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child at this point is futile, and at worst results in them being intubated on intensive care, having to have treatment withdrawn.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!!