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Wednesday, July 20, 2016

Guest writer Linda K. Anderson, BSN, RN, is a retired nurse who lives in Seattle, Wa.

 

Evening

I'm too relaxed to breathe.

Until now, I was unaware how much effort, unconscious certainly, but effort nevertheless, was required to perform that rhythmic in-out, in-out, in-out of respiration. I feel calm, peaceful, and quiet in a way I've never felt before.

Beep. Beep. Beep.

"Breathe," says the nurse.

I don't want to breathe. I don't need to breathe. I'm just fine. This is the best I've ever felt. But okay, I'll breathe just to stop that beeping.

Deep inhale, deep exhale. That should do it.

The beeping stops. Silence again. Blessed peace.

Beep. Beep. Beep.

"Deep breaths." The woman's voice is jarring, too loud for my serene mood. If I had the energy, I'd tell her to please be quiet, I'm trying to sleep. But first, I have to stop the beeping.

Deep inhale, deep exhale. It's going to be a long night.

Right before I finally doze off, I think, something about this is familiar.

Morning

The pain stabs me in the gut before I open my eyes.

The world is bright and blurry. I see a white ceiling, but I sense movement next to me. I can't focus on the movement, can't blink away the haze from my eyes. My stomach hurts! What happened? My tongue is dry, and when I swallow, it feels like the back of my throat sticks together. My right hand flails, clanking against the metal side rail.

"Good morning! How are you feeling? Do you need something for pain?"

Yes, please yes, something for pain. I try to tell her something terrible has happened to me, some unidentified catastrophe has eviscerated me.

"Water," is all I can get out.

"You can't have anything to drink yet."

A minty sponge, barely damp, scrapes against my lips and tongue. In vain, I try to suck water from the tiny sponge. No use, not enough water on the swab. Then, soon after, peace again; not enough to take away the agony, but peace on top of hurt. It's like my nerve endings register every bit of pain, but my mind doesn't take it personally.

Afternoon

"Let's get you up, OK?" A new nurse floats into view.

I'm afraid to move. My belly feels flayed. I press my hand to my stomach, and feel the distinct crinkle of plastic.

I got the bag after all. Tears well up and trickle into my ears. One should never cry while laying on one's back. I'm not sure what I'm crying about, the excruciating pain or the bag. Both, or either one, it doesn't matter now. It's over – my active life, my love life, my life.

"Can I have something for pain before you get me up?"

"I just gave you some, you can't have any more for 4 hours. Now, let's swing your legs over."

One of the characters from a children's cartoon is watching the scene from the foot of my bed. What are you looking at? Haven't you seen a woman with a colostomy before? A woman split stem to stern, and pieced together again like a meaty puzzle?

I stand, swaying on my feet, bent nearly double, hands on my belly, as the nurse guides me to a chair. My head is detached and floating, and doesn't feel the same pain the rest of my body does. That cartoon creature is still staring at me, annoying me, taunting me. I feel like a sideshow.

"Please make him leave."

"Make who leave?"

I point a shaky finger. "Him."

It's quiet for a moment.

"There's nobody there, hon."

I've been through surgeries before, I know how the drugs affect me. I think she might be right. I decide to ignore him, while he keeps staring at me, not saying a word.

I hate being called "hon."

Evening

I recognize the doctor as he walks into the room. Clearly, compassionately, and in as few words as possible, he tells me what I already know. And leaves.

I check out the character at the foot of my bed. He turns out to be a BP cuff on wheels. Suddenly, I'm feeling lonely. Mute or not, he was pretty good company.

I look up at the television, and see a show about alpine skiing. I've never seen such beautiful photography. The white snow, the blue shadows, the shushing sound as the skis pierce the snow. I'm transfixed. I can feel the cold on my face, the damp of the snowflakes on my eyelashes. It feels like I'm the one skiing down the mountain. The show goes on and on. It's a relaxing and pleasant diversion from the pain and despair.

The nurse walks into the room with a new bag of I.V. fluids. I point to the television.

"Have you ever seen anything so beautiful?"

"Where?"

"On the TV, that show."

Silence.

"The TV's not on."

Oops. Did it again.

Morning

I wake up, still in pain, and press my call button. When the nurse comes, I explain I need something for pain, but can I please get something, anything, besides morphine? The nurse smiles and says "I'll see what you have ordered." I envy her straight, white teeth. I also envy her health, the smooth, easy way she moves.

Gone is the BP device at the foot of my bed. The television is off. No alarms scream in the background. The piercing pain in my belly is still there, but mostly just when I move. If I lay perfectly still, I can almost feel normal.

And I'm still alive.

And then I remember. I remember that I am a nurse. I've listened to the pulse oximeter alarms beeping, absently calling out "Breathe. Deep breaths." I've watched the monitor numbers, periodically looking at the patient, not always seeing the person. I remember getting patients out of bed the morning after surgery, and it seemed like I was always in a hurry, forever impatient. I knew they were in pain, but I had no idea. I remember chuckling to myself at the things my patients would say in a post-operative, opioid-induced delirium. I remember my patients' tears when they discovered the results, how they were disfigured in efforts to prolong their lives.

I want to turn back the clock, slow down, go back to these patients, and to myself. I want to say, you're alive, you're going to be okay. I'm going to make sure you keep breathing. You're not losing your mind. I will hold your hand and tell you that the pain will end, your family will love your imperfect body, you will see your baby graduate, and you will have a love life again. I want that to be true for my patients, just as it's true for me.

I promise to remember this.


Wednesday, July 6, 2016

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Guest writer Angela F. Henry, BSN, RN, ADN, TNCC, ENPC, ACLS is a registered nurse at Southern Maine Health Care in Biddeford, Maine.​


I always knew I wanted to be a nurse; it was my dream when I was a little girl. Reality threw in some detours; my first career in hospitality provided a wonderful 16 year detour. That job left me with great experiences and friends, but never felt like it was my true calling. Over time, mastery of the skills and tasks involved in hospitality wasn't as fulfilling as I hoped. I wanted to be involved in meaningful work that made a difference in people's lives. While providing someone with a pleasant hotel stay or vacation was satisfying, it left me feeling that I needed something more. So I decided to change my path and 3 years ago I graduated from nursing school and began working as a nurse.

I'd been a hotel manager for so long it wasn't challenging anymore, and it was intimidating to begin a job that was completely new to me. Suddenly, I was the novice instead of the veteran in a job that had a much higher level of responsibility. I literally held lives in my hands. However, from my first day I could tell that the nurses I worked with would take me under their wing and share their knowledge with me. There was a strong thread of teamwork on the floor, and everyone made patient safety their priority. I felt so fortunate to have this opportunity to work on a fast paced cardiac floor with a great team; it was the perfect learning environment.

While the staff try to have a little fun, it's clear that our job is serious and things we do during the day impact the patient and the patients' family. Caring for the patients' family was not something I was prepared for and I had to learn that skill quickly. Emotions can run high when family members are worried about a loved one, and the nurse becomes the sounding board for the family. Nurses try to bring them some solace during a difficult time, regardless of how unpleasant they are. This was the perfect opportunity to use my hospitality skills to listen to what they had to say, find out exactly what they needed to feel better about the situation, and then get that for them.

It quickly became apparent that my role affected the patient in a variety of ways. I would advocate for them, keep them comfortable and on a path of recovery, and manage the demands of their families. Taking the time to educate patients about what to expect before going down for a test, or teaching them ways to manage their health makes a difference. The unknown is scary; people often find some peace in just understanding what is happening to them. It's fulfilling to be the one to bring that to them. It's also fulfilling when they bring that to me.

A patient I was caring for received an unexpected diagnosis of terminal lung cancer. When the physician left the room I asked the patient what I could do for him. He said, "I'm fine; I only worry about my wife. I've lived a wonderful life and have done everything I wanted to do--I have no regrets. My bucket list is complete." This man was genuinely at peace with his life. I offered him a hug, but I think we both knew it was more for me than him. His words stuck with me and I hope at the end of my life I will have the same sense of peace and completion.

During another shift, I was caring for a patient who'd been in and out of the hospital many times over the past few months with respiratory issues. She had end stage chronic obstructive pulmonary disorder. Even with increasing levels of oxygen, she struggled to get a breath that made her feel comfortable. She told me she was tired of fighting to breathe and was ready to rest. She said her body was so tired, she couldn't do it anymore. She was ready to die.

When a patient decides to die they often decline very quickly, which was something I hadn't seen before. She no longer accepted food or medicine, only sips of water to wet her mouth. As an advocate for her care, I contacted her physician and family, and we created a plan to ensure the patient was comfortable and cared for as she wished. I also involved my peers, because this was a new situation for me and I was a little emotional about it. While I'd cared for patients who passed away, I hadn't yet cared for a patient who chose to pass away; there's a big difference in how that felt to me.

When I left work that night I stopped in to say goodnight to the patient and her family, who'd gathered at the bedside. The family moved aside to let me sit on the bed for a moment. I held my patient's hand and told her I would see her in the morning. She responded, "I hope not--I'm ready to go. I hope when I get up there I'll be able to find my husband and won't be alone anymore. And it won't be so hard to breathe." I hugged her with tears in my eyes. Each member of the family hugged me and thanked me for caring for their mom. The daughter remarked that I must see this all the time. I told her that while I do see people pass, not everyone touched my heart the way her mom did.

I walked to my car that night and felt, maybe for the first time, that nursing is the job I was meant to do. It's an honor and a gift to be able to care for people during some of the most vulnerable times of their lives. Going into nursing was a way to give back to people; but I didn't expect that my patients would give so much to me.


Friday, June 24, 2016

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Guest writer Samuel Franklin Engs, BSN, RN, is a hospice nurse in Lake Mary, Fla.​


My relationships with numerous hospice patients over the years have usually been very amiable. I believe that there are several reasons that I'm able to establish good relationships with my patients. First and foremost is the fact that, in most cases, I am close to their age. I've experienced many of the things that they've experienced over our combined lifetimes. Even if we don't have much in common, most patients love to hear the story of how I ended up going to nursing school when I did. They're amazed that I graduated from nursing school when I was almost fifty.

I learned over the years that my tour of duty in the Marine Corps and my years in banking and construction present good topics for conversation. I've also lived in 25 cities in nine states over my lifetime. The benefit of all those moves is that I usually have something in common with my patients, even if it's only geography. Many times I've discovered that I've either lived in the city where my patient grew up or close enough to that city that we had still had plenty to talk about.

I also know hundreds of jokes and funny stories that many patients seem to relish. I've always believed that a good laugh is, in many cases, as therapeutic as medication. At least that's what some patients have told me. But the crown jewel of my non-medical interventions is my magic tricks! Or at least I thought so--until I met Bill.

Bill, 68, was a very dignified gentleman who had been, up to his admission to our hospice program, an exceptionally successful entrepreneur with interests in everything from stocks, bonds, and real estate to medical equipment and manufacturing. When I met him he was well known, highly respected, and terminally ill.

He had a hard time accepting his diagnosis, and had a reputation for being hostile to his caretakers. During visits, Bill would be silent or quite gruff, depending on the day. Caretakers reported that Bill would resist any suggestion that might make his journey easier. Because of this, my initial nursing visit was short--to say the least! His wife was very apologetic and made excuses for his behavior, assuring me that it was not personal. I assured her that I didn't take it personally and that I looked forward to future visits, confident that my various interventions would eventually help us build rapport. They'd helped so often in the past I trusted that they would in Bill's case.

I visited and assessed Bill a couple of times a week in his home without establishing any type of relationship with him. His wife continued to be glad to see me, but Bill was unchanged. His pain was well managed and his wife stated that he didn't appear overly anxious. I began to suspect that he was simply furious that his life was coming to a rapid end and there was absolutely nothing that he could do about it. It wasn't in his character to be powerless.

On one visit, I tried a couple of my best jokes, neither of which got any response from him. On another visit I told a funny story about my past, but Bill just sat in his hospital bed and a stared at me. I suspected that he was thinking that here he was, a powerful businessman, having to stay in bed and listen to some nurse tell stupid anecdotes about his insignificant past. That was the moment when I decided to reach into my bag of magic tricks.

My collection of magic tricks is very elementary, really simple, and doesn't require any significant props or special devices. I call them "pocket tricks" because I carry what I need to perform the tricks in my pocket. I can make a tissue disappear and reappear in the palm of my hand. I love turning a dollar bill into a twenty dollar bill right before my patient's eyes. And I always enjoy making a penny disappear only to find it in my patient's ear…that trick always goes over well with children!

I elected to begin my magic show with my most baffling pocket trick: the vanishing tissue. I got Bill's attention and completed the trick without a flaw. The tissue disappeared and miraculously reappeared, seemingly from thin air. I looked at Bill for a reaction, and noticed that his face was unchanged. Suddenly, he yelled, "How dare you come to my home and show me a trick that I learned in the seventh grade!"

The bedroom became quiet. I said, "Look, Bill, I'm willing to try whatever it takes to help you feel better, even if that includes doing junior high magic tricks." Bill began laughing like I've never heard anyone laugh before. His wife came into the room, and we stood watching him laugh until tears started to roll down his cheeks. He finally regained control of himself, looked straight into my eyes and said, "That's enough for today, but you better have a better trick when you come back to see me!"

I assured him that I would, and departed for the day.

I discovered on my next visit that the disappearing tissue had broken the ice and allowed Bill and me to talk about the things we had in common. Our experiences early in life were very similar, much more so than I had ever expected. He'd even tried to enlist in the Marines, but failed because he had flat feet!

It took a while, but we became friends. I believe that I laughed more with Bill over the final 3 weeks of his life than I have laughed with any other patient. And now, I always smile when I perform a pocket trick, because it reminds me of my friend Bill.


Tuesday, March 1, 2016

“The ED is full of people who shouldn't be there. That's why the wait is so long.” 

I've heard many iterations of that sentiment from patients, visitors, the general public, politicians, and even healthcare professionals more times than I care to count in my 30-plus years in emergency services.​​In my early days as an emergency nurse, I witnessed coworkers show obvious disdain when patients came to the ED with chief complaints that didn't fit their definition of an emergency. Unchecked, those attitudes were contagious and toxic. 

Fast-forward many years, and I gained a new perspective as an emergency nurse leader with elderly parents and in-laws. Frequent ED visits became a reality. My family members' fragile health conditions rapidly worsened if their infections and other concerning symptoms weren't evaluated and managed quickly and aggressively. They simply couldn't wait for an office appointment.

I'd like to set the record straight: Our ED population represents people in need. The definition of emergency is personal, especially for those who are scared, in pain, or lack healthcare knowledge. When you have a garden-variety UTI and can't access timely care because of personal circumstances, you seek relief ASAP. Urgent care centers and medical aid units can be good options, but many aren't open 24/7, have limited capabilities, and expect payment up front, which all pose barriers.

What about “drug seekers” and challenging patients with behavioral health issues? Granted, the ED may not be the best place for them—but with the right systems in place, we can try to connect them to the services that they need.ED crowding is a complex problem with roots in the availability of health services in a particular community, care management systems, financial resources, public expectations for instant access, and many other factors. We need to stop blaming patients and focus on tangible, systemwide improvements. Many view ED care as expensive, but preventable harm from lack of timely access to that care carries a much higher price.

The ED is a safety net. No, it can't be all things to all people, but like the Statue of Liberty, it stands ready to help those in need: “Give me your tired, your poor, your huddled masses, yearning to breathe free...”.


Tuesday, November 24, 2015
Tissues for Runny Noses 10-26-09 -- IMG_9276

The irony of nurses reporting to work while sick is obvious. Nurses are responsible for healing, not spreading infections. Presenteeism is a problem that runs deep within the healthcare community. The constant exposure to infection, stress, and fatigue lead to one almost inescapable outcome: the dreaded sick day.

A recent study from JAMA Pediatrics conducted a mixed-methods analysis of more than 500 clinicians and their self-report on presenteeism. Of those surveyed, more than 95% demonstrated the knowledge that working while sick puts patients at risk. Despite this knowledge, 83% reported working despite illness at least once that year. They didn’t want to let down their colleagues, create staffing problems, or disappoint their patients.1 However, the study conclusions show that the issue is more complex; presenteeism is shaped by sociocultural factors (peer pressure) and systems-level factors (facility policy).

Culturally, nurses are educated to work as a team, care deeply about their patients, and value their job. However, we must realize that in the long run, we are undermining all three by coming to work sick. At a systems level, attendance policies meant to assure that adequate staff are present to care for patients may inadvertently encourage presenteeism at the wrong time. This situation is especially true for those staff who push the limits on calling out sick when perhaps they really aren’t, and subsequently ride the fence on their sick time limits. Loss of income also may be an underlying reason for presenteeism-- depending on their employment status, some nurses may not get paid when they take sick time.

As the JAMA study points out, nurses and physicians hold themselves accountable for providing quality care. In the grand scheme, very few clinicians actually abuse sick days, but all too often nurses are caught between justifying their illness and endangering patients. This ethical dilemma is a difficult one, but we should err on the side of safety for our patients and ourselves by staying home. Until nurses and organizations come together to eliminate the root causes of presenteeism, we will continue to see a cycle of illness perpetuated among patients, colleagues, and professionals.

References:

1. Szymczak JE, Smathers S, Hoegg C, Klieger S, Coffin SE, Sammons JS. Reasons why physicians and advanced practice clinicians work while sick: A mixed-methods analysis. JAMA Pediatr. 2015;169(9):815-21.

About the Author

Linda Laskowski-Jones
Linda Laskowski-Jones, MS, RN, ACNS-BC, CEN, FAWM, is editor-in-chief of Nursing and vice president of Emergency, Trauma, and Aeromedical Services at Christiana Care Health System in Wilmington, Delaware.