Schools Out.....Yeah

This semester was busy, chaotic, energizing, challenging, enriching, involved many 5am starts and a few late nights.  Faculty meetings, exams, student evals.......its all done and I am ready to take a breath.

I feel like a did a bit of everything this semester, I was teaching pediatrics, care of the elderly and nurse leadership, but the basic foundation was there.  I want to know who my students are first and then weed out their strengths and weakness and build on their competencies.  Its interesting to those who know me well because I am not an incredibly social person.  I do not seek out friends, parties and gatherings on my free time.  I hate, detest, abhor Christmas parties, small talk wears me down and I feel overwhelmed in a large group.  However, when it comes to students, I can't wait to get to know them.  Their stories are fascinating, how they operate as individuals and as a group in extremely interesting, and watching the generational changes is something I would like to publish on (if I get any spare time that is!!).  I have mainly millenials but I have also had several students who are second career nurses and their stories are rich and their experience of life seems to give them that extra edge.

One of my pediatric clinical groups was like a meeting of the United Nations, I wondered how it would go.  To be honest it was challenging in places, not only if the student did not have English as a first language but also making sense of the cultural context.  However, I saw tremendous growth in all my students and felt privileged to be a part of their journey.  To celebrate a successful end to the semester all my students came to me for afternoon tea.  Everyone brought a dish to pass, what a feast.  We had cucumber sandwiches, Vietnamese shrimp, Peruvian Chicken, Albanian Baklava and good old American Pizza.  Its so hard at the beginning, its exhausting in the middle when you realise you still have a great deal of semester to go, but the feeling of accomplishment at the end is like no other and motivates me to sign on for another semester.

My online teaching classes also finished up this weekend.  The Care of the Elderly class has a final assignment on grief and the student must reflect on a personal experience they have had with the death of a loved one.  I am found grading this assignment with the dog on one side and the cat on the other, howling my eyes out.  There is something about this assignment that is so raw, so beautiful it gets me every time.  Leadership class was excellent, one day I am going to design a class called Leadership and Professionalism, where the curriculum focuses on how to be a good kind and fair leader who nurtures and develops their staff and works hard at eradicating all that in fighting that nursing teams are famous for (again, something I will do in my spare time!!!)

Next semester I will continue with all four classes but it works out that I am out of the house only 2 half days a week and the rest is completed on line.  Busy busy busy but in a good way.  I feel blessed, enriched by what I do and ready for a break!!!!  Spring semester starts middle of January.  Yeah!

Making Mistakes

"Anyone who has never made a mistake has never tried anything new"  Albert Einstein

Making a mistake can be an awful blow to the ego.  Making a mistake in nursing can have life changing consequences.  Making a mistake in pediatric nursing can make you the most hated person for the rest of your life!!!  

Yesterday while teaching pediatric clinicals I made a mistake while supervising a student giving an IV antibiotic to a small child.  Yep, the earth stopped turning, my stomach did several somersaults and it kept me awake all night.  Thankfully it was not a huge mistake, I got the right drug, right patient right route (thank goodness) but I calculated the rate incorrectly resulting in IV was done and pump was still running end game.... in air in the line.  It was not me who discovered the mistake but an observant staff nurse.  However, she chose to take her wrath out on the student and when I stepped in and said its not her fault at all, totally me, I was supervising her.  I then encouraged the staff to make this a teachable moment and go step by step through how to calculate the rate so (me) and the students will hopefully not make that same mistake again.

The student was mortified but in post conference I reminded them that everyone makes mistakes.  Most nurses have made med errors and if they deny it they are lying.  I remember the first time I made a med error I did not sleep for 3 weeks!!  The point is we have to at all costs prevent mistakes through careful teaching and supervision but it's going to happen.  So let's create an environment of "no fail", where its only a failure if you don't learn from it.  I have made many mistakes as a novice and seasoned nurse and there is really no point hiding from it, or getting defensive.  You just have to swallow big, own the mistake and move on.  It still hurts though, spend the night asking myself how did I make such a simple mistake?  How arrogant!!!  It happens to us all, we all have an off day.  

If you see one of your colleagues making a mistake of any proportion say to yourself "there but for the grace of God....."  Embrace them, sympathize, empathize, learn and move on.

Have missed blogging for a couple of weeks, got totally caught up in that holiday called Thanksgiving.  Young adult college age children came home which also means their entourage arrived shortly thereafter.  I love having young adults in the house, spent my time making bacon everything, filling/emptying the dishwasher, folding laundry, picking up beer bottles....you get the idea.  It was heaven, I loved every minute of it. 

Now thankful for a day when I can sit in my office with my buddy (the puppy) and get stuff done as the snow falls heavily outside.......a perfect day.

So....know there is life after you make a mistake, it may even make you a better clinician.

Taking a Breath

Taking a breath sometimes..no often; is essential to create that balance in our lives.  It is something I always seems to be striving for but never quite attaining.  I recently was approached to act as a nurse consultant to a medical health care advertising company for a project they are working on for a major pharma company.   It would involve me stepping away from community health for a while.  All of a sudden that seemed like a very attractive proposition and I realized I needed a break more than I thought I did.  Like most women I think I am superwoman Mon-Fri, then your diet goes to hell in a hand basket because you have less time to organize the pantry, then the fitness regime you promised to follow starts to teeter, then the sleep pattern goes and well, then its all over, you may as well ask the men in white coats to come and take you away in straight jacket!!!  This epiphany came just in time, during a recent trip to see my college age children they informed me that when I am over committed (like all the time!) I range from nasty to an extreme micro manager......really.......and I thought I was handling everything so well!!!

So, I took the option not to renew my contract with the home health agency I have been working with for the past 3 years, put on my corporate clothes (dug them out from the back of the closet) and went off to my first meeting.  Intimidated?  Oh yes, these ad agency creative types are way above me in terms of creativity and dialogue, but during my first meeting I realized we were talking a similar language and our mutual link of health care gave us more in common than I thought.  I have really enjoyed working with this group, not sure where it will go as it is a contract position that could be short or long lived depending on the success of the project.  

I was also asked to pick up an extra clinical teaching day for a colleague who had to go out sick for the rest of the semester.  More students, mentoring and coaching the next generation of nurses, bring it on.  So far they have proved to be a promising and lovely group, I am enjoying them a great deal.  So even though I am still working several jobs, apart from 2 days of teaching I am at home telecommuting and I love it!!  I love the flexibility, I love the fact that I do not quite know what I will be doing after Christmas.  I love the ability to breath a little and recover from that burnout that we all experience every now and again.

Only a week until the kids come home for Thanksgiving, it has to be my favorite week in the whole year, hanging out in our pj's, eating bad food and lots of it and crazy hours of the day and night.  And then packing everyone off back to school with all the leftovers.  Cannot wait!!!  All I need now is a huge snowstorm and I will be extremely happy.

Nursing is like a Hurricane

We have just survived hurricane Sandy.  Compared to our neighbors in New Jersey our experience was the inconvenience of being without power for 48 hours and some minor cosmetic damage to the front of the house.  We are lucky to live in a community where we have close friends with power so at least we could get a hot shower and local coffee shops where we could plug in and stay connected.  But still it disrupted the week.  From a work point of view not much got done, although I did get a 1000 page novel read that I had been meaning to do all year!!  Sleep was not great as it was sooo cold, even with the dog in bed as a foot warmer!  And there was a general feeling of not being in control, of wishing, hoping the power would come on NOW!, and even a rumbling panic of what if the power does not come back for days and days.

When patients become a patient they must feel like this.  A loss of control, someone else is in charge of their destiny for the course of their treatment.  A patient is at the mercy of the medical team and their decisions of what/when care will be administered.  At pediatric clinicals yesterday this was highlighted for me.  A parent had been visited by her medical team at 6.30am (usual time for rounds!  really... busy days of clinic surgery mean an early start).  The team decided her child was well enough to go home.  Well, by 11am the discharge process had not even begun as the doc had not written the order.  Mom was going nuts, as she had other kids at home to care for and was being told if she just walked out ( I could see she was tempted) she would be leaving against medical advice, therefore risking the wrath of the medical team and social work (more aggro than she was willing to take on).  I could see the medical teams point, on a priority list this was low on the totem pole, especially on a week where staffing members were down due to inability to get to the hospital (I have lost count of the number of fallen trees on power lines around here).  But also I had great sympathy/empathy for this parent, we are here to serve her family, not just her child and I am not sure we were doing a great job of keeping her in the loop of communication and hustling the discharge process along better.

When a nurse joins a team she/he may feel like the power went out in the hurricane too.  So many unknowns, what is the culture of the team/organization.  Will people like me?  Will I be competent?  Will there be someone who will show me what to do (for weeks or months if needed)? Will there be that safe person I can ask all my stupid questions to?  Then there is the lack of control over work schedule and assignments, coming to work early, staying late to do paperwork, dealing with the difficult patient, family member, staff member!!  Dealing with the truth that we do not always make it all better and some patients get worse and die, and dealing with our own emotional grief and physical exhaustion throughout that.

Wow, I just reread that last paragraph and wondered if this is truth why would anyone want to be a nurse! However, many have had an incredibly rewarding life in this profession, myself included.  But it is OK to admit the rough stuff, to get it out of the closet of perfectionism.  Over the years you build resilience as a nurse, I am not sure if resilience can be taught but it certainly comes with experience. 

On the 48th hour exactly without power the lights came back on in my house, very very happy.  It was an rough week even though all we really experienced was some minor discomfort but it gave me a greater perspective to not dwell on the small things, I mean really, does it really matter if I cannot log onto Facebook?!!  And to dwell and prioritize the important stuff, family, great friends and work that I love and despite all the thorny points cannot imagine myself doing anything else but staying in Health Care.

Burn Out and Bullying

Did you know the term burnout was first used to describe exhausted an disillusioned health care workers in the 60's, it certainly was a very relevant term.  As nurses it is not uncommon for us to suffer from burn out at some point, this condition is especially prevalent in high acuity areas such as the ER, ICU and Oncology but I think you can suffer it in every speciality, certainly more so if you have one of more bullies in your team!  At a time in nursing when nursing informatics is changing the face of clinical care so much (really when I walk on the floor now often nurses are glued to computer monitors and smart phones and not walking the halls and talking to each other!), and we are being asked to do more with less, who would not get burned out.

For me it is cyclical, I can have peace and harmony for a while then juggling all the different roles I have, clinician, nurse educator, consultant suddenly tumbles like a good game of Jenga and I have to step back and breath a little.  For me that means slowing down, making sure I get to that kickboxing and yoga class (really, it helps sooo much), get a good nights sleep and take care of my diet.  Small changes somehow make me feel a little more in control of the chaos that surrounds me, let's face it, it surrounds us all.  My family always knows when I am super stressed as I am in the kitchen making a dinner that Julia Child would be proud of.  Somehow creating something nutritious centers me, not surprisingly the family are not too upset when I get stressed......they know they are going to get fed.

Taking a step back and taking care of myself also helps me put those bullies and the control I am allowing them to have in my life into some perspective.  As I hinted in my last post a bully usually lashes out because they are operating from a place of pain, insecurity, surely someone who is that nasty must be in personal pain of some kind.  It allows me to think compassionately about that toxic person in my life without condoning their behavior and reestablish good boundaries, so I do not let the bully bother me so much and let them know how little they may get away with at my emotional expense.

The last couple of weeks have been that crazy for me and this week even though I perceived I had no time I walked the dog around the reservoir and just took in the colors and the great weather, went that extra mile at kickboxing (boy does it make me sleep better) and determined to make that yoga class tonight before my 4.30am start tomorrow for pediatric clinicals, which is going really well.  Heck I love students.

I promise this is the last post on bullying for a while but probably not the last word on taking care of ourselves as nurses.  We have to give ourselves permission to put ourselves first for at least 5 minutes a day and have/be a great day!!!!

Bullying In Nursing Culture Part 2

There is a point when you get way into your 40's (like me!) that you hope all the bullying and passive aggressive remarks in nursing will 1. Disappear or 2. Float off your back without sustaining the sting they intended.  Sadly I have more luck of the sun not rising in the morning.  Let's face it, we are a female dominated, dysfunction relationship, sad example of girlfriends gone toxic.   

My husband who is very successful in business can have a heated discussion with a co-worker and then go out with him for a beer.  I can interpret the most innocent of remarks as an attack on my performance, intentions, work ethic and character and not sleep for a week!!  This is because men are able to compartmentalize professional and personal and women cannot and therein lies part of the issue.

I was once a part of such a dysfunctional team that management forced us to do group therapy....yep that was about as much fun as cleaning up an over full exploding colostomy bag!!  But I do remember one this the therapist told us.

"Think the best of me and I will think the best of you!"

I have tried (not always successful) to apply that to my work relationships.  Maybe if that colleague called out she really is sick, maybe when your co-worker gave you the stink eye she was thinking about other things like troubles at home, maybe when your team mate snapped your head off it was because her to-do list is so long and she has not slept in 2 nights as she was up with her baby who is teething.  Who knows what the reason is, but the point is peoples bad moods and reactions to us is not always about us and so we should try and take the high road and focus on what we are doing right and not on that one thing we may have done wrong or that one thing that your co-worker wants the whole team to know you did wrong!!

We cannot change the psychosis of bullying within our profession over night but we can start with us.  Chose to be kind, chose not to participate in the gossip, in fact flee from it and make it known you will not participate.  Set an example for the novice nurse and the nurse who is unable to defend herself.  Be a champion of kindness and let's start caring for each other the way we care for our patients.

Bullying Within Nursing Culture Part 1

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Nurses are often called “Angels”.  This term has made me feel uncomfortable when directed at me.  If that patient and their family only knew all my foibles and judgmental thoughts that go through my head in the course of a day.  However, sometimes we are not very angelic towards our colleagues.   

This phenomenon has many terms these days, nurses eating their young, nurse bullying, horizontal violence.  The good thing is, it is being documented and written about more and more in nurse literature, but is it decreasing the incidence of horizontal violence.

I am sure every nurse reading this can remember a time when they were the victim of bullying in the workplace.  The discomfort of being victimized by this never leaves us.  It can be especially bad for new nurses; at a time when they need to be mentored and supported they are wondering if they made the biggest mistake of their lives by joining this angelic vocation called Nursing?!

I once left a job when the bullying got so bad.  I loved the job, but a few burned out cynical nurses who decided to put a target on my back made life at work so toxic I did something I am not proud of.  I handed in my notice and walked out the same day!  This is not something I would recommend, but the situation had become so bad and once I handed in my notice I actually was in fear of the consequences so I just left and never went back.  Not cool, really not cool but I also have to say it was a vote for my emotional safety and I do not entirely regret it. 

The job started well enough, it was a new area for me but I was eager to learn.  The team were supportive, wanted to get to know me but it was obvious that a few nurses who had been there several years were burned out in the high stress area of pediatric oncology and had become victims to their situation, claiming their victim hood as a source of self-soothing for the daily grind.  It started with the usual gossip of other team members; with things as trivial as a perceived bad hair style to accusations of work ethic (really sometimes junior high never ends for some people).  I tried hard not to participate in these conversations; maybe that was my first mistake and the beginning of the target on my back.  I soon was avoiding coffee and lunch with certain nurses because then the trash talking would get really bad.  It set me apart; maybe they thought I was better than them.  Nothing could be further from the truth, not a novice nurse, but one in a new area, I felt I was drowning in information I did not completely understand and had nowhere to turn.  Physicians were too busy to entertain my frequent questions and certain nurses looked at me as if I was asking yet another stupid question.

Then started the withholding information, a power play that made me feel even more isolated.  Sometimes it was just that almost insignificant team stuff that makes you feel a part of the team, so and so if pregnant, isn’t that great?  Drinks after work, would you like to come?  Then this escalated to the team emails, highlighting that one small error I had made in a very public way. Often they came on a Friday afternoon so I would be in agony about the issue all weekend and dreading going back to work by Monday morning.  

Reasonable conversation helped in the short term but then the abusive behavior would start again.  When I took it to my supervisor I was told I needed to deal with this myself, it was the best way.  I had always prided myself as having good communication skills and not lacking in personal confidence in the workplace and a team player.  But I recognized I too was turning into a victim.  I seconded guessed what I was doing.  Once after I addressed the passive aggressive behavior face to face no one talked to me for two weeks!!! Well, clearly that did not work.  Soon I was crying every day on the way home from work and then I was waking at 2am dreading going to work.  My husband begged me to find a solution. I left but for a long time felt like I had failed in that position, when in reality the organization failed me.  It can be a silent lonely experience to be victimized in the workplace.  Bullies have a perceived power that is hard to come up against, it takes a fair amount of courage and emotional energy to make the daily attack that will enable long term change.

This was my story, everyone has one, and sadly I know this is true.  As I start this series on nurse on nurse conflict I would love to hear your story.  Please email me at angiemiller1966@yahoo.com and I will publish your story, anonymously if you prefer.

·        
        What is your experience?

·       How would you have handled it differently?

·       What tools and support do you think would have made the situation better

·       How can we finally stop this happening to novice and expert nurses alike

Nursing Informatics - Curse or Crucial

As the title of this post may suggest I am having a love hate relationship with technology this week.  However, I learned long ago I better get with the program or I would be left far far behind in every aspect of nursing.  Technology is a fast growing, rapidly essential part of everyone's nursing practice.  From learning to take a blood pressure with the touchscreen monitor at the bedside (first you have to set the right profile, know the right buttons to press, being able to trouble shoot - you get the idea!) to the ipad applications that are just there for those in the health care profession.  Yes, yes I know these tools are there to make my job easier and promote high quality of nursing care, but instead of getting a BSN there are some days I wish I had a degree in computer science!

The online class I teach has just changed it learning environment from EPIC to Blackboard.  Now I had just come to terms with EPIC, me and EPIC had recently become friends, I was able to join the discussion board, use the grade book, send and receive emails all without too much stress.  Now my new love is Blackboard but we are like a dysfunctional couple from the "Bachelor", we desperately want to make it work but we do not really know each other yet, and we are in love with the thought of being together but the reality.....well it leaves me wanting.  Learning a whole new system has seriously slowed down my productivity and increased my stress this week.

The University I am a clinical instructor for recently changed their email server from Outlook to Google.....What!!!!  What was wrong with Outlook, it was an old friend, like sleeping in your favorite t-shirt.  This Google thing is for the millennials, how do I populate my address book,why am I now getting emails from the whole university not just the nursing department.  I am not really interested in who is running for freshman student government (although I am sure it is extremely valid), but now I am getting daily emails from Tiffany, Justin and Dave trying to persuade me why they need my vote!!!

Now don't get me wrong, I am a lover of technology.  In our house we have more computers than TVs, sad fact is you will often find my husband and myself in the evening working on our laptops and ipads spontaneously.  I pride myself on being a multi tasker, I can cook dinner and text my kids with one hand behind my back.  But sometimes technology goes so fast I feel stressed, marooned with nowhere to go.  Thank goodness I have very techy children who are also nocturnal so I can call them at anytime of the night.  Goodness knows how I would have got through grad school without Elliot showing me how to use PowerPoint.

And it got me thinking, nursing is one of those multi generational professions.  We have nurses in their 60's and their 20's who must both coexist with peace in the clinical environment.  And technology can make it hard for those who have not been exposed to it all their lives and fear looking stupid if they ask for help too many times.  In the converse, the older more mastered nurses often do not tolerate the millenials with the insane ability of opposable thumbs and the ability to listen to you while playing on their smart phone!  There must be tolerance both ways because I am afraid my friends that accelerated technology is here to stay.  

All I can say is HELP!!!!!

Nurse Leadership

I have just come to the end of teaching an online class on nurse leadership, it is a class I have done a few times now and its good to deal with a familiar syllabus and understand upcoming assignments better.  The course content has stirred in my thoughts about nurse leadership and a discussion with students that is new and energizing.

I look back at the nurse leaders I have been fortunate enough to work with and I learned something from all of them, the good ones as well as the bad!  I have had leaders who have had a transformational democratic style and those who were undoubtedly autocratic dictators!!  I remember one of my first student nurse clinical experiences on a surgical unit in a small mining town in Northern England.  The matron on the floor had trained in the military..enough said, you could eat off her floors.  She ran her floor like a D Day reenactment!  It was intimidating, we asked very few questions but somehow learning took place and the patients were cared for beautifully.  I do not remember one post op surgical infection, no-one went a day and a half without pooping! and those beds were made with crisp sharp angles on the corners!  But I also took from that experience I did not want to be an intimidating leader, I wanted relationship, to be a mentor, more of a coach and that is what I have based my hands on and teaching career on in nursing.  I also remember my first job as a graduate nurse on a busy Neuro Ward in Oxford, England.  The matron had an open door policy, wanted to know all her staff and their husbands, wives and children.  We socialized outside of work, it felt like family, community.  It was a gift as a new nurse to be able to make mistakes in a safe and supported place, I learned so much and still think back on that time with fondness.

The syllabus for this leadership class also presents the students with a survey of how politically savvy are they.  Very valuable tool, are they connected to the staff as a community or do they operate in an isolated way?  Is their voice influential and is their leadership style appropriate for the environment or do they need to consider changing it?   This survey led to much class room discussion on who we are, why we are the way we are, and what is the cost benefit/loss of all of it.  To be influential, powerful and effective as a leader I do not think you have to have the loudest voice, strongest personality or the most letters after your name, although I do think education gives you greater credibility.  But I do think you must be authentic, have incredibly high standards of nursing care, treat patients, colleagues of every color, rank and skill with respect and keep working on growing professionally and personally.

Yet Another Nursing Dilemma

Of course as nurses we often have daily dilemma's because caring for people can be messy, does not always fit into any ethically correct template, all those variables of people, family, diagnosis, living arrangements, emotional state, motivation or lack of it play into the outcomes of the nursing plan I devise at admission.

I have this patient, lets call her Alice, she lives with her mentally challenged brother who is high functioning but certainly not capable of making any of the household decisions.  Alice has COPD caused undoubtedly from her addiction to cigarettes.  She is admitted to the hospital on average once a month due to an exacerbation of COPD, is on 6 liters of O2, still smokes at least a pack a day.  Alice has type 2 diabetes caused undoubtedly from extended use of steroids for her COPD and an addiction to fast food, she is low income and so I have organized meals on wheels to be delivered every week, she is completely home bound so I also organized a food pantry to deliver to her every week.  She orders out fast food to be delivered daily.  The end of the money always comes way before the end of the month.  She cries and cries by the 20th of every month that she has no funds to feed her or her brother even though the fridge and freezer is full of donated food she does not want to eat.  She is estranged from most of her family due to her unhealthy lifestyle, they are all exhausted with trying to help her, so Alice is basically alone with her brother.

Alice has pulse ox consistently in the high 80's on O2 and her blood sugars are regularly over 250 in the morning if she takes them at all.  There are many other diagnosis including colitis, depression, fibromyalgia, cataracts to name but a few.  She sees her physician monthly (when she is not in hospital) but he has all but given up on her because she never follows instructions.

For the past 18 months I have been seeing Alice, twice sometimes three times a week to monitor her physical status and teach/encourage her on smoking cessation strategies, compliance with a diabetic diet, and most of all O2 safety in the home (I am so afraid she will blow up her and her brother when smoking during O2 use).  Nothing has changed, if anything her physical condition gets progressively worse.  And in the midst of all this, we became friends, I like Alice, she likes me.  We start and end our visits with a hug.  She has my cell phone number memorized (not always a good thing!).  And so I continued to go and attend to her needs, and I know her physical therapist was working as hard as I was to help Alice reach her potential, all to no avail.  This week I realized I had become another one of her enablers.  It would have been easier if Alice were obnoxious, verbally aggressive but she is not, she is sweet and grateful and has no interest in participating in her plan of care.  I am no longer helping her in anyway.  So after a case conference with the team and her family doctor this will be the last week I will see Alice.

She cried when I told her, she scowled when I honestly told her why, she does not want to change but she does not want to lose her team.  Unfortunately when Medicare is paying all the bills you cannot have it both ways.  Above all that I realized Alice needs a new team, fresh eyes and she also needs to see accountability in her poor sick addicted life.  I am torn about this decision as I am certain it is the right direction to go but I also struggle with Alice's perception that I am abandoning her.  I continue to explore the benefits of keeping a nurse patient relationship therapeutic, sometimes its not as easy as the text book says it is!

Summer.....what Summer

So great plans and all that.  My summer was supposed to be quiet and serene, lots of time for getting through that pile of books in my study and do some writing, including updating this blog on a weekly basis.  What happened?  Life happened.  We spent the beginning and the end of the summer travelling to Barcelona, London, and later South Carolina and Colorado and thoroughly enjoyed all of it, especially Colorado, there is something about being in the mountains that speaks to my soul, restores me a little, we all need that every now and again, especially in a high burnout profession like Nursing.

I continued with community nursing which had its very busy weeks covering for staff who were gone on vacation.  I had both interesting, sweet and challenging patients and some very hostile relatives.  I continually tell myself, their aggression is not really about me, its more about the frustration of their situation.  For an elderly patient who is facing end of life issues, a helpless relative can feel powerless and this can come across as dissatisfaction of care to the health professional in the line of fire (literally!).  Even though I know all this after several "not so nice" rels this summer I admit to it all getting a little old, being shouted at and second guessed several times a week.  But we soldier on, the hands on care is still the most magical part of nursing for me.

I also continued with my online teaching commitments.  This summer I have been coaching a leadership class and thoroughly enjoying it.  These young BSN students see themselves as novices even though many of them have years of clinical experience.  But the online education experience is a wonderful medium to exchange powerful ideas, lively discussions, solve issues hypothetically through PowerPoint presentations and develop a base knowledge that will hopefully lead them onto successful leadership positions.  All I really have to do is facilitate and grade 60 papers every weekend (groan!), all done at home by the power of my laptop, my perfect kind of job.

Just when things got to August and looked like I may have a month of breathing space before my semester starts again for my traditional teaching job at a Philadelphia University we met this guy....

I really was uncertain about doing the dog thing after losing our beloved Golden Retriever in April.  However one particular weekend when I was missing him so acutely my husband put me in the car and took me to a pet adoption at a local pet store....and there we met Toby.  It was love at first sight.  An adorable choc lab/pointer mix.  Loves to snuggle, chew cell phones and TV remotes.  He is especially fond of the 3am pee followed by a snuggle in bed.  And so I am now walking the neighborhood at 7am/pm every day, chasing him around the house with my carpet shampooer (forgot how much work potty training is), trying to persuade him not to eat the cat daily ( I secretly think the cat quite enjoys it!).  Exhausted and enjoying every minute of him

Faculty meetings have begun, planning and organizing a new semester is ongoing, I am ready to roll with whatever fall brings me and looking forward to it.

How was your summer?

Global Nursing

I was recently in London and attended a conference titled, Nurse Led Clinics.  It was a fascinating day with many excellent speakers.  As an advanced practice nurse who runs her own company and loves being my own boss I was interested to see how this concept was being developed in the UK, my homeland but one I have not worked in as a health care professional for nearly 20 years.

It seems the National Health Care Service is moving in the same way (relatively speaking) as the US, in terms of need for accountability of costs, tendering of services - which means there is no reason why nurses, physical therapists and others cannot form their own groups and bid for contracts.  It is an exciting time of change in the UK.  However, I appreciate not being a part of the NHS anymore it is probably very frustrating to live with these changes.  What is refreshing is that the UK system is still a service based industry whereas the US health care system is very much profit driven, sometimes quality of care gets lost in both systems.

I see a two tier system developing in the UK, where many people now have private insurance through their employers and prefer to get their point of service care, elective surgery and treatment through the private route.  Does this make the free NHS suffer, not sure, have not had enough exposure to that lately to make a judgement.  However, it does not seem that much different to the US system where we have the medicare/medicaid population, the totally uninsured and the rest of the nation.  It certainly is a tiered system where there are different levels of quality care depending of what coverage you have.

It was not all work though, I thoroughly enjoyed Barcelona, especially the flamenco festival that was taking place right outside our hotel.  It was lovely to see London draped in Union Jacks in anticipation of the Queens Jubilee (God Bless her) and the Summer Olympics.

Now back to the reality of home.  Have started double duty in my community health class that I teach on line, balancing 50 students instead of the usual 30!!!  I just keep saying to myself "Angie, you got this, you so have this!!"  Community health work has slowed down a little this week for which I am grateful.  I have not taught this class since February so I am taking the extra time to catch up on readings and go through the syllabus in detail.

I feel like I am on a new summer schedule and it feels good, getting up late, lazy breakfast, check in with my students, do a few visits, wander around my beautiful yard dead heading and pruning and then back to check in with my students later on in the day.  I could get used to this, very satisfying.

Next trip is to South Carolina in July and potentially a trip to Colorado in August. Life is good, long may it continue.

End of One Thing, Beginning of Another

The spring semester has finally been completed.  I should not be shocked at how much I learn from the students, but I do and I hope they learn much from me not just about pediatrics but about the art of nursing.  I think I have said before I am not just interested in developing these young adults as nurses but also as people.  The time I have getting to know them, learning their stresses and their joys brings a great deal of satisfaction to my teaching experience.  Every group seems to have its own "personality".  This group was more nervous than previous ones but very personable and teachable, they made me smile and though some of them lacked confidence (unduly) in their clinical skills their people skills were excellent.  I was very pleased the way they reached out to the children and family on the floor.

One of the most difficult cases we had this semester and one many of them spoke of in their reflection paper was the admission of a child who had been severely abused and showed evidence of several old fractures.  The students were quick to judge the parents/caretakers of this child, and I too struggled with the pain this small child was enduring.  But it was a lesson in tolerance and practicing non-judgemental care to the whole family.  While child abuse for me will always be without question inexcusable we have to remind ourselves as practitioners that we do not know the whole story and we must suspend our strong emotions so they do not get in the way of the care we are called to give.  I am thankful for Social Workers and DHS who do the hard work in these situations.  Needless to say this child received a huge amount of attention by all students and staff while he was in our care, we managed to get a few smiles out of him.

The rest of the semester was uneventful, we had our fair share of asthma, bronchiolitis, pylonephritis, basic stuff but excellent to teach the fundamentals.  I am excited to have just found some wonderful 3D applications for my ipad of the kidney and lungs that will make great teaching tools next semester (thanks hubby)  Its always easier to visualize the anatomy and explain the disease process rather than just verbalize it.

Exams and evaluations are complete, even had my students over for a celebratory afternoon tea which I loved so I intend to do that again.  Whats next for me.

A summer of work but in a different way, I intend to teach two classes simultaneously online which will be busy but hopefully done from the sun trap called my deck.  Of course I will continue with my community nursing but the goal is to gradually scale back and do more teaching on line and in the traditional setting, we shall see what future opportunities bring.

At the moment we are having a sad time in my house, mourning the loss of my dear 13 year old Golden Retriever who we had since he was 8 weeks old and was as much an integral part of the family as the kids.  Medicating my grief with some travel, about to tag along on my husbands business trips to Barcelona, England and South Carolina to name but a few.  When the kids leave for college and the animals start dying we find ourselves in transition again, I want to embrace the change sometimes it just comes a bit quick!!!!!

Weekend On Call

About once a month I do the on call schedule for the nursing agency I contract with.  This weekend was my turn on call and it was horrific.  I spent the weekend looking at stinky butts and feet with no toes on!!

Enough said.......just wanted to get that off my chest.

Ageism and My Misconceptions

So, this week I started teaching a new online class on aging populations.  It is an extreme change for me after being so involved in pediatrics for the past 20 plus years.  However, following my return to community health I have seen a mainly an elderly population and have found I absolutely love this demographic.  Anyways, week ones topic was ageism, what is it, are we guilty of it and how do we deal with it.

First of all the students were required to take a self assessment survey to judge their baseline prejudices and knowledge of the elderly.  I took the survey myself, found not only did I hold many prejudices about the elderly but I also assumed to be true many myths and did not do as well as I thought I should....a little humbling moment for Angie.  For example, I am a huge offender of calling the elderly sweetie and honey.  Now I have to admit that on a busy day I sometimes do this if I cannot remember a patients name, but still it must stop, a person is a person (Happy Birthday Dr Seuss) and they deserve to be addressed correctly.  On first meeting I do try very hard to greet the new patient as Mr or Mrs So and So but after that all bets are off.....I will make a better effort.  

I assumed that pain was a natural symptom of aging, not so, pain is a symptom of disease and should always be assessed and evaluated.  Here I am Miss Self Righteous Pediatric Clinical Instructor preaching to my students every week that pain is what the patient says it is and all children should be assessed with the appropriate scale.  Going to do a better job on that one too!

I also incorrectly assumed that the elderly get more religious as they get older and deal with change better but apparently this is also not true.  When I think about it I am getting less enamoured with organized religion and less inclined to change my present situation because I have about as much I can handle right now so why should aging be a catalyst to liking religion or change anymore than you do when younger.

I can see how this course will challenge me on many levels but will only help me in my scope of practice.  The discussions are already lively and challenging, a good bunch of students.  Looking forward to the next 5 weeks of learning and facilitating all I can.

New Semester. New Challenges

Its January, its cold (not as cold as it could be) and class has started for the traditional setting and the online environment.  This semester I continue as clinical instructor for the pediatric module at Holy Family doing our clinicals at a busy inner city pediatric hospital.  I think as a faculty we well and truly overwhelmed these poor students the first two weeks of orientation, I know I had a headache by the end of it.  Finally last Thursday at 6.30am sharp (I had been there a while by then.....yawn!) we were all on the floor, ready for assignments, implementing the nursing process, using evaluation and critical thinking skills like it was second nature, and oh yes....mastering the dreaded paperwork!  It went well, again a lovely bunch of students, I already know I am going to enjoy them once they stop being so terrified and realize they know more than they think they do.  But its good to be cautious in a new situation like this.  We will work on and build skills as we go.

Comparing that with the online class I am teaching there is a world of difference and similarities with the two learning environments.  I am in week 4 of teaching a community health class called Vulnerable Populations, the syllabus is excellent (thank goodness I did not have to write it), the readings are wonderful, engaging and up to date, the online environment is a nightmare to navigate.  The first week I struggled to do such simple tasks as post my welcome letter, get to email, and grading papers gave me hives.....too many buttons to push.  Everything has to be done within the online world, it has been a sharp learning curve but now we are in week 4 I feel I am just beginning to get the hang of it.  I have already signed on to teach another class in February on Older Populations....it cant be that different from pediatrics ...right?  That being said, a student is a student, these students have an electronic relationship with me but I still think given a little effort you can build a sense of community.  I have tried to get involved with the discussion boards, answer questions and emails promptly and even put in that extra human-Angie touch.  These students struggle like every other student with balancing work, family, school...been there...done that.  Its hard, you give up a great deal, tv, a social life, food beyond frozen pizza.  However, online education means you can plan and write papers, participate in group discussion at any time of the day or night.  For example I graded papers this morning in my pajamas in bed while watching the Today Show.......that's a pretty good gig.

It is expensive with time though, I am online seven days a week, I am working as a community health nurse sometimes seven days a week.  But thank goodness I have a job that I love and my sweet dog just lies by my feet and keeps me company!!  Next week I am praying for snow (with no power cuts) so I don't have to go anywhere.

Dealing With The Difficult Patient

Amazing as it may sound not everyone is thrilled to see me when I knock on the door with my sunshine and promises of supernatural healing powers!!  Some people are grumpy, angry, weepy, unresponsive, talk too much, talk too little.  Some people have an agenda to get me in the middle of their family squabbles and of course pass judgement in their favor.  Some people expect me to stay for dinner, walk the dog, do the laundry and clean the bathroom.  Yep, I have been asked to do it all and seen so much dysfunction in the family group I almost think my family is normal (steady on, I said "almost).

I was once asked in an interview for a job how I dealt with difficult people and after I thought about it for a moment, I answered something like this.

I do not consider that I have difficult patients.  I have patients that have baggage like most of us, maybe their baggage is more focused because of an acute illness or the exacerbation of a chronic one.  People exhibit stress in so many different ways.  The way a person manifests stressed maybe directed at me, the nurse, because I am supposed to be there to fix the problem and don't I have a resource list the size of a telephone book!  I have learned to take a deep breath before answering and realize the negativity in the room is not about me and I should not take it personally.  This person has a problem that needs solving, and we can brainstorm together.  When I turn it around and show concern for a patients anxiety they usually calm down and we can discuss/identify the real problem at hand, be that financial, emotional, a pain response, a lack of acceptance of the health issue.  But sometimes a person does not calm down, then its time for a time out and I try and leave to protect everyone.

When I am in a patients house, carrying out care I tend to be chatty, some may say overly chatty!  I like to ask a lot of questions, why? because fact finding is a safety tool to find out more of a persons health status.  But I also ask lots of questions because I think peoples stories are just so interesting.  In the medicare population I serve I have met a survivor from Auschwitz, a lady (now 90) who immigrated on her own from Italy when she was 16, WW2 veterans and more recently veterans from Iraq and Afghanistan wars.  These boys are just a little older than my oldest son so the maternal feelings kick in very strongly.   One young man I a seeing right now, several times a week for wound care needs can be pleasant and sociable and then the next day can be as dark as a black hole, PTSD is a terrible thing.

Unfortunately, not everyone wants chatty Kathy in their ear when I am doing wound care or checking a BP, I have learned to be quiet when I need to.  Quietness can be an important therapeutic tool when dealing with "difficult patients".  It gives a person control of what to say and when.  Its hard as heck for me to shut up sometimes but it is valuable to hear what comes back.

Now, if I could just learn to do that at home!!!!!