is it time for a nursing moratorium?

Dragging myself to a shift has been a struggle for a while now, but I only realised the extent of my malaise when I sat down now to write - going back over my (rather sparse) posts, I discovered it was a way back in October that I first reported my almost decision to quit. That's six months of hating my job.

Attempting to be objective, I can see that it isn't necessarily nursing I hate. It's more a case of my ward environment getting me down.

Horizontal violence still lives - in fact it's kicking along quite strongly in my corner of the world.

When I first started on this ward I thought if I could put my head down, hive off to my patients and put in a good days work I might survive. I was wrong. More than wrong. I was seriously deluding myself. My work environment is slowly killing my passion for nursing and care.

All this became quite clear to me a few nights ago. I was working a late shift with a male nurse from the hospital's nursing pool. He had previously been employed on the ward, but a few months ago left to (among other things) escape the ward culture. As we chatted I found a different man - relaxed, pleasant, altogether transformed. When I pointed out his new found peace he detailed his journey to the edge and back. He too almost quit nursing because of the ward environment. Since leaving he has rediscovered his nursing mojo. Now when he works a shift on my ward he is appalled by the shallowness, nastiness, exclusivity and power games. I am not imagining things.

So where does this leave me? What to do?

Get out. Leave the ward. Find another work environment fast, before my soul is destroyed.

Easier said than done, believe me! In my corner of the world there is one public hospital (where I am employed) with four medical, two surgical, one paediatric and three women's health wards. Throw in a limited number of specialty areas (with often equally nasty nurses) and we're not talking a huge range of choice. Across town there are two private hospitals. I do not find the prospect of working under a bigger pump in an institution attempting to operate profitably the least bit appealing. A minor issue is that I would also lose the tax benefits offered to those who choose to stay in the public sector (to the tune of several thousand dollars annually).

One option is to return to the ward where I was previously employed, but I don't like orthopaedics. The mindless churning through of total knee and hip replacements is almost as soul destroying as bitchy work mates. Nursing pool offers some hope, but it doesn't really offer the stimulation I need - those medical wards are full of patients awaiting nursing home placement. Yes, they still deserve care but I'm a surgical nurse by nature. Endless cycles of bed baths and pressure area rounds don't appeal.

I'm almost stumped. Quitting nursing appears the only option... Unless...

Unless I take up my friend's offer of employment in the ORS. In my grad year I did a few months in theatre. Admittedly it's a big stretch from scrubbing independently for knee arthroscopy after knee arthroscopy to being a functioning, independent member of the team. But maybe that's just the stimulation I need! And I know there is good educational support.

So I might not quit nursing, I might just step sideways. I'll keep you posted.

the influence and power of being a nurse

I have always felt the weight of the influence I can exert as a nurse in my sphere of the world - acquaintances sidle up to me and ask for advice on this or that ailment as we mingle at social gatherings; my emphasis on the importance of this or that medication contributes to patient compliance on discharge; a failure to stress the importance of chest physio or leg exercises or sitting out may make the difference between a complication free recuperation or not.

Conversely, what I say may make no difference at all. Which nurse hasn't experienced the mortification of educating a patient only to have them ask the doctor the self same questions? Of course when the doctor advises them of the exact same information we provided, they sit up and listen as if it is news they have never heard before and we, silly nurses, are left looking incompetent and uninformed.

What fascinates me is the subtlety with which a person can be swayed. A couple of weeks ago I was looking after a patient who needed significant rehabilitation, but he had no insight into this. In fact, because he was improving physically he was convinced he was ready to discharge straight away. He repeatedly asked why he could not leave today and I repeatedly advised him of the need to wait for a place in the rehab unit in order to ensure he was fully ready for discharge. He wrestled with the constraints of the delay, but with constant redirection he could be reminded of how useful waiting would be. His wife backed me up in reinforcing the situation.

The next morning another nurse sailed into the room, listened to the patient's pleas for discharge and, before providing any care in terms of assistance with daily living or observation of mental capability, decided he could see no reason why the patient could not be discharged. The next thing I knew the patient was surrounded by his four young children advising me he was going home to be with his five children. The children stared rather strangely at him, because in truth there were only four of them, but they still smiled with shy joy, for dad was finally coming home. Suddenly occupational therapists, physios, doctors and the charge nurse were all milling around trying to ensure the patient would be well supported at home despite his decision to discharge himself against medical advice. The patient was discharged into his wife's care with a full range of community support in place.

I can't help wondering what role the patient's allocated nurse played that day. When I cared for the patient the day before there had been no talk from the wife or the patient of going home immediately. We continually steered the conversation back into the safe waters of rehabilitation. What did that nurse say that day to convince the patient he might succeed in his quest to go leave hospital?

I was so curious about this I actually challenged the nurse about his actions and comments to the patient and his wife. He looked wounded as he defended himself, assuring me he had said nothing that might be construed as encouraging the patient to discharge himself. But I am not convinced - nurses have influence, patients listen to what we say. They observe our actions, they notice our attitudes and they make decisions with this in mind. That nurse only needed to imply agreement with the patient's readiness to discharge and it could have been enough to convince him to pursue the option.

Two weeks on, I wonder how he's going, the too-soon-discharged man. Is his wife coping with the demands of someone who in all truth needed rehabilitation? What impact is his early departure from hospital having on those four young children?

Maybe I will never know, but one thing I am sure of is this - what I say makes a difference to my patients. Whether I like it or not, a great deal of power is vested in my status as a nurse, and with that power comes the responsibility to work through the implications of my influence for a patient's good or bad. It would be beneficial if I used my power wisely and carefully in order to achieve the best outcomes possible for those entrusted to my care.

oh what a night

Disclaimer: Please stop reading now if you don't deal well with death or have lost a loved one recently. There is probably another blog more suited to your needs right now and I urge you to visit them rather than linger here.

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Call me good or (philosophical debates aside) call it luck, but in my twelve years as a nurse I've never had a patient die unexpectedly while under my care. Of course various patients have died along the way, but their deaths were relatively peaceful and anticipated and I was able to offer comfort and dignity in their last moments. I find these ministrations rewarding and meaningful and I don't shy away from them. For me it is an honour to be there in a person's final hours.

Still, it came as something of a shock to find a patient obviously dead at 4am last night. I knew the moment I stepped behind the curtain, but as she was still listed for resuscitation I had to respond to the emergency and call a code. She'd been unwell for some time and we could not revive her. As we pulled up the sheet and recorded the time of death our heads were spinning. Night shifts run on skeleton staff so there was no chance to sit with the patient and pay our respects. It was immediately on to the tasks left undone during the emergency.

At 5am I helped turn a patient and was not happy with her condition. She had deteriorated significantly during the course of the night so I asked the doctor to come and review her. At 6:15am we called another code. After 15 minutes this patient too was declared deceased, in the bed right next to the first patient. Again there was no time to contemplate, reflect, or honour the long, full life of this patient. We had little choice but to madly try to complete our duties before the morning staff arrived.

The whole episode seemed quite surreal. Two patients in one night, right next to each other? Unheard of, at least in this small place. Then there was the automatic defibrillator that kept telling us in a mechanical voice to stop CPR while it analysed a heart rhythm we knew did not exist. As I shut the lid to silence it, the strident voice called out 'open lid to continue CPR' and we couldn't help but laugh wryly at the incongruity of the situation. Then there was the nurse on another ward, who could not have failed to hear the code called over the hospital PA, but still kept phoning and asking for assistance with a relatively minor problem they had. Things became more absurd when other patients, oblivious to the mayhem, buzzed for blankets, bed pans, clean sheets, panadol. I stared at them dazedly - blankets, bedpans, clean sheets and panadol in the midst of pandemonium as we attempted to cheat death? I dished out requests quickly and quietly, asking for patience as we sought to recover from each crisis.

When the night finally ended we four nurses ducked down to the local cafe for a drink and debrief before heading home to sleep and do it all again tonight.

Only I'm not doing it again tonight, because as it turns out I couldn't sleep. I kept seeing the dead, pondering what we did, wondering if we could have done more as my heart raced. Calm balm, soothing music, reading to tire me out... nothing worked. I repeatedly dropped off to sleep for a few minutes before waking with a start and returning to the night's events in my mind.

So while I seemed to cope at the time and accept the patient's deaths (they were old, unwell, one can't keep people alive forever), the emotional toll played out in my head today. What a terrible way to die. What an indignity. What a miserable end. And what of the families, rudely awoken with the sad news? And the other patients in the room who endured the events behind rustling curtains? Unpleasant. Disturbing.

Twelve years code free, but what a horrible way to end the run. Miserable. Unpleasant. Hideous. I know it had to happen some time, but I'd like another twelve years event free. Please.

checking out - checking in

I checked out of blogging for a while. (That's not entirely true - my personal blog has been going great guns) Anyway, sorry about that.

The more serious issues is that along the way I nearly checked out of nursing too.

I finished working as a Clinical Support Nurse at the end of April and returned to the ward environment. Well, I had never really left the ward environment, but I returned to the hard labour of being the one doing the work rather than supervising and observing others doing the work. I hated it and wanted to quit. While I was trying to find my feet and get my time management back on track I kept getting landed with student nurses and I just couldn't seem to get myself together. (Interestingly, now that I'm flying again I hardly ever am allocated students!)

Somehow nursing seemed little more than a list of tedious jobs I needed to get through by a certain time. Then I could go home. And put my tired, aching feet up and dream of leaving nursing. I mean, mixing up and pushing antibiotics into a cannula - where's the art in that? For me, nursing is all about caring, but all I seemed to be doing was cleaning up excrement and a host of other menial tasks.

None of us like change, and adjustment is uncomfortable, but eventually we get there. As did I. After about two months something clicked. I started to love my job again. Nursing took on new meaning. I cherished my interactions with patients and families in crisis. I saw where each task fitted into the overall picture of caring. I checked back in to nursing.

And now I'm checking back into blogging about nursing. Here's to many reflective posts on nursing in general and my practice in particular!

what's the point of policies?

I left work feeling quite discouraged the other day, just wondering what's the point of it all. Why do I even bother encouraging graduates to demonstrate excellence in their practice? Nobody else cares. Why should I? (Broad brush strokes, broad brush strokes!)

In two short weeks I will no longer be a graduate support nurse. Instead I'm moving back to shift work on a general surgical ward. Before I make this transition (can I have a support nurse for myself please?!) I'm trying to work a day with every graduate RN in order to write a comprehensive assessment of their practice for the clinical educators who will take on my role. It's been quite an eye opener!

As usual, there's a broad range of competence. Some are the most amazing graduates I've come across. Thorough, well informed, good skills. A few practice in a way that is altogether too risky for my liking. They consistently select patients outside of their scope of practice and make mistakes because they're not quite sure what they should be doing. One or two are just plain careless. They drift through their day without paying a great deal of attention to anything and they certainly aren't interested in doing anything properly.

It was a slap dash, careless graduate who sparked my outburst at the beginning of this post. For once I mastered the art of standing back and letting them do the work while I observed. How very revealing! By the end of the shift any pressure area care was only performed at my desperate suggestion; those requiring assistance with hygiene were simply not washed; and huge slabs of time were spent defending why this or that policy was not being followed in their practice.

Come knock off time, I was infuriated. What a cheek, swanning into nursing and refusing to follow policies and protocols because after two months of practice they deem them an unnecessary hindrance?! The arrogance.

I was so angry I couldn't stay around and give the graduate any feedback. I needed time to calm down, gather my thoughts and form a measured response.

As I debriefed with a colleague I realised the graduate is not the only one at fault here. One of their stated reasons for not following policy is that 'nobody else does'. Here I am running around highlighting policies, reviewing protocols, urging professional practice while at the same time a host of other nurses are running around breaking policies, ignorant of protocols and role modeling unprofessional practice. What hope does this or any other graduate have of developing professional work habits? Why should they follow the policies when no one else does?

And here I come to my question - what's the point of policies? Why have them? We can all get along fine without them!

"See, I just moved the patient up the bed without that simple lifting device, and did I hurt my back? No!

"And what about giving an injection without gloves? I didn't sustain a needle stick injury!

"Did I give the medication to the wrong patient when I didn't check their hospital number? Of course not!

"Where's the wound infection in the patient who I failed to maintain asepsis with?

"I didn't splash myself in the eye when I didn't wear protective goggles to remove that drain!

"Get over yourself Muse! Stop pushing policies onto me that I just don't need."

Stated like that they do seem like silly, insignificant things. Maybe I should just get over myself and stop obsessing over every broken policy. Maybe it doesn't matter. We're all doing fine without them.

But it does matter! Policies are there for a reason. (I'm such a rule follower) Somewhere, sometime, something terrible happened enough times that a policy was drawn up to protect patients, and to protect nurses.

We can't just ignore policies and protocols because they are inconvenient or slow us down. We can't rebel against the machine because we don't like somebody telling us how to practice. And we certainly can't let our standards slip because everybody else has.

Take a stand, make a difference. For yourself and for the patient!

I don't have much longer to teach graduates the importance of policies, but soon I'll be on the ward working beside them as one of the staff. My goal? To be a role model who does practice professionally, and who does follow policies. We're sunk if we don't!

violins and nursing errors

I had a violin lesson with my teacher this evening and, in between the making of music, our conversation turned to teaching methods. Strangely I found a parallel between this and nursing.

As a child I learned the piano, and I remember practicing long and hard in order to attain the 'tick of completion' on a piece of music. This was no easy task, requiring nigh on perfection, at least in my mind. Since I commenced learning the violin as an adult I've noticed 'the tick' is much easier to attain - despite playing far from perfectly, my pages of music are littered with golden ticks!

I decided the difference lay in being an adult learner. Adults have little time to practice long and hard, so the teacher awards 'the tick' more liberally in order to prevent us from becoming discouraged. When I floated this idea past my teacher she laughed and explained the real reasoning behind the liberal tick.

When learning violin there are many techniques to master. As a student plays a certain piece of music, their performance sits in the context of their overall progress. It is unrealistic to expect a beginner to play perfect music when they are only just beginning to manage basic techniques. 'The tick' indicates that, in view of their evolving mastery, they are playing the piece to the best of their current abilities. Perfection is not the goal, only continuing development.

My teacher's explanation struck a chord with me, since the principle has relevance to evaluating the practice of graduate nurses.

Recently I observed a graduate making a significant error in their care of a patient, since their actions were in direct contravention of medical orders. I rectified the problem and educated the patient before speaking with the graduate. They struggled to explain the incident since they had not realised they were doing anything wrong until I came into the room.

Admittedly when I make an error on the violin I do not place anyone at risk, where a clinical error can have grave consequences. But putting this aside, along with the fact of the graduate's failure to work within their scope of practice, and their lack of responsibility for their actions, I have begun pondering my response to the situation.

On the surface I remained calm and measured, reassuring the patient and educating the graduate. Internally, I was exasperated: How could they not have known about this? What a terrible graduate they are to make such a mistake! Can they be trusted with anything? How poor is their clinical knowledge?

Right at this point I need to take a leaf from my violin teacher's book. Let's put this incident in it's proper context! They are a graduate - they're new, they're learning, and chances are, if they've never seen something before, they don't know about it! Cut them some slack. (Remember we're ignoring the fact the graduate should have known their scope of practice and not stepped out of it!)

Just as I am on a journey towards becoming a violin virtuoso (allow me to dream), so this graduate is on a journey towards becoming an experienced practitioner. Along the way we both make mistakes. Just as my teacher encourages me with the golden tick, so I am to encourage the graduate and congratulate them upon their successes. At the same time I can teach them new skills, helping them to develop.

I feel challenged to broaden my outlook on graduate mistakes. It would be helpful if I overcame my initial judgmental reaction, instead seeing each graduate in context, seeking to nurture them, and valuing the whole of their practice.

I did speak further with this particular graduate, explaining my concerns, feeding back on excellent aspects of their practice and encouraging them to know their limits and ask more questions! The patient is fine and all is well. I shall continue to learn the violin and the graduate will continue to develop their practice, and over time we will both move closer to perfection.

welcome to nursing

The year is nearly two months old, but in some ways I feel as if my working year has just begun! The 2007 graduate nurses are out on the wards, and I have the task of smoothing the path of another cohort as they ease their way into the workforce. The graduates are all excited and jittery and earnest in their efforts to be a good nurse. I am smiling and encouraging them in an effort to provide good support.

They might be anxious and apprehensive, but I’m delighted to see them! Last year I let myself slump into a malaise – I don’t really know what I did for the last six months. Nothing?!

The extent of my slackness became evident when I was asked to provide a referee report for a graduate. When I sat down to gather my thoughts and write I could remember lots of pleasant chats, but recalling their practice?… I couldn’t! I know I observed them, answered their questions, provided supervision and direction on a number of occasions, but I can’t remember anything specific about their practice. When I consulted my notes – I found a few scribbles here and there in my diary. No formal evaluation, nothing!

If that was the only evidence of my slump it wouldn’t be too bad, but there’s more! The 2006 graduates are in the process of completing their practice portfolios. They’re racing around asking for signatures here and there, making last minute records and squashing 12 months of reflection into one week. I know they’re responsible for their own development – but didn’t I check their progress towards completion of the book and spur them on to professional growth? Nope.

And then there are the interviews where I sat with the graduates and preceptors to provide clinical feedback. Same as the referee report really – what can I feedback when I haven’t observed much of their practice? “You’re doing well. You have good skills. You’ve made progress over the last year.” Great. That’s really useful and meaningful feedback that will definitely help them develop greater competence. Not.

I don’t know what I did for the last six months – whatever it was, it didn’t amount to much. My body might have been at work everyday, but my mind was elsewhere.

What a relief that the 2007 graduates are here – this is my chance to make amends. With this new group I can start afresh, enthusiastically and energetically supporting them, observing them and recording everything I see and do! When it comes time to report on their progress I’ll be armed with all the information I need.

Welcome to nursing, graduates of 2007! Welcome back to nursing Muse!