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.

A Nurse’s Guide to The Art Of Rescue


Horrified, I watched helplessly on the esplanade as a fuzzy, yellow gosling struggled to right itself from his back in the high water of Oregon’s Willamette River. Four feet away, his mother placidly treaded water, making no attempt to help.

The Willamette River runs swift and cold, with a notorious undertow. Impulsively, I considered jumping in to save the gosling, but the imaginary headline on the evening news played inside my head:

Crazy Nurse Drowns in Failed Attempt to Rescue Gosling. Pictures at Eleven.

Luckily, the gosling righted itself and swam away with its mom and siblings.

I feel a similar sense of helplessness caring for the occasional patient (and sometimes a family), drowning in profound grief expressed as anger.

They present at each appointment with unending lists of complaints. They antagonize their families, find fault with every caregiver, and disparage the home cooked meals generously provided by neighbors. They complain until you contact the oncologist on their behalf, only to find this patient refuses the prescription you are requesting every time his doctor offers it.

Your co-workers snigger when you tell them; they’ve made the same phone call for this patient. You believe your patient is stuck in the grief process at anger, expressing it by making everyone around him crazy. These patients are not violent, nor verbally abusive to nurses. The problem is the amount of energy they require, without solution or resolution. Eventually this may cause nurses to emotionally shun them, like the goose watching her gosling drown.

How can you help these patients without drowning along with them?

  • Enlist the help of nurse navigators, social services, and spiritual care. Some patients will refuse or sabotage this help, but ensure that it’s offered. These experts have experience dealing with these situations. Enlist their help.
  • Resist triangulating yourself between the patient and family, or patient and oncologist. Encourage the patient to interact with caregivers directly by scheduling her own appointments, rides, and prescription refills.
  • Using input from the nurse navigators, social services and spiritual care, create a care plan for this patient. Through consensus, gain buy-in from staff caring for him or her. Some patients benefit from consistent staff assignment — however, beware of establishing “favorite nurses.”
  • A characteristic of dysfunctional grief/anger is playing people (especially nurses) against each other. Ensure the care plan is ethically sustainable for the nursing unit. Other patients know when another receives “special” treatment. Keep things fair.

I think about the goose watching her gosling struggle helplessly, accepting that he may drown. It’s difficult to reconcile this image with the role of a nurse. Not every patient will die a good death, but with a little help, some, like the gosling, may right themselves.

What suggestions do you have for nurses with patients stuck in the grief process?


Learn to Say No

Developing creativity requires personal time. You’ve heard it before: Learn to say no.

I was a new-ish nurse working night shifts on a busy hospital unit. Our census exploded,

The Bride by jparadisiWhat are you married to?

The Bride by jparadisi
What are you married to?

and every evening the nurse manager called all off-duty staff begging until someone accepted the overtime shift. It is difficult to refuse extra shifts when it’s your manager asking. This went on for what seemed an inordinate amount of time. Answering machines were new back then, and I resisted owning one.

One afternoon, my daughter raced to the ringing phone, picking up the call before I could. I overheard my manager asking, “Hello, is your mommy there?” As I reached for the receiver, my daughter blurted out, “You’re not going to make my mommy go to work again, are you?” Embarrassed, I grabbed the phone. On the other end, the manager apologized: “I’m sorry, I guess I’ve been calling too often. Enjoy the evening with your daughter.”

The next day, I bought an answering machine, and learned to screen calls.

Not long afterwards, something unexpected happened: The manager took her overtime-paid hours to administration, along with the record of increased census. They discovered they’d save money by hiring another FTE. The overtime calls became occasional.

Moral of the story: it’s not my personal responsibility to fix my unit’s staffing problem. I’m not advocating nurses refuse shifts during staffing crunches. In nursing, being a team player is essential. However, I found that if I work more than two overtime shifts a pay period, I get a diminishing return on the extra income because of taxes where I live. Therefore, my flexible boundary is to limit overtime to two shifts a pay period. I learned to say, “No,” to more than that.

Recognizing which problems are yours to solve, and which are the responsibility of others is the key to learning to say “no,” to coworkers, patients, children, spouses, boyfriends, girlfriends, parents, soccer moms, whomever.

Write this down and tape it to your bathroom mirror:

I am responsible for my own stuff, and that is enough.”

The caveat to this affirmation is:

If you step in it, you’re going to have to clean your shoes.”


▪ Avoid drama.

▪ Evaluate commitments carefully.

▪ Protect your personal time.

Our ability to say no is strongly connected to the important relationships in our lives. Nurses in particular are conditioned to believe that saying “No” in order to make time for ourselves is selfish. Add the nurturing nature of a nurse to this training, and saying “No” becomes nearly impossible.

You cannot grow creatively without time to yourself. Recognizing what stuff is yours, and what belongs to others is the first step towards self-care and personal growth.

Do you think nurses have more difficulty saying “No” than other professionals? Do you think this problem is gender related? What experiences have helped you learn to say no?

What I Learned in Nursing School about Customer Service

Detail of painting (2009) artist: JParadisi

Many of my patients are recently discharged from the hospital. Most of them tell me about the wonderful care they’ve received there, and even mention their favorite nurses by name. I know a patient who memorized the names of all twenty nurses caring for him during a lengthy hospitalization, because he is so impressed by the care he received.

Patients sometimes ask  if it’s difficult taking care of sick people. I always laugh when I’m asked this question, because it reminds me of the summer job I had before my last semester of nursing school. My classmates took summer jobs as certified nurse assistants, honing their new nursing skills. I needed a new to me, used car that summer, and working as a cocktail waitress in a resort town dining establishment paid better than working as a CNA.

While most dinner/cocktail customers I served enjoyed their evenings out, occasionally I’d get a cranky one or two. Besides the perennial customer complaining his “medium” steak was not medium, is there a more subjective term in cooking than medium?, my favorite story is of the drunken male customer who began making lewd gestures and statements while I brought drinks to his table. I refused to serve this customer anymore alcohol, and he complained to the restaurant’s owner, who tried ordering me to serve him. I told him I wouldn’t do it; if he wanted to fire me on the spot, right before Labor Day, fine; I’d already earned the money I needed to buy the car and I was going to be a nurse soon anyway. Realizing he had no influence over me, the boss took a tray of drinks to the offending drinker and his buddies.

Minutes later, the drunken customer jumped up on the  stage where live music was playing, and stripped off all his clothes, butt naked. Horrified, my ex-boss tried to man-handle the guy off the stage. He was prevented from doing so by the customer’s drunken buddies, who jumped up from their table and threw my ex-boss out the door of his own restaurant, and then dead-bolting it behind him. The bartender yelled to me, “Juli, get behind the bar,” and called the police. This time I did as I was told.

I’ve had one or two comparably difficult patients, since becoming a Registered Nurse. But, for the most part I’m gratified by the graciousness, and kindness of the people who come in for care, trusting that my colleagues and I will take good care of them.