Not listed, but also expected: picking up paperclips from the floor, trying to keep my piles neat, and telling someone when the Kleenex are running low.  And really, truth be told, I probably spend as much of my day doing the things that aren’t explicit as the things that are.

A couple of weeks ago I was filling in at the other end of the clinic.  I took a phone call from a patient who was basically gasping for air on the other end of the phone.  She had been in a couple of days earlier with bronchitis, but was worse.  She wanted was another prescription.  What I wanted was for her to call 911.  Our compromise was an appointment at the clinic in about 45 minutes.  I told her to call a cab because her husband was out of town and she didn’t have any friends who could bring her.

In the end, she came in with lungs that sounded like they could be coughed up at any moment.  The doctor called an ambulance to take her to the hospital.  She hobbled out to the desk where I was sitting and started talking about her puppies.  Her distress had much more to do with how they would be cared for than the fact she was about to be admitted.  Before I knew what had happened, she was digging through her address book looking for names and numbers of people who might be able to check on them. And she wrote them down for ME to call. 

Say what?  She also wrote down her husband’s email address because he was at a conference out of state and could not be reached by cell phone during the day, but would have his laptop opened.

Next thing I know, I’m emailing this poor man to let him know his wife is headed to the hospital via ambulance.  Once that was out of the way, I had the task of finding those darn dogs a babysitter. 

As I left messages on various answering machines, I realized the ludicrousness of the situation. 

When I hung up for the last time I said to the doctor, “I don’t remember this being in my job description.”

But as I said, much of what happens in nursing isn’t actually about the job description.  It’s the little things we do everyday that go above and beyond the expected that really speak to who we are.  We are a helpful and caring lot.  We see what needs to be done and we do it.  We care about more than just the physical needs of our patients.  At least that’s what I hope we’re about.

So what have you been asked to do lately that wasn’t in your job description?

From my observations, may ER nurses treat patients like they’re stupid, like they’re a waste of time, like they’re a major inconvenience to the staff, especially if the patient’s complaint is not truly “emergent”. This attitude is often plainly seen by patients and their family members, which leads to friction, mistrust and complaints; it also effects if the patients will follow up after discharge.

I have observed that if you can come into the room with a non-confrontational, compassionate approach, and can convey to the patient that you are on their side, and want to make them better (by listening to their story from the start to the finish and really listening to what they’re complaining about) you will almost never get complaints–or angry patients/family members.

Then you have happy patients… and your day gets easier as a result. We all know how stressful it can be to deal with ‘ornery’ and ‘cantankerous’ patients and family members, but 99% of the time, they are only upset and mistrustful because they feel they are not being listened to, or that they are being swept aside.

I’m not saying you need to sit down and hold each and every hand, and wipe each and every tear, but be aware of your attitudes. The patients can read you much better than you think they can.

I, on the other hand, am not panicked.  I am annoyed.  The phones of every doctor’s office in the country, and possibly a few other countries, are ringing off the hook.  Every person with a fever, every kid with a cough, every kid who sat next to a kid with a cough: They are all worried to death (or at least their mothers are) and looking to the medical profession for answers.

Unfortunately, the answers I want to provide are sarcastic.  “Do you know how many people die of influenza every year in the US?  36,000!  And do you know how many have died of H1N1 flu in the US so far?  One!  That’s how many.  So go home and take some Advil, get some rest, and drink plenty of fluids.  Trust me, the chances are pretty good that you’ll live.”

Fortunately for my patients, I never actually say what I think.  It doesn’t actually matter what I think.  What matters is that people are scared.  My job is to care for them.  In part, that’s relieving those fears, but it’s never dismissing them.  The term pandemic is scary.  It causes a low-level hysteria that rapidly grows into a high-level hysteria as news pundits discuss it day after day.  I can share my personal opinion with friends, but not with my patients.  I have to handle each person and each concern like it matters to me.

My best friend is an advice nurse in California.  She told me yesterday that they have received thousands of calls in the last couple weeks about the Swine flu.  The other day they were 6 1/2 hours behind on answering calls.  Of course, people were calling with “normal” stuff, too.  They also had to wait to be called back because of the flu calls.  It’s completely overwhelming.  But one call at a time, they go through the protocol, giving advice, making appointments as needed, and talking people off the ledge.

I guess what I’m saying is that it’s okay to feel frustrated about stuff like this, it’s just not okay to show it.  At least not to our patients.  They deserve to feel like their illness, real or perceived, is important to the ones they have entrusted themselves to.

I thought it was PVC’s, which I have occasionally, but it felt a little different.  I took the stethoscope that was hanging around my neck and listened to my heart.  Wow, I thought, that’s pretty fast.  As I counted the beats, I tried to take some deep breaths and calm it down.  I looked up at the other two nurses standing there and said, “My pulse is 160, and I feel a little weird.”

Next thing I new, I was in a room with a gown on and hooked up to our ECG machine.  “Do you want to stay here while I go get a doctor?” my co-worker said.

“You’ve got to be kidding!  Of course I don’t want to stay here!” I said.  “I don’t want to be a patient.”  I got dressed and headed down the hall to find my doctor consulting with another doc, ECG in hand.  Before I knew it, I was in another exam room getting my carotid massaged.

Now the reason for this little story is not to sound dramatic or to get your medical advice regarding my SVT. It’s to remind you that being a patient sucks.  It’s uncomfortable.  And I’m not talking physically.  It puts you in this place of feeling totally out of control.

And you know us nurses: We like our control.  But I don’t think we’re alone in that.

So the next time you’re caring for a patient, try to put yourself in their shoes.  Try to remember what it was like before you knew anything about medicine. Imagine how they must feel as you spew your new-found knowledge all over them.  Think about the last time you found yourself wearing nothing but an ugly, and all- too-thin piece of cloth (or in my case, paper).  Try to imagine being told that something inside of you isn’t working the way it’s supposed to.  Or that you will soon be having someone with a very sharp knife standing over you.  Or that there’s nothing more to do to make some horrible cancer go away.

None of it feels very good.  Emotions soar.  Fear hovers.

You may not be able to relate to every patient you care for, but you can certainly try to remember a time when you felt out of control, too.

So put on your best empathetic face tomorrow.  Acknowledge your patients’ feelings before they even have to voice them.  Help them feel like they still have a little dignity.  Like they aren’t stupid.  Like they aren’t a bother.  Like they’re exactly where they’re suppose to be: Getting the best care they can get.

Trust me.  It makes a difference.  And soon enough you’ll know just how much.

I walked into work one day and one of our little patients went into respiratory arrest right as I finished getting report on her.  We spent the next 12 hours saving the life of this poor little girl.

The patient had been born with problems (though all these years later I have no idea what they were) and was blind and deaf.  In fact, she was non-responsive.  She had been in the hospital since birth.  Her mother was already pregnant with child number four and hadn’t been to see her in several months.  It was her father who had been faithful in holding vigil and wanted everything possible done for her.

It wasn’t the intensity of the day that sent me running.  It wasn’t the profound sadness either.  It was the fact that we put this 6-month-old through hell for the entire shift.  Sure we kept her alive, but I felt no pride in that.  I was so conflicted during the entire shift.  I worked my tail off to keep this child alive while praying the entire time she would die and wake up in heaven.

She finally died, but not for another two weeks.  Not until we had spent a few hundred thousand more dollars and put that child through every imaginable horror.

It was ethics that finally made me resign.  It seemed wrong that all I truly wanted for this child was release from this life though I worked heroically to keep her in it.  I finally decided a good PICU nurse should only think about life, so I moved to Colorado and started a career in Family Practice.

I would handle such internal conflict differently now.  Maturity of self and career gives one perspective only time allows for.  The truth is, much of life is filled with ethical dilemmas, but we, as medical professionals, seem to face them on a routine basis.

Have you had some situations like mine?  How did you handle them?  Do any of them still haunt you?

I came across the story of another nurse who faces a similar conflict.  You can find it at http://well.blogs.nytimes.com/2009/03/18/a-nurses-distress-over-a-dying-patient/?hp

It’s so helpful to all of us when we see ourselves in other people’s stories.  It makes us feel like we’re not alone, wrong, or just plain crazy.  Take a few minutes and share your story with us.

She is a school nurse and meets weekly with the school counselors to discuss the overall health of kids.  She and the other nurses are often sharing things about students that may affect their psychological health, feeling like it is a team effort to care for these kids.

The other day she found out that one of the students has Bulimia.  Apparently, it’s something the counselors have known, but did not share with the nurses because it was confidential.  This nurse feels like they should have been told in order “to safely assess and treat any physical condition with the student. At the end of the day, it’s my butt on the line when things go wrong with the kid’s health. It’s me the parents yell at first/threaten to sue.”

In fact, she HAS treated this student for physical issues she now knows are associated with the Bulimia.
The counselors still feel like this kind of information should never be shared.  The nurses think they need this kind of information in order to do their jobs fully.

So what do you think?  Does confidentiality trump giving a patient the best possible care, or does patient care win out?  Let us know where you fall on this issue.

I remember one of my clinical instructors praising me for a care plan I had written; it received the highest grade that particular week.  Her caveat: listen and learn during clinical so I could improve.

Laziness prevailed.

The next week, I wrote essentially the same care plan. This time I earned the lowest grade of all the care plans.

I didn’t learn, I didn’t listen, and I paid for it.

And, if I embraced that “know enough” attitude, I think in the long run the patient would have paid for it, too.

Florence Nightingale pioneered the art that is nursing today, but she was never a “true” nurse.  As my current nursing education instructor says, Ms. Nightingale, one of the first nursing administrators, adhered to the policy that nurses could never stop learning.  If a nurse thought they had learned all there was to know, she frowned upon them.

To stop learning was to stop caring-and to stop being the best patient advocate.

As a nurse, you have the unique opportunity to daily learn something new. Some days you may simply rethink a concept you already thought you mastered-and apply it in a completely new way.

In this way, learning is cyclical.  The things that are taught in school never go away; they just take on a new form.

As a student, I remember fussing about clinical instructors teaching me how to chart the way they did back in the 1800s. I wondered, How can this possibly relate to my current job, now that charting is electronic? Yet, I learned, after some foibles, that I should’ve heeded the advice. Charting follows many of the same guidelines as centuries ago-just in a different medium.

Change doesn’t necessarily mean different, it just means a different way of doing the exact same thing.

And as you put forth effort to learn-as well as allow yourself to be taught by some of those seasoned nurses who you swore you’d never talk to-you’ll grow, you’ll thrive, and you’ll care for your patients better.

But what do you believe?

The day didn’t start out great—-and soon got worse.

That day I asked the hospital cleaning crew to mop up some fresh vomit. “We don’t clean up body fluids,” she replied. I tried to borrow her mop to clean it up myself.

“You’re not allowed to use my equipment. You’re not trained. It’s company rules!” So I went to the cleaning cupboard to get some equipment to clean the mess myself. But it was locked and the cleaner wouldn’t open it for me. I ended up using a towel to clean up the vomit.

Then a patient slipped from his chair, and I found him sitting on the floor… asleep. I tried to find a nurse to help me sit him up, but couldn’t find one in the immediate area. I asked the cleaner to help me sit him up.

“We’re not trained to do that. It’s against company policy.”

My anger swelled. “I don’t give a damn what your company policy is. Show some bloody compassion and get over here and help me.” My appeal worked, as we helped the patient up off the floor.

Where were the other nurses? I wondered.

When I think of this type of sagging medical care in hospitals, I think back to Mr. Smith. His breakfast tray was always left out of reach. I’d come over from my side of the ward (I didn’t have the time, but I did when I could) just to feed him. Every day he got weaker, more dehydrated. The infection spread throughout his lungs. He just stopped breathing one day. If he wasn’t left in bed or in a chair all the time, maybe he wouldn’t have died. If there were enough physical bodies to just get him going, I’m sure he would have made it.

Managers and government people are always trying to find ways to improve hospitals. They set goals, devise plans, install new systems, but they never work.

Frankly, I think we just need more bodies to do the basic work of a nurse–which is simply to care.

Is anyone out there listening? Do you agree? I’m not the brightest or the most knowledgeable. I just want a chance to be heard. And I think I can make a difference. I think you—a new nurse—can make a difference, too.

These are all people who I have prayed for, prayed with, or prayed over. Of course, there have been many more. Some I’ve forgotten, some I never could. Some who knew I was doing it, some who never will.

For me, prayer is essential. It’s the act of inviting God into a situation–whatever it is.

I work with a doctor who prays for the patients on her schedule each day. Sometimes nurses join her. I know of another doctor who actually has a special room designated for prayer in her clinic. How would you feel if you were her patient and knew her interaction with you and all her decisions regarding your care had been prayed over?

Of course not everyone feels the way I do about prayer. It might even be offensive to some. That’s okay. But I earnestly believe most people have some sort of spiritual inclination. A patient has never become offended when I’ve said I’d be praying for him. I think we all find it comforting to think God might actually care about our circumstances and take the time to intercede for us.

I heard a story the other day of an anesthesiologist who ministered to a little boy and his family in a most unlikely way. The boy, who is in a losing battle with cancer, was having yet another procedure done. After it was over, but while he was still unconscious, the doctor decided to bathe him and trim his nails. Something he was in too much pain to have done while awake. She told the mom that, as a mother herself, she felt it was one small thing she could do to help.

I have this vision in my head of this kind doctor washing off caked blood and grime, all the while asking God to care for this little boy.

It’s one of those amazing moments we get to be a part of in the health care profession. Meeting people in there rawest form. Reaching out to them in whatever way we can. Ministering to them as we meet their medical needs. Often these are holy moments. I cherish several.

Do you have any moments like that? Times when you’ve taken care of a patient spiritually and not just physically? Times when you felt used by God? Times when you’ve realized nursing is so much more than you ever dreamed?

“Who triaged this patient?” She called out across the room to anyone who would pay her attention. Everyone ignored her except me. I knew whose file she had and I knew she’d make a fuss, not because there was a problem, but because she loved to pick faults and seemed to relish making people squirm in front of her.

“A name would help, Pru,” I said, “Whose file you got there?”

Pru glanced at the file in her hand. “Mrs. Smith. Did you triage Mrs. Smith?” She said accusingly. “Yeah, I did. What’s the problem?” I asked.

“Could you tell me why she’s in the triage 3 box? She’s at most a four, or maybe even a five. For goodness sake, why? Why? Why?”

“Well, she is 93 years old, Pru. She’s from a rest home, and it was a big deal getting here. They had to get an ambulance to get her here, then have to arrange one to take her back. She’s got a care giver sitting with her as well. I’d thought I’d sneak her in first. It just doesn’t seem right to let a 93-yr-old lady wait for three or four hours,” I explained.

Pru sighed and rolled her eyes, “We do not triage on age,” she said as if this was the end of the argument and placed her file in the triage four box.

“But Pru, it’ll only take ten minutes to get her fixed. All we need is for you to take a look at her and I’ll do the rest. C’mon, Pru, I’m not going to leave a frail old lady sitting there for ages.”

Pru grabbed Mrs. Smith’s file from the drawer. I felt hope. She then put it in the triage five box. She grabbed another triage three file and marched out to the room.