That Special Relationship Between Nurses & Doctors: A New Episode of The Adventures of Nurse Niki

The Adventures of Nurse Niki
The Adventures of Nurse Niki

JParadisiRN readers may know that last year I began writing a monthly blog post for Off the Chartsthe blog of the American Journal of Nursing. The latest post, Voice of Dissension: When Nurse Teamwork and Patient Safety Diverge published yesterday. I think it’s worth a read, and even a comment, if I do say so myself. For readers unfamiliar with JParadisiRN, I also made the drawing that accompanies the piece.

Buy Yourself Another One, The Adventures of Nurse Niki Chapter 27, posted today. It’s about the eating habits of nightshift nurses and that special relationship between doctors and nurses.

The Adventures of Nurse Niki is a work of serial fiction. The blog is formatted so the most recent episodes appear at the top. New readers not wanting spoilers of The Adventures of Nurse Niki may begin at Chapter 1 and scroll up from there.  Chapters are archived by month (click on the lined square icon on the home page). New chapters post weekly on Thursdays.

Off the Charts has this to say about The Adventures of Nurse Niki:

This blog is made up entirely of first-person episodes told by a fictional nurse named Niki. Each episode is short, detailed, and engaging, and it’s easy to keep up with it on a regular basis, or quickly catch up if you haven’t yet read any episodes. Jacob Molyneux, AJN senior editor/blog editor

Kevin Ross, aka @InnovativeNurse wrote a review of The Adventures of Nurse Niki, with this highlight:

Julianna has embarked on something special for the nursing community. The Adventures Of Nurse Niki is one of the most intelligent perspectives of life as a nurse. These are the experiences of a “real nurse” if you ask me. Nurse Niki is a smart and dynamic character who works night shift in the PICU at a California hospital. A good television show or fiction novel could certainly draw out the sexiness of working in the ICU, but with Niki’s story we quickly discover that this dynamic character is also struggling to cope with life at the bedside, and as a mother and wife. Hidden within each chapter the discovery is that Nurse Niki is in fact you. She’s me. Well that is of course if I was a woman.

You can interact with Niki on The Adventures of Nurse Niki’s  Facebook page. Please don’t forget to “Like” it too. Show Niki some love! Thank YOU!! to the readers following The Adventures of Nurse Niki, the retweets of  @NurseNikiAdven (Hashtag #NurseNiki) and those who Like Nurse Niki’s Facebook Fan Page. The support is very much appreciated!

Welcome Back

Welcome Back photo: jparadisi

Reluctantly, I sit at my computer writing this post. Tomorrow I will spend eight hours at a training computer learning the electronic medical record system, Epic. The following day, I will spend another eight hours doing the same thing. I previously posted that our hospital converted from paper charts to EMR last week while I was on medical leave. I am making up the classes that my colleagues took last month. Although I’m not thrilled about spending so much time at a computer, I am looking forward to participating in patient care again.

I provided precious little help to my coworkers during the two shifts I worked last week, since besides having limits on lifting, I won’t have a computer sign on until I complete the two classes mentioned above. Instead, I spent much of my time following coworkers who kindly taught me as much as they could about Epic in a live patient care setting.

The hardest thing about those two shifts was my feeling of incompetence, because nothing in our unit operates the way it did before EMR. I can’t even open a patient’s chart, look up the name of their doctor, or find an order without a sign on. I’m used to being nursing muscle, not a helpless bystander. I felt uncomfortable, and I have to admit, mildly anxious.

The funny thing was, because Epic is still so new, my coworkers are struggling too. In that way, we remain on level ground, although at least they can access charts, and record the care they gave. However, I could see how learning to navigate the new system slows them down. One way that I helped was to listen thoughtfully as they described the frustrations of providing patient care while simultaneously learning a new system. I let them vent, and I learned from their experiences.

Week by week, things will improve. I hope so, because EMR isn’t going away.

Did I mention that despite all of the controlled chaos at work, I brought a cake to work for my coworkers on my first day back? And that one of them found time to bring in flowers for me?

Remember: be nice to one another.

Nurses’ Week: Sometimes The Best Recognition is None at All

The Broken Elevator photo: jparadisi 2011

Saturday morning, David and I woke to a noisy buzzing alarm coming from the elevator in the hallway of our building. It was stuck on our floor with its doors half open. Because it’s the weekend, I’m not hopeful of it getting fixed promptly. Next, as if we are under attack from a conspiracy of machines, our normally silent dryer started making a loud thumping noise, like tumbling canvas shoes, but all that’s in the drum is a small load of delicates. David is on his computer, looking for a repairperson as I write this post. The coincidental mechanical malfunctions remind me that as long as things meet my expectations, I often take them for granted.

At a social event, I was surprised to see an ex-patient and his wife also in attendance. I remembered them vividly, because of the longer than expected amount of time spent admitting him to our unit. The husband had the misfortune of being discharged from the hospital on a Saturday evening. Commonly, hospitals have a minimum of discharge planners on weekends, and the discharge planner’s job is frustrated by the fact that most of the outpatient services he or she needs to coordinate are closed. Also, he did not have a primary care provider, meaning no physician or nurse practitioner was in charge of his outpatient follow-up. To fix this problem, he was given a physician referral, and a phone number to call on Monday.

He arrived in our ambulatory clinic on a Sunday morning for daily treatment in pain, after a difficult night at home.  His wife and son accompanied him. The son was concerned about the eschar on his father’s wound, and I agreed with his assessment. Eschar is a dark, leather-like tissue formed on the surface of a wound. In the worst- case scenarios, it creates a tight band around an extremity, cutting off the blood flow to the body part below it. It increases the patient’s pain by preventing oxygen-rich blood from reaching the affected area. Fortunately, the body part below the eschar of this patient was warm to touch, with strong pulses, and a brisk capillary refill, so he wasn’t in imminent danger. He didn’t have a fever, and his vitals signs were normal, so pain control and obtaining a surgical consult became our priorities. We needed a doctor to write orders.

Luckily, the resident who treated my patient in the hospital was still there. I paged him, and told him what was happening. He agreed to see the patient in the clinic. This was generous of him, because once a patient is discharged from the hospital, technically, he is no longer responsible for his care. He wrote a script for breakthrough pain medication, and made a phone call for a surgical consult to address the eschar. In this way, the patient avoided a trip to the ER, the only other option on a Sunday. On Monday morning, a surgeon removed the eschar. I was pleased with myself for mobilizing the necessary resources on a weekend. The rest of the patient’s course flowed uneventfully until discharge.

The Dryer: Things That Go Thump photo: jparadisi 2011

At the social event, I approached the former patient and his wife to say hello. Looking at me blankly, they reciprocated, then awkward silence. Realizing I’d made a mistake, I said, “I didn’t mean to bother you. We’ve met before. I just wanted to say hello.” “Really?” said the wife. “Where would that have been?” Uh, oh. I mumbled the name of the hospital, but not the unit. Even the name did not prompt a recollection. They continued to stare blankly.  I desired to end the interaction, unsure if I was circling the drain of a possible HIPPA violation. Complementing the wife on her earrings, I retreated to another part of the room.

Later, it occurred to me that their discharge ordeal wasn’t an ordeal to them, because by means of coöperation and teamwork, I fixed it. They expected a smooth discharge with seamless follow-up care, and they got it. They took it for granted, because they didn’t experience the frustration of falling through the cracks. They didn’t recognize me, because I hadn’t stood out. They did not experience poor care versus quality care. In their mind, I did my job, and that did not merit recognition. They are right.

I appreciate the effort hospital administrators make each year during Nurses Week to thank nurses. Recognition for a job well done is one way of saying, “Thank you.” However, a lack of recognition, because the person served is unaware of the effort made on their behalf, is a form of reward too. The best recognition of a job well done comes from within.

Learning Curves, Leadership and Empathy

Mac Attack photo: jparadisi 2010

I finally did it.  Readers who are artists and graphic designers prepare for a collective groan at my old, ass backwards ways: JParadisi RN has converted from PC to Mac. The feeling is similar to the moment you find true love after looking for it in all the wrong places. The same as finally enrolling in art school, and marrying the right guy. I wonder what took me so long? This is my first post using the new computer.

Delaying the conversion had a lot to do with the unavoidable learning curve that comes along with new software and programs, I mean apps. It’s difficult to find answers when you have to learn new terminology to ask questions. Imagine what a patient or family member in crisis feels, trying to talk to nurses and doctors about unfamiliar treatments or end of life issues when they don’t know what questions to ask or the terminology, often with little or no time to prepare. This is the obvious metaphor and an easy post to write. This is not the post I am writing.

This is the post I am writing: I am gaining empathy for my coworkers. A series of unanticipated events has hit our department infrastructure with the force of a tsunami, resulting in several colleagues stepping into leadership roles with little preparation.  Meanwhile, changes continue coming at us like a set of ocean waves pounding the shore.  When these nurse leaders come in for their shifts they find new expectations added on to their day, and I admire their commitment. You can argue that they volunteered for the extra responsibility, and that is true, but someone has to oversee the daily continuity or the unit is crippled. Unit leaders have to make immediate decisions in the midst of the controlled chaos that is patient care. There’s a learning curve for them too, especially for those developing new skills in a constantly changing environment.

Empathy for residents and new nurses is necessary too. There is always a learning curve when you begin something new. First do no harm is a guiding personal ethic for all interactions, not only those involving patients. Not all forms of inflicted pain leave a visible mark.

Just now, after twenty minutes of work, I lost a paragraph while trying to cut and paste it into a future post—Frick! Learning how to use Mac and keep up with JParadisi RN’s Blog“s production schedule is simultaneously frustrating and exciting. I am lucky to learn in privacy, away from the critical eyes of coworkers or patients. My colleagues stepping up to the plate in a time of transition do not have the same luxury.

Not All Days are Magically Delicious

Wound Vac ink & pastel on paper 2010 by JParadisi

        When I was a pediatric critical care nurse working in busy trauma centers, my duties included wound care. I have salved and wrapped burns, and limbs ravaged by meningococcemia. I’ve dressed the fingers of a child whose surgeon successfully used leeches to regain their circulation.  As an adult oncology nurse, I occasionally float to the wound care area and change dressings. 

       A few weeks ago, I changed a wound vac dressing. A wound vac is a small mechanical device in a fanny bag, worn by the patient 24/7.  Black sponge is packed into the wound and covered with an adhesive, transparent film. A suction tube connects the dressing to a canister attached to the wound vac. When the wound vac is turned on, it sucks all the air out, compressing the sponge tightly into the wound. There is barely any sound as the machine “vacuums” the wound’s drainage into the canister. The suction stimulates healthy tissue, often reducing healing time dramatically. If an air leak is present, there is a loud sucking noise when the machine powers on, and the sponge will not compress. This means it needs more transparent covering to seal it. If that fails, the entire dressing comes off and redone, which is not very comfortable for the patient. 

     The patient I was seeing dreaded the dressing changes. I sat on a rolly stool, listening to him express his feelings about the progress he was making. I used my best communication skills. We connected, and he trusted me with the dressing change. 

     His wound was shaped like one of the marshmallows in a box of Lucky Charms cereal. Its complex shape made cutting the bulky, black sponge to fit difficult. Nope, there wasn’t a template from the previous dressing changes, but that would have been nice. The wound’s location made keeping the sponge in place challenging. Using tricks, I managed to get everything in place. The patient tolerated the procedure well. I turned on the wound vac. 

     The machine made a loud sucking noise and the sponge did not compress. I looked at my patient and the disappointment in his eyes matched my own. I was unable to make an airtight seal by reinforcing suspicious areas with more transparent film. My patient said, “You’re not going to redo the dressing, are you?” It sounded more like a statement than a question. I knew he had reached his limit of tolerance, and I felt terrible.  “Let me try one more thing first,” I said. I stepped into the hallway and looked for help. Fortuitously, one of my WCON friends was out there, holding her lunch sack.  Also a nurse, she has advanced certification in wound and ostomy care.  “I need help, I can’t get a seal on a wound vac,” I pleaded. She put away her lunch and in five minutes she found the leak, fixed it, and the wound vac powered on in silence. The black sponge fully compressed. My patient went home. 

     I was not the hero I wanted to be that day. Someone else stepped in for me. That’s why I like being part of a team, because not all days are magically delicious.

Consensus and Majority Rule are Siblings not Twins

     Just because you are not in charge, it doesn’t mean you are not a leader.

Anonymous

         I’ve thought a lot about working in groups and leadership lately. I think it’s important for nurses to respect the skills necessary to do either. In a perfect world, all nurses, or at least all the ones I work with would.  In my dream team-nursing unit, every nurse communicates his or her needs and patient care concerns clearly and concisely. Every nurse stays focused on the present situation, without bringing past history or personal issues to work. My first-rank draft pick teammates respect each other and never say anything hurtful about a coworker. In my dream team unit, passive aggressive behavior doesn’t exist, because nurses speak openly about their feelings and concerns. My dream team colleagues and I would never have a lapse in judgment or make a mistake.

     Anyone out there know where I can find a job like that? Anybody? Bueller?

     I was speaking with someone about leadership in the workplace. She says she goes along with the majority’s decisions, even if it’s not what she believes in, because that’s consensus.  That feels wrong to me. While I admire this person’s willingness to put her own beliefs aside to move her department’s work forward, I have concerns. First, what if the majority is wrong? Second, why would a group lack concern for the feelings of one of its members, if the goal were to develop a team working effectively together? Lastly, what are the effects on a team member’s performance and psyche that regularly has their needs and concerns ignored? At what point will habitual sacrifice transform a willing team player into a nurse whining, “No one ever listens to me”?    

     News Flash: No one will ever listen to you if you don’t speak up. You have to speak your mind. I know it isn’t easy for everyone, but like learning to start IV’s, it gets easier with each attempt. It’s tempting to go to your “nice” coworkers for help with uncomfortable staff dynamics instead, but eventually you will wear out these people too.

      As for leaders, if you say things like, “The problem with you…” or “This is your problem, not mine…”, you are promoting passive-aggressive behavior. Eventually, this coworker who appears weak, will consciously or unconsciously create a situation that may sabotage positive clinical outcomes. No one wants that.

    Majority rule says, “This is how we’re going to do it, and you will do it this way or else we will __________ (fill in the blank). Common nursing punishments for peers who don’t comply are shunning, refusing to help them (leaving patients at risk), rudeness, and belittling them to other coworkers.

         In comparison, consensus is the voice of reconciliation achieved through sincerity. Consensus says, to the minority, “This is how most of us want to do it, but we don’t want to alienate anyone on our team. What can we do to make the way we are going to do things easier for you? What concessions can we give you to make the work flow well for you too?” 

     I do not work with my dream team, and neither do my colleagues. Our patients depend on us, so we work together as a team to move each shift forward. Some shifts move easier than others do. Each morning we start the clock over, leaving the past where it belongs, and play a new game.