Blood Rules

We're settling into an interesting groove, now, with the nursing program, and the most complicating piece of the whole process is how we try to find a way to preform the mechanical skills and receive feedback about them while everyone is online only.  This process involves lots of awkward camera angles, pretending, use of stuffed animals, videos, and no small amount of creativity.  I did a recording of myself a week or so ago with my brother as the patient I was helping turn to his side and I told Andy his role was to be bedrails, placing his arms down next to Mike to make two ninety degree edges.  I used my lapdesk as a backboard to help the patient onto the stretcher that we didn't have.  Changing the sheets in an occupied bed involved a couple of fitted sheets on an easy chair.  And oddly enough, we had fun with it.  Some of the banter during the bedbath was the right kind of ridiculous, in particular; Andy was happy to be my pretend patient for that one, until it occurred to him I was going to be professional about it.  

As we look into procedures and their pieces, I have made three important observations.  

So there is the book way of doing things, the step-by-step process and why each step happens in this order as opposed to any other and why it needs to be done.  There are parts that are left intentionally vague, stating that different facilities will have different policies.  This leads to an important realization:  these steps are composites, the culmination of practices and policies from all kinds of different places and attempts to be applicable to all of them at once and account for all kinds of different scenarios at once.  Inevitably, some are left out--for example, the rectal suppository steps didn't have much to say about ostomies, which caught my attention because I was looking for it specifically.  (The answer, by the bye, is it depends somewhat on what it is, but in my case since I have no anus and no rectum to speak of, we'd be looking into a different route.)

And then we had some discussion in lab, where our instructors have stated in different words that there a lot of these steps that we will be doing simultaneously in the future or we will otherwise be moving with the situation at hand (i.e. if your patient can't breathe well, trying to get a laundry list of questions completed as the first step every time isn't exactly feasible).  In a couple of steps, some have even said directly that "no one does that in the real world."  This means that there is the book way of doing things and the real world way of doing things.  

Then the medication chapter hit.  Suddenly, the book way of doing things and the real world way of doing things took on a severe and marked parallel.  Giving a bath, that can move with the situation and the patient's need to rest and what materials you have on hand.  With medication, there is no playing around--those rules are written in blood.  Every rule is there because someone's direct or potential suffering brought it to the table.  Even the tone that our instructors brought to these areas shifted:  most everyone knows a story of when the blood rules were not honored and the calamity that followed.  And that sounded more Lovecraftian than I meant it, but, truly, where someone did not do the proper checks and what happened or what could have happened, there are some truly horrifying possibilities, elder gods aside.  

So in short, regarding all of the mechanical pieces that I will be expected to perform as a nurse, the following three things appear to be true:
1.  The book rules and guidelines are composites, an average to establish a pattern and the best collective way to perform a task.  
2.  The real-world way allows style and preference to come in to play, provided it stays within certain parameters.  
3.  Anywhere the real world way and the book way are in lockstep with one another, these are the blood rules that must be adhered to with reverence and no small amount of fear.  

The tricky part is right now I don't know which parts are blood rules and which ones allow for style--the book way is presented as the blood rule, and I won't know otherwise until I have some experience, meaning that I need to assume all rules are blood rules.  Some parameters can be moved, but at this point I need to assume that they cannot be, until I am hired by an institution that directs for a particular variation or evidence leads us to make some necessary changes.  In short, I have to feel for the right places to be flexible, but assume a constant rigidity, which is an interesting balance of thoughts while still mimicking the person we're following as best we can.  

It's going to take some practice yet.