A forum to discuss the latest news and ideas in nursing and healthcare.
Friday, September 9, 2016
Guest editor Joyce Hislop, AD, RN, is a freelance writer in Breinigsville, Pa.
Anxiously, I answered the firm knock on my father's kitchen door.
At 1 p.m., the nursing agency had called to say they were scrambling to replace the previously scheduled evening aide for my father. A retired nurse myself, I understand schedule frustrations. My dad needed assistance for the day and evening shifts 7 days a week. Of his five adult children, my youngest brother and I lived locally and did what we could, but we each had work obligations. Our dad had agreed to hire an agency to provide home health aides during day and evening hours; our brother covered any late night needs, and our sister JoAnne drove from upstate New York for the weekends.
Standing in the doorway, a tall, stunning woman with a wide smile put her hand toward me in a friendly greeting, at the same time offering an apology. I'll call her Sandra.
"Hi, I'm Sandra, from the agency. So sorry to be late- I didn't anticipate all the traffic lights along the highway and I managed to hit them all!"
The agency had sent us yet another new aide. Sandra was in her 30's, and she looked like a runway model, draped in a gracefully flowing skirt in muted colors of turquoise. The color suited her grey eyes and shoulder-length dark hair. I had to admire her presentation.
Our introductions made, Sandra followed me toward my dad, who was watching and listening from his red leather chair in the middle of the large kitchen. Sandra confidently stretched out her hand to him and smiled broadly, repeating her name in case he had not heard clearly.
"I love your kitchen," she said, and he beamed. In better days he had liked to cook and appreciated any notice of how the kitchen reflected that interest.
"Perfect," I thought, listening to the two chat for a minute about the baker's rack filled with his favorite cook books and shiny pots. The slight Southern drawl in the aide's voice was both charming and soothing.
I showed Sandra where to put her purse and pointed out the phone and emergency contact list. My main concern was that she use good body mechanics to get him up from sitting or lying down: He was a tall man and weak after several months of dialysis. I asked Sandra if she'd mind demonstrating how she'd help him up from his chair.
"Why, sure!" she replied, and squared herself in front of him. In just a couple seconds he was on his feet, looking somewhat surprised at the power behind the position change.
"As long as I'm up, I might as well go in there," he said, and motioned toward the bathroom. Sandra's steps matched his as they slowly moved the short distance. Allowing him privacy in the handicapped bathroom, she stood by the closed door and waited for his call. I gathered my jacket and bag, telling Sandra that our sister was coming in for the weekend and she'd arrive tonight in plenty of time for the shift change. I could see that Sandra and her charge were comfortable with one another and it would be okay if I left.
About 9 the next morning I got my sister's update on Sandra's shift.
"So, Joyce," she began, exaggerating a laid back and casual tone.
Oh-oh. Her tone was leading up to something.
"Is everything okay?" I was afraid to ask.
JoAnne assured me that our dad was fine. She went on to tell me she'd arrived at the house about 9 p.m. Dad was having his usual evening issues with restlessness, alternating between the kitchen and his hospital bed in the living room. Sandra had just settled him back to the bed; it seemed they'd both had a relatively uneventful evening. JoAnne went into the living room to say hello and goodnight to Dad and then came back to the kitchen. Getting a snack, she offered Sandra the same. A cup of coffee and conversation led to the discovery they had mutual friends, and during a second companionable cup Sandra shared a personal confidence: 'Sandra' was really Samuel; her biological gender was male. Through her elementary and high school years she'd rejected the gender assignment she'd been given at birth and had never felt comfortable having to live as a man.
This revelation was astonishing to me. The quality of care Sandra provided had been excellent, and Dad had even suggested that Sandra become one of his regular aides. However, my father, at age 78, might have seen it as a deception. If he'd known Sandra was born male, I believe he wouldn't have understood her choice to live, behave, and dress as a woman.
This encounter happened nearly 20 years ago. It was a different time, before terms like gender dysphoria and transgender were common. With a society more open to different expressions of gender identity,1 I wonder how this situation would play out in today's world.
How would you have handled this situation?
1. Pitts L. Human dignity gets an important boost. The Morning Call. July 3, 2015.
Tuesday, August 23, 2016
Guest writer Ellen Zimmerman, MSN-Ed, RN, is a former faculty program director in the ADN program at Excelsior College in Albany, N.Y. and online adjunct faculty at Excelsior College and the CUNY School of Professional Studies in N.Y.
"I can't ever imagine you crying at work!"
This simple statement, made by a former nursing student, made me stop and think. As an RN of almost 40 years, my immediate reaction was "Of course I have."
Here I was, a faculty member with years of experience, and I was immediately brought back to the fears, anxieties, and insecurities I experienced when I was a new nurse. I thought very carefully before I typed my response to her. Is it ok to cry? Yes. But it's not OK to cry so hard you can't keep doing your job.
I told her we cry because we're human, and because we care. If you lose that passion, that commitment, then you've lost the essence of what makes us caring individuals.
I've been a new graduate, staff nurse, charge nurse, supervisor, and nursing faculty. Most of my career has been in critical care and emergency where life and death hang in suspension on a daily basis.
I cried when a child was brought to the ED, who'd died from a broken neck after being hit by a car. I've cried while holding the hands of dying patients as they took their last breath. Tears flowed at work when I learned that a valued coworker had succumbed to her metastatic cancer. I wiped away tears watching the birth of a baby with my nursing students. I cried behind the closed door of my office after informing a student that she wasn't successful, and would have to leave the nursing program despite her hard work.
But I didn't cry when it was time to leave the ED. I always went with the physician to inform families about the result of our resuscitative efforts. My last evening was no different. We'd just finished yet another code and I stood there while the sad news was delivered. I'd always found it impossible to stand there without my eyes filling up with tears.
This time I felt nothing! I went through all of the motions, but my own emotion was gone. I was caring, compassionate, and helpful to the family, but I felt absolutely nothing.
I knew in that moment that I wasn't the critical care nurse that I was when I started. I knew deep in my soul that I needed to leave and find my passion again. I finished my BSN and my MSN and started teaching. It's my true passion, and I can impart my years of experience to others. I make a point to teach not only curriculum, but the caring as well.
So my young graduate, please do not worry about crying at work. It's because you care, you're passionate, and you want to make a difference. Never lose that despite the crazy, overwhelming shifts, long hours, exhaustion, short staffing, and school work. Keep your focus and keep caring, and if your eyes fill up with tears now and then--trust me--it's OK.
Wednesday, August 3, 2016
Guest writer Alison Cody, BSN, RN, CHPN, is a case manager at Providence Hospice in Portland, OR.
Eunice had the best yard in the neighborhood--where all the children on the block played hide and seek. She had huge, wide trees and the children liked to hide in them. This is one of the first things she told me, her hospice nurse, on my first visit to her house. Eunice loved to watch the neighborhood through the large picture window in her living room. Eunice wanted me to listen; she wanted to tell me her story. She was looking for a safe space to talk things through without judgment.
Eunice invited me along on her journey and she was the one driving the bus. As a hospice nurse, I'm often given the privilege of being one of the passengers on board. My role is to help navigate a path that can be uneven and often cluttered with debris. The path may have forks in the road--and although I can offer expertise on which path to take, they all ultimately lead to the same destination.
Eunice had been diagnosed with a recurrence of her lymphoma. She had a new tumor on her spine that caused increasing pain in her right leg and back. This diagnosis came after Eunice awoke one day about 2 weeks before we met and was unable to get out of bed. She was unable to stand or walk; her disease was advanced, and she was too frail to undergo chemotherapy. She elected not to pursue palliative radiation that may have lessened her pain, and chose hospice care instead. She required full-time care and needed assistance with her activities of daily living.
On that first day with Eunice, I invited her to tell me what was most important to her, to share what brought her joy. She answered me from her bed in the living room where she had a view of her front yard. She told me she wanted to walk, or at least get out of bed and sit in her wheelchair. She hoped that maybe she could feel her leg again. Eunice shared stories of her radiation treatment and how she never wanted to do that again. She admitted she was in a great deal of pain, but didn't want to become addicted so she took her pain medication only at night.
I had many nursing visits with Eunice where she talked and I listened. Sure, I provided nursing care, did dressing changes, filled her medication box, and adjusted her pain medications as she would allow, but my time with Eunice was much more than simple nursing care. I could've spent my visits doing the talking and trying to persuade Eunice to do things a certain way. But that wasn't why she had invited me in. It wasn't my right to determine what defined quality end-of-life care for Eunice. I wasn't in charge, Eunice was. In healthcare, we sometimes need to remind ourselves that we aren't the ones driving the bus!
In time, Eunice decided she was ready to be in less pain and changes were made that accomplished this, including an increase in her pain medication and starting anxiety medication. She allowed the other members of my team to board her bus and ride along with us. She even had a period of a few days where she was able to sit in her wheelchair. She drove the bus until the very end. When Eunice could no longer speak, I still knew how to help her drive. I knew because I listened. I met Eunice where she was, not where I wanted her to be.
Eunice died 6 weeks after she enrolled in hospice. It was an honor to provide care for her, and even more important, to be her passenger.
Wednesday, July 20, 2016
Guest writer Linda K. Anderson, BSN, RN, is a retired nurse who lives in Seattle, Wa.
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.
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.
"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."
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?"
"On the TV, that show."
"The TV's not on."
Oops. Did it again.
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
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.