Where Science, Humanity and Art Converge

JParadisiRN blog began by discussing art and nursing. For the most part it remains so, through observations of the way science, humanity, and art converge, transferring these observations into blog posts.

Nursing is a tactile profession, at least when practiced at the bedside. It’s difficult to do the work of a nurse without actually touching people. Nurses learn that some skin or veins are so tough they almost repel an IV catheter, while other types are so fragile, even the paper tape used to secure a dressing or IV can easily tear it.

Nurses bathe the newborn’s firm, plump flesh, or rub lotion into the loose, wrinkled flesh of the elderly to prevent its breakdown. We measure and weigh the under and overweight, then calculate body surface area to administer the correct dose of chemotherapy.

This summer, I enrolled in an open life drawing studio. A model sits for a few hours, while artists, in meditative silence, draw the human body on paper.

Drawing is also a tactile experience: holding charcoal against toothed paper, making shapes and lines into limbs and torso, adding shadow to give them volume.

Patients and models allow nurses and artists into the sacred space of their nakedness. This privilege demands respect. Administering nursing care to a patient, or capturing the model’s likeness on paper requires concentration, skill, and love of humanity.

 

Surviving The Realities of Nursing

Adriamycin by jparadisi

Adriamycin by jparadisi

One of the things I love about blogging is conversation through comments on posts with people I may not otherwise meet. I learn as much from the comments as I do writing the posts.

I received a comment from a nursing student, quoted in part:

I am finishing up my RN degree and so want to go into oncology, but I fear that it will turn into nothing more than a loosing battle. A battle that I lose almost every day. Do you ever feel this way and do you ever wonder if the chemo is worth the pain your patients suffer through sometimes?

I think this sensitivity makes her an excellent candidate for oncology nursing. I wanted to answer her honestly. After taking a few days to consider, I responded:

You must have done some clinical rotations in oncology if you have interest in it. I’m wondering what experiences led you to believe it will turn into a losing battle? As a cancer survivor, and a nurse, I would answer, “Yes, the chemo was worth it.”
I suspect the question you might really be asking is,
“When should curative treatment be withheld or stopped?” and that is the big question in any nursing or medical specialty. I’m sure you are aware that some chemo, surgery, and radiation are done to control cancer symptoms when cure is not possible, and that is different.
Doctors and nurses do not have crystal balls. The best we can do is listen to our patients, offer advice when asked, and respect the decisions they make. Nurses are patient advocates. We cannot control outcomes, only do our best for each. Every nurse must find a way to reconcile this.

Perhaps I could have/should have added at the end, “in order to survive our profession.”

I thought about this nursing student’s question while sitting on the rolly stool gently pushing chemotherapy into the side arm of IV tubing connected to a patient. She asked how long it would be before her hair fell out.

There and then, I wanted to apologize for being the nurse dealing this blow to her self-image, but I did not. Instead, I reminded myself that the chemo might very well save her life. The blow I administered was to her tumor. Her hair will grow back.

This is how I have to look at oncology nursing for my patient’s survivorship — and my own.

Do you feel nurses face a losing battle? How have you reconciled the harsh realities of treatment with your desire to help others? How would you advise this student?

TMI? How Transparent Should Nurses Be With Patients?

by jparadisi

cartoon by jparadisi

While on vacation, my husband and I waited patiently in a restaurant for our food.  In contrast with our leisurely pace, the wait staff swarmed almost cartoony in the effort to serve the endless crowd of customers. Clearly, they were short staffed, but not a single server complained.

Since we work in healthcare, my husband and I were sympathetic. Our server earned every bit of his tip.

Likewise, most nurses feel badly when patients wait too long for their care. Delays occur for many reasons: orders that haven’t arrived, lab results that aren’t back, unexpected admissions, critical changes in a patient, short staffing, unavailability of a medication, clerical errors, the list goes on. Because nurses are at the bedside we take on the brunt of the problem, whether or not the patient complains.

Hospitals competing for healthcare dollars compound a nurse’s frustration by intertwining messages of customer service with expectations for patient safety. In the worst cases, under duress, nurses and patients also confuse the two.

Most patients admitted for treatments are already aware of the potential risks: medication errors, hospital-acquired infections, or enduring the wrong procedure.They come to us for treatment because their options are otherwise limited. So, where is the line between giving patients honest answers about their treatment delays, and disclosing that you are short-staffed on the day of this patient’s very first chemotherapy infusion? Do you tell a patient that their treatment is delayed because there’s a mistake on the orders? If so, how do you do so without intensifying their anxiety?

Putting this conundrum into another context, I’m imagining how I’d feel if a flight attendant announced that our flight is delayed because “The captain heard a funny noise during the landing gear check,” instead of simply saying, “Please remain patient. We’ll take off shortly.” Would you want to know, and perhaps exit the plane? Or would you rather not know, trusting the plane wouldn’t take-off if there is an unresolved problem? How much transparency is too much?

Do you feel patients need to know everything happening behind the scenes about their care? If so, how do you engage in this disclosure? Does consideration for colleagues come into play? For example, has a colleague ever blamed you for a delay or mistake in front of a patient?

Nurses Can Offer Reassurance When Cancer Changes Relationship Roles

Many relationships thrive after cancer, but how?

painting by jparadisi

Self Portrait by jparadisi

I think they transcend.

In a way, a patient is lost to loved ones during cancer treatment. Roles within the relationship change. The big, powerful husband adored by his wife of many years is now too weak to get in or out of their car without assistance, let alone do his longtime chores around the house. The wife and mother who makes Martha Stewart look like an amateur has not only stopped preparing gourmet meals, but can’t tolerate the smell of cooking food either, forcing Dad to pick up deli stuff, or order pizza to feed their hungry children.

Everyone has to adjust when a family member has cancer. The roles have changed.

  • There’s a new chapter in the family medical history. The cancer patient is the unwilling author of a family cancer history. Genetic counseling is an option, but family members may not want to know the results. It depends on their comfort level with the sword of Damocles dangling above them.
  • Partners become caregivers. Suddenly, there are extra duties around the house. Some learn to help with ostomy appliances or continuous infusion pumps. It’s common to teach spouses to flush PICCs. I often assess my patient’s status by the level of distress expressed by the spouse.
  • There is an uninvited guest who never leaves: fear of recurrence. David and I married after my cancer treatment. It’s a cute story; maybe I’ll post it one day. A few years ago, my surveillance labs came back with abnormal liver function results. My doctor ordered an ultrasound. Watching the monitor while the tech swabbed my belly with a wand, I said to David, “Look, Honey, I’m not pregnant!” I laughed, the tech laughed, but I will never forget the look of pain in my husband’s eyes as he uncharacteristically admonished me, “This isn’t funny.” I felt guilty for his fear, for letting someone fall in love with me when the cancer could come back. It turned out, an antibiotic I had taken a few weeks before caused the elevated LFT results. There was no cancer, but our uninvited guest remains.

Nurses cannot make these things disappear for our patients. We can, however, be sensitive to their needs, and reassure that they’re on a well-traveled path. Remind them that the most important thing they can do to help themselves is to talk about the pressures they feel as the cancer patient, or as the partner with increased responsibilities. We can also encourage them to develop strategies against their common enemy as a couple. Finally, we can be prepared to provide information about community resources available to support them.

And hope for the best.

How do you help patients and their families adapt to changing roles during cancer treatment?

I Wish I’d Said It

“To relieve a full bladder is one of the great human joys.” Henry Miller

Nurses, agreed?

Alopecia And The Pirate

As I write this post, some scientists are searching for ways to prevent male baldness through genetic manipulation. Others are conducting similar research to cure cancer. Is hair really as significant a part of our identity as we are sold to believe?

My hair began falling out the 14th day after the first chemotherapy infusion. In preparation, I bought a wig, styled and colored the same as my real hair. Like a feral animal, it perched on its stand, awaiting an opportunity.

When I saw the first ungodly huge handful of fallen hair I was too stunned to cry. Instead, I mumbled, “F***,” repeatedly, like a demented chicken.

It didn’t fall out all at once. Each morning for a week, I’d step out of the shower holding gobs of hair in my hands to prevent clogging the drain. After blow-drying what was left on my head, I’d take a pair of manicure scissors, like a naughty three-year-old, and try to even it out and disguise the bald patches. When I no longer could, a coworker’s husband shaved my head while she collected the locks, tying them into small bundles with blue satin ribbons. Image

After a time, I stopped wearing the wig. I preferred to cover my baldness with a red bandana, pirate style.

It was summertime, and I was at downtown Portland’s Pioneer Square, when a young man wearing a pirate’s black hat, white blouse with buckskin laces, black britches, and boots approached me. He clutched an authentic-looking sword. This was years before Johnny Depp made pirates sexy. Despite fatigue and chemo brain, I understood: “Oh, no, this guy sees my bandana. Pirate guy thinks he’s found pirate girl.” There was no place to run.

He spoke to me. “Ahoy! Me beauty, how art thee this fine afternoon?”

“I art fine, thanks,” I replied. “Why are you dressed like a pirate? Is that sword real?”

“Aye.”

He belonged to a club, of sorts, of people who dress like pirates and act out sword fights. I puzzled over what he wanted until he reached into his blouse and pulled up a goddess pendant dangling from a leather thong around his neck. He brought the goddess to his lips, kissed it, and then pointed to the carved turquoise goddess I had worn on a silver chain since my diagnosis.

“My fair Muse hails from Hungary, where she symbolized the female spirit of war and led her people to victory. I see you wear the Goddess yourself.” Doffing his hat, he bowed before swaggering back into the crowd.

He had approached because of the necklace, not the bandana. He hadn’t noticed that I was bald — or had he? Did I just have an encounter with an eccentric or a very kind man dressed as a pirate offering encouragement?

He left me smiling. There is more to each of us than what we look like.

This post was originally published by TheONC.

The Damaging Effect of Preciosity

Preciosity is over-refinement in art, music, or language, especially in the choice of words.

Nurse as Sisyphus by jparadisi 2012

Nurse as Sisyphus by jparadisi

I am struggling with preciosity while writing this post. A clever idea isn’t coming, and I feel distress, because I need to wrap it up. If I cannot write something profound, then at least I should be entertaining.

Preciosity is an art term with a negative connotation. An artist should never hold something she makes so precious that she cannot bring herself to change or even destroy it, because the bit of paint or brush stroke that’s considered precious enslaves the painting.

Writers are familiar with preciosity too. Sometimes the best-loved words are the very ones that need editing to clarify the thought. Any precious bit a writer or artist insists on retaining becomes an obstacle to the larger creative process, very often ruining the result.

Being a nurse also requires a resistance to preciosity. The best care plans are never perfect. A beautifully constructed work schedule becomes overwhelming, because of a staff sick call or unexpected admissions. We administer a medication, and the infusion is delayed or halted, because the patient has an allergic reaction to it. We are disheartened by the recurrence of disease in a favorite patient. On very bad days, we make an error.

There is no preciosity allowed in either art or nursing. Everything is up for grabs and can change in a heartbeat. Nurses striving the hardest for preciosity are the most doomed to disappointment in colleagues, patient outcomes, and themselves.

A good day of patient care cannot be summoned on command from a nurse any more than a masterpiece can be summoned from an artist or the next great American novel (or a blog post) can be summoned from a writer. Some days, both in nursing and in art, the best you can do is show up and try your best.

At the end of a shift, you may have made someone feel better, but perhaps all you did was prevent that person from getting worse. Likewise, after painting all day, you may end up taking a palette knife to the canvas and scraping all that newly applied paint to the floor, so that you can start again tomorrow.

Seated in my favorite chair while writing this post on a laptop, I struggle to keep myself from deleting it. Some days, both as  nurse and a blogger, this is the best I can do.

You Can Find Me Here: AJN’s Blog Off The Charts

Nurses Day 2013 has come and gone. I had a particularly good one, which I wrote a blog post The Best Nurses Day Gift: Enough Time for Patients for Off The Charts, the blog of the American Journal of Nursing.

Illustrating this post is my painting, What’s Left Behind.

Can Nurses Change Course? Thoughts on Inertia

When I hear the word inertia, the meaning I think of is actually paralysis:

The loss of the ability to move (and sometimes to feel anything) in part or most of the body, typically as a result of

Take One Daily by jparadisi

Take One Daily by jparadisi

 

illness, poison, or injury; inability to act or function in a person, organization, or place.

The actual definition of inertia is:

A property of matter by which it continues in its existing state of rest or uniform motion in a straight line, unless that state is changed by an external force. Inertia is the inability to change course.

Nurses experience inertia when we are unable to switch gears from the high emotional output of our jobs to the more “normal” activities of our personal lives.

I wrote about my difficulty changing course in “The Hostess With The Mostest.” In that post, I describe struggling to transform from on-duty nurse into a party guest at the end of a shift. The difficulty is not only in physically changing from work clothes to party wear. It’s also in retooling my brain for party talk. I have to remember how to talk about favorite restaurants, or the latest film I have not yet seen, instead of cancer nursing, blogging about nursing, or the other related things I spend large amounts of my time doing, casting a shadow over a perfectly good cocktail party.

I think about this while observing people who are not nurses enjoying themselves by taking funny pictures with their cellphones while I avoid being caught in any photographs I wouldn’t want an employer to find on Facebook. Do I worry too much, or is it this a characteristic that makes me a nurse?

It’s healthy for nurses, like myself, to avoid inertia and change course through external activities after leaving our places of work. I find it easier said than done, however, not because I can’t relax, but because “normal” life sometimes fails to hold my attention.

I suspect other nurses find normal life less interesting than their nursing roles, too. If we aren’t over-scheduling ourselves with committee meetings, working overtime, all the while being the World’s Best Soccer Mom, we don’t feel busy enough.

This point was brought home to me by a friend who commented that I seemed tired after I said I was going for a run after getting off a 12-hour shift early. I told her, “No, I’m not tired. I only worked eight hours today.” She replied, “For most people, eight hours is a full day’s work. Go home and get some rest.”

I didn’t. I went for the run. I do my best thinking while running, not meditating on a yoga mat. It’s hard to walk when you’re born to run.

Do you think preferring a busy and sometimes-hectic lifestyle is a characteristic of nurses?

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?