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!!!!!

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.