AS A FORMER oncology nurse, I pride myself on my ability to communicate effectively, especially during difficult times. I have stood by patients as a source of comfort when a physician delivered a terminal diagnosis. I have served as a pillar of strength for patients and friends who have lost loved ones, and I have held the hands of patients who took their final breaths. I am sure my husband knows when I will say, “Tell me why you feel that way” before it leaves my lips. It's my thing. However, until an experience with a student in clinical, I never realized that while I grasped therapeutic communication easily and without hesitation, we as nurse instructors have more work to do to prepare students with the tools needed to communicate effectively during unexpected or unpleasant patient-care experiences.
The code blue
At my institution, I facilitate medical-surgical clinicals one day a week with third-semester students. On a typical day, I send three or four of my seven students to specialty units to work with a designated nurse. One day, I sent Adam to work with a nurse named Debbie in the cardiovascular ICU.* Debbie was providing one-on-one care for a patient undergoing continuous renal replacement therapy (CRRT) after a heart transplant. Because our didactic lesson that week covered CRRT, I thought this would be a great experience for Adam. I communicated Adam's goals and objectives of the day to Debbie and told Adam, as always, to call me if he needed anything.
I went to the medical-surgical unit with my other students and started our day performing head-to-toe assessments, administering medications, documenting, and so on. At around 0900 I heard a code blue being called in the ICU, but I didn't think much of it. Even in the unlikely event that Adam's patient was at the receiving end of a code blue, I was confident he was well equipped to handle it under Debbie's guidance.
At lunch, however, Adam appeared with his face and eyes bright red. Visibly shaken, he slowly walked to my table and said, “My patient died.” His patient had been recovering; he had not been expected to die. How could recovery turn into termination of life?
Adam began to recite the downhill spiral that led to the code team working to revive the patient for almost 2 hours. His family was in the room when his heart stopped. Adam had to perform CPR as the physician performed pericardiocentesis, with no success. The patient was pronounced dead with his family—and Adam—left to wonder what had just happened. He stated he didn't know what to say. The family was crying, as was he. The look on his face at that moment told me all I needed to know.
In that instant, I wondered if our program prepared Adam for this situation. Was it even possible to prepare a student for a situation like this? I looked at my other students sitting at the table and wondered, would they be equipped to handle a sudden and unexpected death with a code team, physicians, a crying family, and so many questions filling the room at rapid speed? I sighed and proceeded to debrief with Adam. He expressed a feeling of sorrow and sadness for the family. He said he felt out of place as they stood crying over their loved one. He didn't know what to say or how to say it, which made him feel inadequate. He was taken by surprise and didn't have the tools to manage the situation.
After we talked, Adam agreed to complete postmortem care on his patient with one of his peers and me at his side. We cleaned the patient he had fought so hard to save. And it was evident from the state of the room that a hard battle had been fought. I was proud of him.
Adam was a stellar student—energetic, smart, and able to execute any skill with care and precision. However, this situation was far different from inserting an I.V. catheter or indwelling urinary catheter. I realized from this experience that nurse instructors have a huge area of opportunity in nursing education to continuously prepare students for end-of-life experiences, not just at one point in time in the curriculum as it is so often done. It is our duty to prepare them to be proficient not only with their technical skills but during emotionally challenging situations.
This aspect of nursing needs to be woven throughout the curriculum, just as technical skills are, so our students graduate with a mastery of the cognitive tools needed to navigate these situations in practice. Because of Adam's experience, I am now working on end-of-life simulation scenarios that will become a staple in my course in the hope that my colleagues will follow suit.
* Names have been changed to protect privacy.