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!!!!