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?

I’ve never experienced the ramifications of such a violation personally, but I have seen the aftermath when others have been suspected.

Often the violation stems from one of man’s greatest assets: curiosity.  We’re geared for acquiring knowledge; yet some things we might be better off being unaware of completely.

Once on the unit I was working, a staff member reported their electronic identification and password as stolen. During the time it was missing, the ID and password were used to access the records of a patient staying at the hospital.

Soon, Corporate Compliance contacted the nurse manager of this staff member’s unit.  A suspected breach of confidentiality had already been reported, without even the manager or the staff member’s knowledge, or anyone else on the unit reporting it.  How? you might ask.

In this particular case audit logs allowed technical support services to track who had accessed this patient’s records.  Should the logs detect someone having accessed the information that was not directly connected to the patient (meaning a provider, nurses or assistants on that particular unit the patient is on, etc), these support staff members can re-trace the access of this record right down to the computer the user was utilizing at the time of the login to see if they truly should have been accessing it.

No reporting, no finger pointing: They simply punch a button and you’re caught!  Makes you feel all warm and fuzzy doesn’t it?

Suffice it to say, when a hospital tells you not to access records that do not pertain to your immediate patients on your unit, (even if they are someone you know, even your own child) do what they say!  If you need that information, chances are someone will contact you shortly.

But, what about all of you?  Have any of you ever had a run in with HIPAA or Corporate Compliance?

What is the point of getting my Masters? After one class and I was ready to tell the tutor where to go.

“You haven’t learned how to think critically,” said Mrs. Crump.

“Ah, I’m still not sure what you mean by thinking critically,” I said.

I’d been working in an east London hospital on an agency shift. I’d been left with eight acute patients, no handover, and a nurse assistant who called in sick. I was in the emergency room as well.

I complained, but like the typical nurse I pulled through the shift for the sake of the patients. I know I didn’t do as good a job as the patients deserved, but there was just too much to do.

“You didn’t deal with the situation as you should have,” explained Mrs. Crump. “If you’d been thinking critically, and by that I mean taking control of your thinking and the situation, you would have made better decisions.”

I shook my head. “So what was the right thing to do? Your explanation still hasn’t helped me. I’m sorry; I just don’t get it. I use common sense, and just try to do what is right. I did think of walking out but…”

I could have walked out, but as an agency nurse filling in a random shift, I’d have been in dire straits. The agency nurse always gets the blame and never has any real support when everything goes wrong.

Mrs. Crump is the typical nursing tutor–idealistic but not practical. She’s probably never done an agency shift in a random hospital; they just didn’t do it back in her day. I don’t think she knows what it means to think “critically”. It hasn’t occurred to her that in some situations there is no right way, sometimes you just can’t win no matter what you choose.

Bryn Hagan, RN, NursingAround.blogspot.com

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.

I am really struggling with how to deal with some of these difficult patients. I just cannot understand the nerve of some people! Just last night, I was discharging a patient and the curtain wasn’t completely closed. The wife of a patient from the room next door peeked in and told me she was going home for the night.

As she began talking and asking for help, I interrupted her and said, “Excuse me, ma’am, but I’m with another patient right now. Please ask one of the other nurses for assistance.”

I have even had patients’ families actually come into other patients’ rooms while there is a code situation- or while I am doing CPR-and repeatedly ask me for pillows, test results, food trays, etc. How do people not understand that we’re in the middle of something?

I have struggled with trying to be polite, but I think in a way that only will encourage this behavior. I just don’t know how to be assertive without getting so upset at patients and their families.

Generally, though, when I make mistakes, I realize I have the best intentions and am able to forgive myself.

But there was one mistake I made in nursing school I can’t get over. I was one of the few nursing students that had been a CNA before school, working at a nursing home for two years. During our first year, I had a post-op hip patient. We were responsible for oral meds and ADL’s at this time. This patient needed to have a BM so I asked the new-grad nurse taking care of her how she had been using the bathroom. She handed me a bedpan (I didn’t know what a fractured bedpan was).

I asked if I needed to help the patient, and she told me the patient had been helping turn herself. So I went in the room and the patient asked me if I should get some help. I had heard this comment a lot at the nursing home, and said my usual joke: “I’m short, but I’m stout.”

I may have pre-planned for this patient, but I did not think about making sure there was a hip abductor between her legs. The patient rolled over with my help and did well, but had some discomfort. I thought this was normal, but after I put the bedpan under her and we rolled her back to her back, she was crying in pain. I ran to get the experienced nurse for help. She came immediately.

After we had the patient comfortable, the experienced nurse told me what I did wrong and what could have happened (how her new hip prosthesis could pop out). She asked me not to take care of that patient anymore. I agreed, but still went into the patient’s room to own up to what I did.  She didn’t say much.

I also told my instructor, who tried to make me feel better. But I couldn’t stop crying. I just can’t get over it because I always wonder if I was trying to impress someone. (Who knows – maybe I was trying to prove something to myself.) I was always told how good of a caretaker I was. I never considered how cautious I should be.

I know what I did was wrong-and I just can’t stop thinking about the pain that woman was in. I still cry about it now.

It won’t stop me from trying to be the best nurse I can, but GOD I wish I could take it back!

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?