The Need For Boundaries

So after stating how passionate I am about community nursing I have had a particularly challenging couple of weeks where I had to modify my personal code for nursing.  This code includes all people regardless of age, socio economic status or sexual orientation not only deserve health care they deserve easy access to excellent health care.  This has led me into situations of great poverty, some questionable safe environments that I would never tell my family about (my husband would never sleep again) but I am reassured by the fact that whatever the situation that person needed nursing in that moment.

So, the week before Christmas I was asked to admit a patient whose only insurance was from the Veterans Affairs Dept, lived in poverty, had limited family support but needed nursing services and possibly physical therapy. Well the place was filthy and the patient was elderly but no bugs (I hate bugs!).  Mild dementia was apparent and during the course of my interview, due to the patients past work experience in security I felt led to ask the question "Any firearms in the house?"  To which the patient replied, "Oh yes, plenty and they are all loaded and ready".  Aahh, dilemma, elderly gentleman, not completely orientated on a good day with the ability to blow my brains out.  This was a no brainer, I quickly said my good byes and backed out of the house keeping my eyes on his hands.  But I was conflicted, not being able to put myself and other members of the team in his household was/is a deficit to this mans well being.  Long chat with the family later, explained if the firearms are removed I would surely return....still waiting to hear  A man and his gun are not easily parted.

Second scenario, a patient who I have had on my caseload for over a year, a non-compliant chain smoking COPD patient on O2 (always a good combination).  Basically lonely and due to his, lets say, less than pleasant disposition has alienated most of his family.  No problem for me, he's not my father, brother, uncle and so have always been able to separate myself from his caustic tongue and tried to give him a bit more company and conversation when I had the opportunity.  However, over the last several months, maybe due to early dementia or hypoxia or both his conversation has become very sexually inappropriate not only to me but to other members of the team.  I tried subtle hints of acceptable behavior which led to a full blown come-to-Jesus conversation of what he was and was not allowed to talk about.  All of this did no good, but my attachment to him and my need to come through for him kept me there.  But our therapeutic relationship continued to deteriorate.  The past couple of weeks he has been incredibly well, chest clear, down to smoking one cigarette a day and almost normal pulse ox readings.  I leapt at the chance and discharged him! Aah dilemma, I am no longer providing services to an individual with a chronic illness where I have had the ability to identify problems early enough to avoid several hospital admissions and there were no bugs so surely, how bad could it be!!!

Third scenario, another veteran (getting a lot of those, love them).  Recently discharged after a lengthy stay in the VA for severe abscess that still would require long term wound care.  I arrived at the house to perform the admission and the first thing I noticed was cockroaches and not just a few, I have never seen an infestation this bad, they were almost swarming in the house, crawling all over me and over every surface (did I mention I hate bugs!).  Sterile, clean procedure.....forget it, just do the best you can.  Family seemed oblivious to the infestation and accompanying  hoarding (really ever played Marco Polo in someones house to find them!!).  Of course I reported to the VA Social Work department and every other agency I could think of, may take them a while to respond.  In the meantime, this guy, who I quite liked and had empathy for still needed wound care 3 times a week.  So at the next visit I explained I could not come in the house but still wanted to help him (really had nightmares for nights of cockroaches crawling all over me!).  So we came to an arrangement, he would come out on the porch and I would do his wound care without coming in the house.  Its December....its freezing, so I wrap him up in blankets, expose the appropriate body part, do the care as quickly/safely as I can.  I spend the time apologizing why I am making him sit outside in the cold, he spends the time apologizing for the state of his house, its mutual purgatory.  Dilemma, I feel terrible making this poor man who has multiple chronic medical issues, including PTSD but I do not want to bring any friends along for the ride to another patient or to my own house.

So, even though I have this personal creed that all peoples deserve the best care at anytime, I have to constantly amend my own code of ethics to do the greatest good for the greatest number of people.  Yep, I love community nursing, but I also love wearing clothes you can boil and the right/need to walk away when I absolutely feel I have to.

The Nurse as an Entrepeneur

So, final exams and evaluations are done, wrapped up with a final faculty meeting where we discussed what worked well and what was a struggle, it was a great semester.  Somehow, I was blessed with a great bunch of students who I truly enjoyed, I am grateful.  Quick 6 week turn around until the spring semester starts, what will I do with myself for all that time, you may ask.  Throw myself into my other job!!

I work for myself as an independent contractor as a community nurse.  I have worked in the community for over 12 years, been a slave to someone elses schedule, been owned by companies that wanted to send me where ever they chose.  After a stint of stepping away from community nursing and taking a management job in hospital I realized it was not for me, I thrive on patient contact and yearned to get back into the community but wanted to do it in a different way.

With the help of my husband I set up my own company.   We have 3 children we are supporting through college so the name of the company was a no-brainer, TFT, or "Tuition for Three " because that is ultimately the main reason why I am working sooo hard at this point in my life.  I committed to give it 6 months to be successful and then I would go and look for a "real job".  Well within 7 days my schedule was full and has not slowed down since, apparently there are a lot of sick people out there and they need services.  The advantages of channeling my pay through my own company is the tax benefits, even so much as a soda or a ball point pen can be claimed, and especially that all expensive mileage!  I have control of my schedule, but I am usually so worried about a pipeline of work I often work 7 days a week.  But I do get to take time off and my boss (me!) usually gives it to me, as an example this year I have accompanied my husband on his business trips to San Diego, Salzburg and Orlando, a welcome break in the chaos of life.  The downside of running your own business, doing the monthly spreadsheets. keeping track of all those pesky receipts, no vacation or sick pay.  But without doubt I am happier and more fulfilled being my own boss than I ever have been in my nursing career.

And, I love love love community nursing, it has become a passion and a ministry.  Nursing one person at a time is a luxury many hospital clinicians do not experience on a daily basis.  When I am in a persons home I am there for them and their family without distraction for as long as it takes.  I have an abundance of varied cases at differing acuity levels and no two days are the same.  Serving a mainly medicare population one day I may have several catheterizations, wound care and BP checks, another day it may be diabetic education, palliative care support and pain control.  As an independent contractor in the community it can be very isolating so communication is even more essential, with the primary care provider, other members of the team (Physical/Occupational Therapy, Social Work etc) to ensure effective and safe case management.

It has been a very busy week, kind of nice not to have a split personality of community nurse and clinical instructor but as I look forward to Christmas and the children coming home from University I am sooo grateful I am doing something that I love so much and have some measure of control over my daily destiny.

The Other Side of The Bed

So this was the week where I became the patient and not the clinician.  Started off with a virus (which I ignored, nurses are good at this) which developed into a UTI (sucks to be a woman sometimes) which developed into Pylonephritis, yikes how did that happen.  Well as soon as I realized I had  UTI called my primary who put me on Cipro, me thinks "Cipro never works for me but too sick to argue with him"  Guess what, 48 hours later I am worse so go to my doc again who throws his hands up and says, you are too sick, go to the ER..........I hate the ER!!  I hate the waiting, I hate going over the story again just give me some Bactrim, let me crawl back to bed and I will be fine.

Predictably the ER was horrifically busy, I knew it was not going to get any better when the Helicopter landed bringing in a patient in life threatening condition.  An hour into my wait the triage nurse called me in.  Despite being very sick I tried very hard to engage her with my incredible humor and huge personality.......no eye contact, not one iota of warmth from her cold detached manner.  Maybe she was having a bad day, maybe she was really tired but does any of that matter to the one patient (not necessarily me) sitting in front of her.  Two hours and a pee pot (full of you know what) later I left with my script for Bactrim.  Two days later still feeling like death, when the hospital called me saying the urine culture had come back with a particular nasty resistant bug and would I like to start another antibiotic before we resort to IV medication because I now had pylonephritis!!!  Well now Friday, I do finally feel better but a bit of a washed out, over cooked wet noodle.  Good for nothing.  But of course have been musing the experience all week as all I could do was lie in bed and play on my Ipad and watch way too much daytime TV.  Here are my thoughts.

• Its OK for us to speak up for ourselves and our patients when we are not sure the right treatment is being prescribed, not sure I would have got better on Bactrim as the front line drug but I kick myself that I settled because I did not feel great.  We must learn to put advocate in our vocabulary.
• Therapeutic touch and communication are as important as taking an accurate set of vitals.  Eye contact is a must, listening is essential.  If we do not develop these skills in ourselves and future nurses it shuts down communication which means we as nurses may not get essential information which could be a huge safety issue.
• I am sooooo grateful my husband was in town (he should have been in Chicago but trip got cancelled) and he unexpectedly showed up in the ER even though I told him not to with a cup of tea and a smile in hand!!!!!

So, I missed simulation day which I was hugely disappointed about but now I am going to comfort myself with a whole weekends worth of grading and lengthy evaluations.  Bring it on!!!!

Guest Blogger Day - Allow Natural Death?

Let me introduce to you a dear friend, Karen Brombley, Kal to those who know her well.  We met many years ago when she moved into my neighborhood and it has been one of those precious and sustaining friendships.  We had our first babies together, now those babies are 22 and have 19 year old siblings.  Kal works as  Nurse Consultant for Children and Young People's Palliative Care, currently working on Masters in Clinical Leadership in Palliative Care. She has  been a children's Nurse for 25 years, the last 14 of which have been in the community. Her piece is part of a very topical and important debate, end of life issues. I often think there are worse things than dying when I see my patient caseload.  Thanks so much Kal, for joining the conversation.

Allow Natural Death?

I work in Paediatric Palliative Care and, as you can imagine, one of the most debated issue is that of DNR/DNAR/DNAPCR (there seems to be no limit to the permutations of the initials that can be used). Basically, to resuscitate or not?

 Part of my job, as well supporting children and their families through this process, is to support the teams that are looking after them. Many struggle with this decision, and I try and help them.

How? I believe it’s about understanding the disease progression that the child is suffering from. Understanding that the medical consensus is that the child has reached the point in their life when their death is fast approaching, and nothing will prevent this. Because resuscitating a child at this point is futile, and at worst results in them being intubated on intensive care, having to have treatment withdrawn. This is not a good way to die.

Obviously the most significant conversations are with the child and their parents. I believe that it is our job to work with them, enable them to somehow come to terms with what is happening. They are the only people who will live with these decisions for the rest of their lives. We, the professionals, will remember them occasionally; some children will impact us more than others. But for those parents it’s every day. And we need to enable them to walk the tightrope of choices about care, ensuring that what is right for the child is not lost in the sea of their parents’ grief.

So once such a decision is made it is vital that everyone supports it. Which brings me to lots and lots of teaching sessions, workshops, meetings, working through the issues.

Which is where ‘allow natural death’ comes in. It’s an alternative phrase, rarely used outside of hospices. It’s a very powerful phrase, it changes the perspective from something negative, that implies a denial of something the child is entitled to, to something positive, something natural. It can transform a person’s view, I’ve literally seen that light bulb moment in people when they see that this time can be seen another way. That death is part of a natural process, and sometimes it is right and proper that we leave nature alone.

Millenials in the Clinical Environment

Critical thinking in the millennial generation is something I have been thinking about all year.   I happen to really enjoy millenials.  Maybe its because I have three of my own, but they are a multi-tasking, multi-media get to the point generation.  But, even though they have grown up with social media I still find they yearn for face to face relationship, sometimes they are not always sure how to fill that need.  They are a generation -that energize me with their I-can-do-anything-I-put -my-mind-to attitude, we can't blame them, after all we raised them that way.  And so to critical thinking, an important part of nursing.  How does it compare between the generations?  Are baby boomers more adept at higher level critical thinking than the millennial generation or is it the other way around?

Critical thinking in nursing is essential, you may even say it is critical! It is knowing the next step to do, think, ask intuitively, through experience and evidence presented at the moment.  Critical thinking involves all of the senses and requires a maturity in verbal and non-verbal communication skills. Critical thinking is becoming a growing area of concern in nurse education and nursing practice.  Gone are the days when nurses are called to be the physicians handmaidens, we are independent, thinking, breathing practitioners in our right, with a license and accountability to prove it!

Some of my students, the older ones, with more life experience seem to have better critical thinking skills, they almost know by osmosis they need to take the next step, sometimes nervous to go there, but just need a bit of coaching to make the leap.  Other students, I have noticed, are very weak in their critical thinking skills, it is stopping them from being an OK, barely safe practitioner to an outstanding one.  So, with information from my reading and a seminar I recently attended I have been trying to figure out is it osmosis or I'm-out-of-breath-with-trying, hard work that creates, promotes a clinician with excellent critical thinking skill?  It is a make or break characteristic in nursing practice, worth the effort to dig deeper and see if I can take these students to the next step, taking the leap by themselves, connecting the dots, thinking the questions to ask in the first place.

To date I have been trying to be very clear with my expectations, pointing out (softly) where there are deficits in critical thinking skills and how they can turn that around, using role play and humor seem to help them feel less threatened.  I am not convinced it can be taught to every student but I certainly think that most students get it.
I need to do some more exercises with the students to exaggerate my point, illuminate to them clearly when they have it and when they don't and build on these skills.  If anyone has any tips, please share!!  One of the things I am realizing with millenials is it is not good talking in code or implying with these students (so often my British humor gets lost in translation!!), you have to be concrete, clear, black and white, there is very little grey in their lives......there is sooooo much grey in nursing!  Is this a good thing or not, its great and simple to think in black and white but sometimes there is fun, knowledge, insight and yes, danger in the grey.

Look for some guest bloggers coming up over the next few weeks.  I have a very rich network of nursing peers and I am eager to hear their point of view on the burning issue du jour.

Happy Thanksgiving to all of you who celebrate, and to those of you who don't!!!!!

Caring For The Child, Caring For The Nurse

So today was our last clinical day, not done with the semester yet, still got some stuff to do with my students such as simulation and exams (yuck!) but we have completed the clinical days in the pediatric area.  We all felt like we had achieved something big.  This group of students were particularly good, but they did not start off that way.  On their first day they all looked terrified and I could see their fear getting in the way of their competency, especially their critical thinking skills, so essential to a competent nurse.  Some of them would literally freeze with fear when faced with a situation where they had to make a decision or answer a question correctly.  With gentle coaching, one on one mentoring and assurances they had a soft place to fall I have seen all of them grow.  It got me thinking that we profess to be a caring profession, especially in pediatrics we promote family centered care, caring for the whole family.  We need to learn how to care for the whole nurse.  Horizontal violence in nursing is a growing problem, one I have been a victim of and have left jobs over.  How can we care for the patients and families in our care if we cannot care for each other.

It surprised me how I would ask these young nurses a simple question of "How are you?" with truly a listening heart and all this "stuff" would pour out.  Some of them had major issues going on in their life's which undoubtedly pours over into their work and study lives.

Now we have a break for Thanksgiving, sooo excited, only 4 sleeps until my boys come home from University for a few days.  Then we complete the semester and we all evaluate, calculate grades and find what I can do better and improve upon for the next semester.

So, send me your thoughts.

• How can nurses care for each other without violating the boundaries of privacy?
• How does bullying show up in your workplace and what are you past experiences?
• What strategies can we develop to universally make nursing a more caring profession and try and prevent that very expensive phenomenon of burn out?

Confessions Of A Rookie Nurse Educator

The alarm goes off at 4.30am.  "What was I thinking?",was my first thought.  But as painful as it was I dragged myself out of my warm bed and was on the road by 5.15am arriving of the floor of one of the cities children's hospital by 6am.  How did I get here, well that's a story too.

In 1994 I arrived in the States from the UK due to my husbands job.  With small children I was not too interested in working and to be honest a little burned out from nursing in a badly run socialized health care system in England, where patient acuity was high, staffing and resources always low.  however, after 6 months it became apparent that I needed to work for financial and sanity reasons.  That's when the battle started.  To gain a current US nursing license I had to jump through many hoops some that brought me to tears of frustration.  Many times, I felt like giving up, actually tried doing a few different things but none of them fulfilled me like nursing did.  

I used to joke that I came into nursing to "Hold hands and wipe bottoms."  There is a truth in that, I am immensely edified by the relationships I stumble upon in nursing, the staff, the patients and the family members.  The human contact, often at a time in someones life when they are most vulnerable is a view to the human soul not everyone has the opportunity to experience.

So, several years, many exams, lost paperwork (by the state board of nursing), foreign nurse exam and the dreaded NCLEX I was finally given a license to nurse in the state of Pennsylvania.  Nursing again became a passion but eventually after getting myself firmly in love with community nursing I wanted to do more, I wanted to know more.  I enrolled in an accelerated Masters program.  Almost 4 years later (yes I took the slow poke route), I graduated with an MSN, a proud day.

Almost a year later, still pondering how to fully maximize the huge investment of gaining my Masters, I saw an advert in a local nursing magazine for a clinical instructor for the pediatric module at a Philadelphia University.  I applied and 10 days later I was hired!!  There started a series of faculty meeting where I constantly told myself "I can't do this!".  How does a British trained nurse from the 80's relate and speak into the lives of nursing students who belong to the millennial generation and whom may not be able to relate to me culturally, generationally and professionally.  I had never really worked in an acute setting in the States, still do not understand the US educational system and understand the health care system even less!!

But I kept remembering when I first arrived in the States and was told I could not nurse immediately, how heartbroken I was.  In those days all I wanted was a nursing license, how here I was, a masters prepared nurse about to influence the next generation of nurses.  I could not have dreamed this big for myself, no not in a whole lifetime of hands to hold or bottoms to wipe!!