onbeinganurse: Can we talk?

Our society has become so enamored of iPhones and texting that people don’t make eye contact or conversation face to face anymore: too interested in the in-coming “mail” or video game rather than the person in front of them. In a restaurant, for example, I’ve watched families have a whole meal without ever exchanging a word except into their phones to who-knows-who; not to their companions. The whole time looking downward at their technological addiction device and fiddling with that.
Today I witnessed what is becoming a rare human encounter; a young father and his son, about 13 or 14 years old, actually sharing a conversation during a meal. My first impression of the father was not good because as they came in he had put out a cigarette (the nurse in me) and also his upper body was covered with tattoos. He had on a skimpy tee-shirt that showed his skin artwork to its best advantage. What surprised me was that they each had cells, but laid them on the table and left them to the side: they never looked at the phones even once. Chatting away to beat the band, they obviously enjoyed one another’s company.
As my husband and I left, I impulsively stopped at their table and excused myself for interrupting, then explained how pleasant it was to see the two talking together and not with their faces engrossed in a small box instead of one another. The dad graciously thanked me and then beamed at his son, saying, “Well, of course- this is my boy- he’s a great kid!”
They made my whole day golden.

onbeinganurse: “Mirror Images”

There are five of us siblings; three brothers, our sister, and myself. Ranging in age from 74 to 50 years old, two are Senior Citizens and three are Baby Boomers. Spread apart also by location, we represent Hawaii, New York, Pennsylvania, and Florida, making it difficult for all to get together at the same time. Eleven years had passed since we’d all been together. I’m happy to say that it was with eager anticipation we planned to meet two weeks ago in Naples, Florida, on June 3rd.
My biggest concern was that I’d cry when I saw my older brother, Jim. Two years apart, we’ve always had a close bond. One of my first memories is of my big brother holding my 4 year old hand within the safety of his as we walked the block from our home to our waiting Grandmother, who stood watching for us at the top of our same street. Jim has always been healthy and strong; and, at 74, what in medicine we call a “good” 74 year old. But these past ten months have brought a diagnosis of cancer and weeks of radiation plus targeted IV chemotherapy. By the 2nd to 3rd week of treatment the side effect of fatigue necessitated a driver for the 3 hour round-trip. Weight loss gradually melted 35 pounds from a tall frame which couldn’t afford it, and by Christmas Eve his new address was a hospital room for two weeks of hydration and enteral feedings. He was positive through it all. Other patients he met along the way made encouraging comments and bolstered his own courage through theirs.
He is a published writer by profession and as his strength improves he feels another book coming on, based on this experience. The best news has been two clear CT scans since completing therapy in January. However, I knew that he was still weak from the weight loss and had issues walking, complicated by an arthritic leg. Not the picture of him that I carried in my mind and heart from stronger days.
As I said, I was nervous about seeing my brother for the first time after such an ordeal. Meanwhile I had a couple mobility issues of my own and had prepared him for a change in what had been my previously sprightly steps.
My husband and I were to pick Jim up at the Florida airport. I had made a sign that said “Reunion 2014″ and held it up at the car’s window as we approached him. I opened the door, we looked at one another, and both of us broke into laughter. As kids we shared many things, and, decades later, I saw that we are still sharing, only now it is our Senior Citizen mirror images: we each have a cane, walk with a hitch, and have wisdom lines on our faces.
“Gosh,” I said with dry-eyed relief, “you sure look familiar.” Immediately he “got it”. He understood my wry comment and we convulsed into giggles again.
It was a great reunion.

onbeinganurse: “Positive deviance”.

During Florence Nightingale’s time and through most the 20th century, doctors and nurses have had an unbalanced colleague relationship: the doctors told nurses what to do and we subserviently took the order. During the 1980’s, collaboration began improving across the medical community as a majority of physicians recognized the extent of nursing skills: they saw that our education and assessment skills adds up to independent clinical thinking. There are times in our patient assessment when we see that a “doctor’s order” might not be in the best interests of the patient, such as giving a particular medication when vital signs or symptoms might indicate withholding the prescription. This concept of ‘positive deviance’ has always been a nursing option. In my day, this was called common sense. Of course as an RN or LPN we inform the physician and/or our facility supervisor of our assessment and that the med has been held pending this change in condition. We are bound by the Nurse Practice Act (NPA) to bring a patient to their fullest health potential: there is nothing in the NPA that encourages a nurse to blindly follow “doctor’s orders”. When, for example, we see an indication that, by administering a scheduled medication, harm could follow, we withhold that order (medication) and notify the physician directly.
In the August 2013 issue of The American Journal of Nursing, Volume 113, No. 8, “Viewpoint”, (C.Reuter, MSN, RN, and V. Fitzsimons, EdD, RN, FAAN) the authors suggest that instead of “order”, the term “prescription”, or “regimen” be used. Collaborative care means working jointly for the benefit of the patient, and since the early 1990’s medical staff committees across the country have encouraged physician and nurse to work together in a collegial, respectful atmosphere. The term ‘regimen’ has a different implication than ‘order’. In the thesaurus, ‘prescription’ is described as making obligatory or mandatory. ‘Regimen’ in Webster’s Dictionary definition states a ‘systematic course of treatment or training’. In my experience the latter more fully encompasses both roles of doctor and nurse, acknowledging the physician’s determination of the most effective treatment at the time of her/his assessment, but also recognizing the nurse’s clinical evaluation of the patient’s condition at the time of following through: symptoms may have changed in the interim and may indicate a change in the regimen. Before following through and in the best interests of our mutual patient, we practice positive deviance; ‘hold’ the regimen as it stands and call the doctor.

onbeinganurse: a fresh start.

It’s been six months since I posted a nurse blog. I don’t know why, but probably because I ran out of what I felt was material to blog. Retired from active practice for 19 months now, there are no patients to inspire me and share a human interest story. They were my material. I had wanted to volunteer at a nursing home or hospice, but mobility issues had by now caught up with me, making my balance somewhat unsteady. Another resource for patient contact lost. So eventually I took a hiatus from blogging and instead formed a writer’s group at our local library. A writer’s group of two; another “want-to-be” writer and me. Instant soul sisters, we provide mutual support, laughing (or crying) at one another’s written words. Who wants a round-robin of criticism when productive comments make for a more pleasant atmosphere? We only have an hour to read and comment on one another’s effort, and no point in going away feeling blue. To guide us we have a writing resource copy from a college journaling course.
So we’ve plundered on, both women totally different in our writing styles. During the Fall, my new BBF bit the bullet and submitted a satirical slant on a popular fairy tale to a national magazine, and darned if they didn’t suggest it be published on their author blog site! I was green. But, truthfully, I enjoyed her surprise and sense of validation that she might just be the writer she thought she was.
Meanwhile, I had given up on my attempt at a fictional novel (about a nurse, wouldn’t you know), having written my protagonist into a corner and left her stuck there. Writer’s block. What appeals to me is “real” life, an active ethical dilemma I could explore and submit to a nursing journal. After the Boston terrorist bombing, I called the Human Resources department of Beth Israel Deaconess Medical Center in Boston and asked how the nursing staff felt about being assigned to care for the terrorist and his injuries, while, at the same time and down the hall, his victims were suffering amputations and other physical and emotional results of the bombing. My questions were put to the ethics committee and answered in a thoughtful and timely manner. After I wrote the article, the same committee reviewed it for any corrections or concerns, meeting their approval. I felt really good about the piece and submitted it to a nursing journal, where it was peer-reviewed by the editors and accepted. Yippee! Inspired, I researched for another article on a subject nurses would be interested in, and a journal accepted it following peer-review. A third article is pending approval. I’m on a roll here!
What I’ve learned is that I can still practice nursing, but in a different way than hands-on. The articles are a form of mentoring my fellow colleagues. And my brain won’t turn to mush.
Reinventing myself, I’m happy to say I’m still a nurse.

onbeinganurse: Where I’m from…

I’m from starched white caps, white uniforms and polished white leather duty shoes…
I’m from giving AM care, PM back rubs and unwrinkled hospital sheets…
I’m from giving up my chair to a doctor at the nurses’ station…
I’m from paper charts and hand-written nurses’ notes to Electronic Medical Records…
I’m from smoking allowed at the nurses’ stations…
I’m from drawing up syringes of chemotherapy in the nurses’ kitchen before ventilated hoods and OSHA guidelines adopted…
I’m from “This is the way we’ve always done it,” to national nursing standard and patient effective Evidence-Based-Practice…
I’m from time-consuming deciphering and clarification of scribbled orders to prevent un-intended consequences…
I’m from initiating physician/nurse meetings to promote recognition of our common goal to bring a patient to their fullest health potential…
I’m from mentoring (with awkward feelings) a Russian-trained M.D. working as a nurses’ aide while learning English and preparing to take U.S. medical boards…
I’m from driving home after 11PM to 7AM shifts and not remembering if I stopped for traffic lights or stop signs…
I’m from calling the nurses’ station as soon as I got home to ask if my patient’s family made it to the hospital to say good-bye for the last time…

onbeinganurse: A nightingale’s and a yellow-bird’s calling to nursing.

I started out this blog to draw attention to May 6-12 being National Nurses Week, and as I wrote a commemoration to my beloved profession it made me think of Florence Nightingale, the Englsh woman who in the mid-1800’s trained in London as a nurse and did so against her wealthy parents’ wishes: Nurses back then were considered to be either drunks, prostitutes, or both. Florence became known as “the Lady with the lamp” for her relentless efforts to obtain better nursing care and improve hygiene conditions for the wounded English soldiers fighting in the 1854-1856 Crimean War; 3,000 men died of their wounds during the war, but 17,000 died of infection. When I see what medical hygiene practice changes she made, I can see the first nursing research of “Evidence Based Practice”, which is today’s nursing standards of care.

At a time when women did not nurse soldiers, Miss Nightingale initiated a nursing program and then took three dozen women with her to Crimea where she saw the terrible conditions of the wounded men and and began to change the filthy state of the make-shift British-run hospitals. Her ethical practice, hygiene changes and diligent pursuasion with the doctors of that time eventually brought professionalism and respect to nursing. Now, 150 years later, national polls note that nurses are among the most respected and trusted professionals in our current time.

The week of May 6-12 is designated to celebrate the nursing profession: National Student Nurses Day on May 8th, and (world-wide) International Nurses Day on May 12, which purposely coinsides with Florence Nightingale’s birthday. However, as I googled the Florence Nightingale Pledge and her personal history, I came across the name of another strong advocate for the soldiers, and, before the war, nursing victims of cholera and yellow fever- Mrs. Mary Seacole, a Jamaican nurse and “doctoress” who was a contemporary of Miss Nightingale. However, she was refused permission by the London War Office and other military offices to volunteer in service to her own Jamaican-born soldiers fighting alongside the English troups. In her memoir she cited racism and Victorian attitudes. Undaunted, Mrs. Seacole went to Turkey at her own expense, setting up a boarding house for both Jamaican and English wounded soldiers, and even going to the Crimean front lines to nurse the fallen. Eventually she volunteered in evenings with Nightingale’s nurses, although Florence had been among those in London who had first refused her offer. Seacole became as well-known as Nightingale, but in a different capacity; she was a hands-on nurse, while Florence’s focus was as an organizer of nursing services and with the monetary means to do anything within her power. The grateful soldiers called Mary “the black Nightingale” and recognized her cheerful yellow dress and blue bonnet with red ribbons. Mary’s brilliant flame as the first advanced nurse practioner was brief, while the wealthy and well-appointed Florence went on to establish the first Training School for Nurses and was hailed over many years for her accomplishments in raising the standards of nursing practice. It was 100 years later, in the 1970’s, that Mrs. Seacole’s life work became a symbol for Black nurses, civil rights, and the women’s liberation movement.

I confess that during my student nursing days I don’t remember hearing of Mary Seacole; it was Florence Nightingale all the way. I am grateful to learn of her and to have been further enlightened of both these influential women as I began this May tribute to Nurses Week: the two leaders would be proud to have been the forefront of the educational advancements, specialty areas, and opportunities that nursing encompasses today. Congratulations to all the Registered Nurses, Liscensed Practical Nurses, and Certified Nursing Assistants devoting their education, skills, and compassion to those who receive their care.

onbeinganurse:Certified Nurses Day

March 19th is not only the day before Spring; it’s the day nurses are recognized for being certified, or specialists, in their field. Nursing starts out with a general knowledge of many diagnoses. In 1984, when I graduated as a nurse (GN), it was common to work in a medical-surgical area for at least one year while passing licensure as an RN and building on the learned base, gaining more experience. Specialty certification in a particular field was an option and has grown tremendously: pediatrics, cardiology, endocrinology (diabetes, thyroid), renal (kidney disease, to identify only a few. For example, the initials after the example RN, MA, CGRN, CNOR, mean this nurse is a licensed Registered Nurse, has graduate education achieving a Masters Degree, and has earned specialized training as a Certified Gastroenterology Registered Nurse and a Certified Operating-room Nurse. The yardstick to become certified in any medical specialty is high and set to establish a standard of care.

Certification in cancer nursing (OCN, or Oncology Certified Nurse) appealed to me within a few months after graduation and after an unexpected transfer to my hospital’s oncology unit. I found I loved this field of nursing and wanted to give the safest oncology care possible. Over the years I’ve worked with many excellent nurses who are not certified in their particular field: there are many valid and individual reasons why this may not be feasible. One reason is that aside from the time commitment to prepare, for example, the oncology certification’s initial sit-down test, the cost is over $200 and many employers will not reimburse. I was fortunate our hospital did reimburse with a passing grade and also a $0.50/hour raise, and my employers since have also encouraged certification with these incentives. The test is given every four years, and recertification is required each time to continue carrying the initials ONC (Oncology Certified Nurse) and all it implies. In recent years more and more recruitement managers are suggesting certification is preferred, but not required. And you can be sure patients & families notice any initials after a medical caregiver’s name and will ask what they stand for. I do, too.

The oncology nursing test involves multiple areas including comfort, coping with psychosocial, cultural and altered body issues, supportive care, sexuality, rehabilitation, pharmacologic and non-pharmacologic interventions, alterations in nutrition and elimination, immune-compromise, cardiopulmonary function, oncology emergencies, radiation, nursing care of the different types of cancer diagnosis, chemotherapy administration & possible side effects. It includes several other issues including health promotion and early detection, and professional performance. I know there’s a few I’ve forgotten here, either by poor memory or deliberatly wanting to forget, whatever the stressful topic. The Oncology Nursing Society (ONS) is based in Pittsburg, PA, and is a globally recognized ooncology educational organization: nurses from all the free countries of the world can take the test for certification. Every ONS educational magazine issue I receive has peer-reiewed articles written by OCN RN’s and from so many countries including Japan, England, Austrailia, Switzerland, etc.: cancer does not exclude any culture.

Today I’m congratulating nursing colleagues everywhere on their special achievement and celebrate this special day, March 19th. Anyone who isn’t a nurse, but reads this blog, may be surprised to see what’s behind the initials on their caregiver’s uniform.

onbeinganurse: Emergencies don’t wait for us to get it together!

Being retired for six months now, I’ve had only the rare medical question or two; no “real” patient care. I’ve missed the frequent contact and teaching, yet I’ve slipped into a different kind of busy as my husband and I fill our dance cards with comfortable pursuits and the complacency of good health. Of course I’m aware that we might not always have smooth-sailing for the rest of our time together: if I thought about it at all, in the back of my mind I’ve felt we’re each emotionally prepared for any emergency the other might encounter some day. However, that “some day” came to elderly friends of ours the other day and awakened me to the intense emotional turmoil an emergency can cause in the partner as well as the patient. Anxiety can play cruel tricks with our body and usual good memory.
My phone rang; it was a friend telling me his wife was having a severe nosebleed. She was on coumadin plus another blood thinner. They had applied pressure on her nose for over fifeteen minutes, but still bleeding from both nostrils without slowing down. Telling him to call 911, I went to their home to wait with them; at 80+ anything can happen. As I walked in two neighbors arrived. This turned out to be a “more is better” scenario, because, while I held pressure on Mrs. M’s nose, her husband, very anxious at this point, became short of breath and felt like he was going to faint. As the emergency personnel arrived they quicklyly assessed the situation and decided the husband needed to go to the ER first (!): he needed oxygen and was in worse shape now than his wife. Extra gauze and more pressure seemed to at least have stabilized her bleeding. As Mr.M was leaving I asked both patients where their emergency phone numbers were so I could call their son, who was at work. Under ordinary circumstances this vital couple looked after one another, independent of outside help, but under this stress their anxiety levels were so high, being worried not only for themselves but also their partner, that neither one could remember anyone’s phone number or the location of their telephone list, or even an area telephone book that we could find. Off they each went to the hospital, and valuable time had been wasted because there was no prepared emergency information readily available. Their home was extremely neat, everything in it’s place, but where was the phone book?? As each patient was enroute to the ER, the neighbors and I found a telephone roll. Of course all I got was an answering machine as I tried one of their children after the other. Within a few minutes a son called back, very concerned, and would follow through with his parents. By late afternoon both were stabilized in the ER and discharged, so it ended well.
However, my lesson from this event reminded me how quickly an emergency can shatter what we think we “know”, and telephone numbers seem the first to fly out of our memory bank. Once home again, I banged out an emergency contact list, our individual medications and allergies, our PCP and pharmacy phone numbers, and what hospital we would want to be taken to (the emergency attendant had asked this question). I will update the lists as needed, especially medications. Also included in this emergency envelope, placed prominently by our phone, is the name of the bank we use so our son can access the box where we keep important papers he might need if neither of us are able to make decisions for the other. He has the key, but he’s busy with a young family and work- why should he have to depend on his own memory while dealing with our emergency?
I’m putting this out so you can get your own medical information together in one easily accessible place. I hope you don’t ever have to use it, but I’m just sayin'; in case.

onbeinganurse:Retired, Part Three of Three.

      How quickly the days go by. Slow down; not so fast! That’s the thought that passes through my mind at the start of each day in the already four months since I retired. Then follows a moment of deep appreciation that every day I have the choice to stay home if that’s my preference; no 8:00AM priority to check-into-work, no appointments that can’t be changed to just about anytime.  I am retired from “have to”.

And it’s true what other retirees had told me, that there aren’t enough hours in the day to accomplish all that I’d like. Every day I make sure I have at least two mental and physical projects so my brain doesn’t turn to mush, or that I god-forbid become a couch potato and have to resort to sweat pants to accommodate my waist. The Internet web sites provide a wealth of brain food, like “Words with Friends”, and the nursing continuing-education credits required to keep my RN license current. Much as I would like, my fingers tapping the computer keyboard don’t qualify as physical activity, and so I make myself do a few minutes of simple yoga moves or lifting hand weights now and then throughout the day. Some days I exercise my taste buds with a no-sugar-added frozen yogurt banana split at Ice Cream World. I’m only human. In  my blog onbeinganurse:Retired,Parts One and Two, I told you that my husband and I had joined a gym. Guess what? A month later he wimped out on me. Well, okay, in all honesty he did develop a (temporary) sciatica. This diagnosis was enough to put a big smile on his face when the doctor told him to rest his leg. The suggestion wasn’t to rest his leg forever, but it gave him a dignified excuse to gratefully forgo a last effort for great abs. So it’s the Silver & Fit program for me at the for-women-only Curves facility.

Am I still a nurse? The opportunities are rare now: a  sea-sick voyager on a rocking, whale-watching tourist boat, some minor questions from friends and family.  However, determined to maintain my nursing identity, I’ve steered myself toward a few questions of my own as I read in my nursing journals about the rising  number of nurses leaving hospitals to do non-acute care or even for non-nursing positions. They site reasons like age… stress… physical safety… dissatisfaction with the nursing environment…and a BIG one;  management often not  making an effort to retain a qualified, seasoned nurse- an Oldie, sure, but a Goodie. During the last four years of my own nursing career I had just the opposite experience: my manager and clinical director went to bat for me, already a Senior Citizen of 66 when I interviewed for the position. They continued to offer support and/or solutions to any concerns I had, like my afore-mentioned nemesis, electronic charting.  So my own question is, who will be there to take care of the Baby Boomers that are beginning the healthcare journey? The  possibilities that many in their number will need nursing care are very real, particularly with statistics revealing a national increase of obesity and its’ complications, like diabetes, cardiac and kidney disease, and orthopedic problems. I’m still a nurse as I research and write an article about retaining older nurses to help fill the deepening shortage gap. I’m still a nurse as I write about patients once in my care; their courage, their humor, the way they and their families coped, or didn’t cope. Sometimes, remembering a joke a patient told me or a funny story about their day, I record the moment, laughing with them all over again.

These stories are for me, still a nurse.

Joyce

onbeinganurse: A nurse one day..the next day NOT. Part two.

     Four weeks ago, on July 27, I retired from 34 years of nursing. I love my profession and, thanks to the patience of my husband and three growing children,  took great pride in becoming a nurse; beginning as an aid, then a Licenced Practical Nurse and then a Registered Nurse, certified in oncology. On this last day, anticipating personal sadness and tears as I shredded my work folder of daily patient schedules and reference papers, I found myself going through the voluminous folder without a twinge and tearless. It felt to me that it was “time” to let go. During the morning and afternoon the staff had filtered in and out of my location with congratulatory good-byes and hugs, surprising me with a luncheon smorgasbord, balloons and a beautifully decorated farewell cake. I was both pleased and humbled to be the focus of their attention. There were several of my “regular” patients on my schedule and I had an opportunity to tell them what a privilege it’s been to help provide their care. Having cared for my final patient, I closed up my computer’s Electronic Medical Records (EMR) system, the Nemesis of my struggle with electronic charting . That’s when I felt a “tug” at my heart-strings: could I really be feeling I was going to miss the EMR, the worst nightmare of my last four years in nursing practice? It was surprisingly disturbing to shut down my ID number and password for the last time. This was not one of the nostalgic moments I had prepared myself for: I actually felt like I was saying good-bye to the computer as if to a colleague. Weird.

Day 7 post-retirement; issues which concern me:

 (1) Having an undefined amount of available time has made me giddy. These first few days being home I have a case of “flight of ideas”; moving from one project to another just because “I can”, yet not completing any of them.

(2) Words with Friends and Daily Challenge social web sites have become addictive for me, as well as these TV sites; The View, The Ellen DeGeneres Show, Chopped, House Hunters, Hoarding, Say Yes to the Dress, and Paula Dean’s “Best Dishes to You”. I love Paula’s laugh and her Southern accent (but she uses waaaay too much butter!). No wonder I’m not getting anything done around here.

(3) My husband has his own TV, but does he ever turn off ESPN ?

(4) Oh, good: I’m still a nurse; the other day I taught my husband how to draw up his insulin and inject himself. He did very well and I told him so.  Then he endeared himself to my ‘nurse side’ by asking if I’d observe him again the next day, just for reinforcement. Why, sure! Grasping at straws here.

(5) After only one week of retirement I can see that my weekly dance card is in danger of filling up quickly: a library volunteer day, a Senior Citizen Silver Sneakers exercise program, and the inevitable doctor appointments, squashing the myth that retired people have more time for leisurely mornings to just watch the Today Show and The View.

(6) Personal maintenance at my age takes a lot of time every morning: instill dry eye lubricating drops, inhale calcium nasal spray to keep my bones strong, pluck overnight “rouge” chin hairs, swallow a myriad of prescriptions to prevent or cause this-or-that, and pull on thigh-high Jobst support stockings without sacrificing the tendons in both arms.

Day 31 post-retirement:

It’s been a month and, just like other retirees told me, there aren’t enough hours in the day. Or there could be if I re-organized a couple non-priorities. I do miss being a caregiver, though. Maybe I can satisfy this personal need by volunteering a few hours a week at the residential care facility very near us. Before I went to nursing school I was an aid at a nursing home, and loved talking to the residents about their past. Stay tuned to onbeinganurse:A nurse one day…the next day NOT;  part three of three.

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