t take long before I saw improvement.

Shortly after that, she came to me requesting a letter of recommendation. She was applying for an advanced practice nursing program. Completing the program would give her a position of autonomy I believe suited her. I wrote the letter. She was accepted into the program. I don’t know what became of her, but I respect her for following her heart.