Fledgling Nurse, Part 8: Boundaries and Abuse

I sat down to listen to a patient one day.  They were angry, frustrated that they had been suffering the effects of an illness for over a year and a half, now, with multiple trips to the emergency room, a gamut of tests, poor empathy responses from work/landlord/family/the world in general, familial stress, arguing with insurance, and the very real anxiety of the looming bills yet to be revealed.  This particular patient clarified several times that they were not mad at us, the nurses and techs, just that they were tired.  I sat down with them to listen for a while, validating the hell out of their feelings--that is a difficult place to be, that not-knowing space.  I want to think that they felt better to get some of that off of their chest--they were at least visibly a little less grumpy.

But this patient had not been particularly harsh to any one of us.  Not very conversational, maybe, but not outright rude.  I cannot say the same for other patients.  

"A Lapse in Perspective and Empathy," a short story:
Scene, nurse enters patient room.

Patient:  (clearly annoyed, sighing dramatically) "I put on my call light twenty minutes ago.  What took you so long to bring that water?"

Nurse:  (sets the cup of water down) "Oh, one of my other patients stopped breathing.  So sorry to keep you waiting!"

I have been intentionally hit in the face, smacked a few times in the arm, pinched, kicked, threatened, yelled at, called a number of names (variants of stupid and incompetent are favored choices), and once was patted on the butt like it was a compliment.  And I've only been a nurse since August.  I daresay every nurse or CNA has at least one story.

The bulk of these were confused persons with varying degrees of dementia; some were patients that fit into that category of "I feel out of control so I'm going to pick a fight to reestablish control."  So logically I know that some of my patients are not angry with me, that I just happen to be a convenient place to focus their anger; I can also recognize that some patients are demonstrating poor boundaries as part of a wholly valid medical reason.  That does not make that behavior okay.  Both the recognition that the behavior is affected by certain factors and is inappropriate exist in the same space.  It's also possible that the individual in question is simply an asshole.  

Yet, there is culture to accept a degree of this abuse.  I have the option to press charges, but whether I have cultural approval to do so is a different question.  From management, I have been told that I have the right to feel safe, that I don't have to be a martyr.  In the same breath, there is an unspoken pressure that there are some places I just need to have a thick skin, and it's difficult to calculate how thick this is supposed to be.  The thick skin is only needed because the microaggressions and then outright aggressions are common, again, because there is a culture formed in this environment, which means that patients know on some level that they can get away with it, becoming a self-perpetuating cycle.  Realistically, too, I know that patients with advanced enough dementia are likely waiting on placement in a facility, where they will be making decisions based on scores of how directable, violent, etc. the patient is, meaning that I might delay some options (certain medications, for example) or bend more than I might otherwise to not affect their chances.  

I have set boundaries with patients, a "I will not be spoken to that way," or "I will call security if we need to" and "I'm not going to engage in that argument."  I have also sat down and said directly, "I don't think you're actually mad at me--what's on your mind?" and start the conversation to the deeper places, find those actionable components from there.  I have also admittedly gotten caught in some of those unproductive arguments, attempting to persuade a confused, suspicious patient for the better part of forty-five minutes to do something (roll off a soiled pad, take their medication, sit back down because they have a history of falls, etc.).  There are times when I have to keep trying, because it is about their safety, and yet their agitation continues to rise as I continue to press, attempt a new angle.  As such, I'm working to refine some of these boundaries, because leaving these rooms six kinds of frustrated and an hour behind does not serve my other patients.  

There are circumstances where a patient has an order for medications that will help decrease agitation--when the patient is a danger to themselves or staff, it is an unfortunate but necessary option.  There are many specific checks and steps to creating these orders, not something that I can dole out because I find someone annoying.  If they cannot or refused to be talked down, again, we have to protect both them and ourselves, meaning that we are no longer asking.  And I usually call security for an assist (the presence of a uniform sometimes changing their demeanor immediately), since an agitated person is also not going to appreciate a shot in the arm.  I would much prefer a one-time dose of something than allow something to escalate to needing locked restraints or the patient falling and injuring themselves or any of the staff getting injured.  I have some cognitive dissonance on when it is okay to use these--I don't want to give someone a shot in the arm that doesn't want one, nor potentially make them more upset by doing so, nor inadvertently alter their options in placement.  Simultaneously, again, this is what the medication is here for, I want to protect the patient from themselves (as well as my fellow staff), acknowledging that allowing agitation to progress further is its own kind of negligence.  On a personal level, I don't have time to be threatened--I pick my battles with patients, but this is a steadily solidifying line.

"What not to do," a study

I shouldn't have to absorb abuse from my patients, whether they're in their right minds or not.  I acknowledge that an unspoken norm to expect this abuse exists, but I also recognize it is an unacceptable norm that needs addressing.  Of course, if it was an easy answer, we would have already figured it out by now.  For myself, I am working on setting cleaner boundary statements, that I am not there to absorb their anger for example, or that I will refuse to engage.  For patients that can be engaged, I can give them a space to vent what they're actually upset about instead of accepting passive-aggressive digs all day.  In other places, I become almost overly professional, stripping out my personality--if I'm going to be seen as a service then I will only be a service--which protects me.  For patients that are unable to engage due to dementia, temporary confusion, or other reasons, I pick my battles--I'm not terribly annoyed that they're pulling the sheets off their bed if they are not putting themselves in danger of falling; I will bring them a fresh ice water every hour if that helps them stay calm and feel they are attended to; I will wait to give them their daily medications until they are eating breakfast rather than wake them up to take them when I think it's more convenient.  

There is grace for a patient's circumstances; there is also recognition of my own emotional and safety needs.  I will not win a prize at the end of the day for absorbing X amount of patient frustration.  It will not make me a better nurse to fail to stand up for myself.  As a culture, it is important to challenge the idea that it's okay for certain workers--any workers--be receive a degree of verbal or physical abuse, whether they're ED staff, teachers, food service, or whatever else.  Right now, we're seeing a lot of discussion about teacher's autonomy in the classroom, but I can also remember when I was student teaching a conversation with a parent that was furious that we scored their child a zero on a project that the child openly refused to do, how rudely they behaved in that moment--in other words, the disrespect to the career is not a new thing, though it does seem to be continually getting worse.  And for food service staff, well, there are too many examples of those to count, and I will never understand why an incorrect drink or burger is a reason to go nuclear on someone.  

In short, we as a culture have collectively allowed this to happen, by not correcting the behavior.  That's an overly simplified statement, to be sure, particularly when we factor in the medical caveats in the hospital setting.  My goal in my practice is to ensure that the boundary is set, for my sake, the patient's sake, and the patient's family's sake.  For the patient and their families, an escalation of the situation will not have the excuse of ignorance, that they were unaware they had crossed a line.  For myself, reaffirming the boundary is an act of self-compassion, one that helps me make tough but necessary decisions and ultimately enforce them.  For my peers, I don't want to hand any of them over to a situation they don't feel safe in either by not deescalating where I'm able to or hesitating too long to call for additional hands.  I am testing my own balance between being gracious to the circumstances while also ensuring it is not at the sacrifice of my own needs.  

Fledgling Nurse, Part 7: When to Flex

I knew getting into nursing was going to have a specific kind of baggage, and it was during nursing school that I began to see the first few signs of it:  friends and family asking for medical advice.  

It was inevitable.  Some of the questions I redirected to Dr. Google--when it's specific side effects of a particular medication, I do not have a complete compendium of these in my head as of yet though some important generalities are firmly lodged in place, such as NSAIDs and gastric bleeding.  Other questions that are more general knowledge or things that I took for granted as general knowledge, though, I've answered a number of these.  I had only completed my program by a couple of days when I received a call from a family member asking whether they should go to the emergency room (after gathering a bit of information, I suggested PromptCare if X and Y did not improve by Z or go to the ED if there were life-threatening symptoms like trouble breathing).  I've had a couple other friends ask, receive permission, and then send me pictures of different parts of their body.  I've looked at weird skin spots.  I've explained the mechanism of action of various medications.  I've explained what to expect as a loved one regresses further into dementia.  I've re-explained procedures that were only half understood after doctors' appointments setting them up.  These and more, I understood that the questions were inevitably part of the territory.  

As happy as I am to help, I am more cheerfully helpful when persons check for permission first.  It's an important boundary check.  However, I won't deny that I am happy to teach where I can teach.  I like sharing the information I know, to flex those pieces of knowledge to help someone else (while still adding the caveats that I'm not a replacement for keeping their doctor appointment).  

And that has to go in reverse, too:  I have to check before I jump in with unrequested information.  Sometimes someone is just venting and not asking for medical advice.  There have been conversations where a loved one was hospitalized or diagnosed with some kind of condition and it's as though the password was spoken and my empathy is overshadowed by overwhelming curiosity.  I want to ask what medications have been tried, have they approached the topic of X or Y therapy, what were the last lab results on Z, have they also experienced Q symptoms, etc.  I have to stop myself, though, when I realize that my curiosity is not necessarily productive to the conversation.  I have to know when to flex the knowledge that I have.  

This can get especially tricky when I'm at work.  When I'm clocked in, I have given implicit permission to be asked medical related questions.  Hell, we have set reminders to chart education, meaning that I am expected to offer it at the very least daily, not just the information dump before discharge.  But the family member who just signed their loved one into hospice, they aren't interested in how the body will mechanically deteriorate at the moment--their questions of "when are they going to die?" are more about coordinating with the family and finding their own processing space.  Factual and practical information could be soothing or it could induce more anxiety.  Or more confusingly, there can be a balance of information that is helpful before tipping over from empowering to overwhelming.  

There isn't a magic formula to know how much information is too much--it involves a fair bit of guessing and gentle prodding.  I try to ask questions along the way to ensure that the party is open to information or otherwise start with where their questions are, titrating information in pieces as I see them throughout the day.  One of my favorite questions especially during discharge instructions is "I just threw a lot of information at you:  what can I clarify?"  This firstly acknowledges and validates any feeling of overwhelm.  It's also an open-ended question, meaning that there isn't a space for a simple, placating yes or no.  Sometimes we cover the same information again; sometimes we're taking it a step further.  I try to also end with a brief "if you remember anything from what I just told you, remember these three things," in order to bring to the forefront one more repetition as the final say.  

Outside of work, though, there are spaces where the information I have learned is helpful and places where it is not.  There are places where people demand it and places where forget that that experience can be a resource.  This means putting out feelers for what is welcome without overstepping.  It's the same process in offering any expertise, that balance between the excitement of knowing the answer and the awareness that "an answer" still may not be what the conversation partner needs in the moment.  I've learned how to ask the questions that are indirect, probing for what someone might want from the conversation, but this still entails more guessing than I would prefer:  as such, I'm growing more comfortable with directness.  I asked a patient the other day, "Would you like to understand or do you just need to vent?"  I've asked many times "How can I help you best?" whether I'm listening or helping someone with a task.  At home, we are learning "That's not helpful right now," when someone is trying to fix something that we only needed a listening ear for.  Sometimes whole conversations are preceded with a phrase or question to help indicate whether listening or problem solving is the goal--85% of the time, I feel, it's listening.  

Sometimes I think I know someone or a particular inflection well enough to guess whether they want input or a listening ear, yet I've learned that it's okay to check even midway through, confirm those thoughts before there is accidental overstep.  My knowledge base in my field will continue to grow, and I will actively be ensuring that my communication skills--particularly checking for consent and boundaries--sharpen along with it.  

Fledgling Nurse, Part 6: Melvin as a Superpower

So, I have had patients that needed to vent before, patients that were so caught up in what their current circumstances.  Being in the hospital is a traumatic thing, where the "normal" is broken.  And being "fine" one day and requiring to call someone to help you go to the bathroom the next does not always sit well with a lot of people.  A lot of people tend to feel very much out of control in these spaces and subconsciously try to reestablish control by making demands or picking a small fight.

Not everyone has the vocabulary to dig into what they're feeling in those spaces.  I am very intentional when I meet a patient to ask them what I may call them and often whether they would like their door open or shut--in other words, I start off by checking for consent and permission while also honoring their space and giving them a modicum of control.  I think it helps.  Giving the patient a degree of choice and autonomy in the first few moments of our interaction is what I would want at least.  

Later in conversation with the patient, while helping them to the bathroom, performing my morning assessment, or documenting all of their morning medications, I tend to see if I can get a conversation going, to understand a bit more about their situation and where they're at.  If I have caught the patient in a space where they A) trust me enough to be honest, B) are emotionally overwhelmed enough that it doesn't matter, C) seek to manipulate me in some capacity (unconsciously or otherwise), or D) some combination thereof, I might be able to tap in to how they are coping emotionally as well.  I try to make specific invitations to these places, actually.  

Every now and again, though, I get a patient that tells me that I don't understand what it's like to actually be in the hospital.  And they cannot see small tightening of my lips under my mask as I have an involuntary, rueful smile.  Then, I tell the patient, that, sure, I cannot understand exactly what they might be going through, but I have some idea, at least.  At that point, I may add in that I have had a chronic illness since I was twelve and have a permanent colostomy that I call Melvin, with a long hospitalization fresh enough that I still remember a lot of those same general feelings.  It's only ever a sentence or two, unless they start to ask about details, because I put the conversation focus right back on them--it is a vessel to validate their feelings, to acknowledge some frustrations that are real yet hitherto unnamed.  I establish my credibility and authority not only as a nurse but now as a human being that has also been in a similar space.  I might mention how inconvenient it is to twist around for the toilet paper in the bathroom, particularly if one is sore and achy or recently had abdominal surgery.  I might mention that the first time one can shower by themselves again is a glorious achievement, as is the first time farting after a surgery.  But I always come back to their current experience.  I show them briefly my authority to empathize, and then it is back to a new, deeper understanding between us.  

And often the conversation is free to dig into the real concerns that they want to talk about.  I listen, paraphrase back, add in my own ways of describing similar feelings, and continue to listen while tidying up the room a bit or occasionally doing some quick charting to allow myself to linger a moment longer.  Other times, it's clear I need to put down some distractions and either touch their shoulder gently or take their hand, offer a tissue.  

I don't always have as much time as I would like for these holy, human moments.  It does make them all the more precious.  

It's odd to think how having a chronic illness and an ostomy can become its own superpower.  Frankly, to some people living with an ostomy is the worst-case scenario, that they cannot "imagine having to do that!" (which people have said to my face, that my life embodies their hell, which is...not exactly uplifting).  And yet.  Here I am.  Certainly with scars and trauma that I wear perhaps too well some days, but I am here.  I went to nursing school and swim laps and am happily married and have a dog and proceed to keep living, even with an ostomy and, in fact, because of my ostomy.  A patient's demeanor can change dramatically when I choose to reveal this vulnerability, this small piece of truth, occasionally putting a couple of other things into perspective for them, too:  their current distress is real and difficult to process; there are also quite possibly ways to accept it and people who have whose experience can be learned from.  

That's with patients, though.  I'm not shy about telling my peers about my ostomy either.  And, honestly, it is such a relief to be around people that I don't have to go into a full lesson about what an ostomy is--there is a base, mechanical understanding immediately there.  I know that if I have a bag blow-out in a shift that I could have hands that would know how to act and help in the immediate physical places (grabbing my supplies, getting new scrubs, checking in on a patient, etc.) and a number that I would trust to support me in the emotional ones.  Inevitably there will be a day where I need that kind of help, and I feel a community present in these spaces.  

Melvin's presence has a way of helping me, too:  I have less trouble asking for help when it comes to Melvin.  It is something so un-normal for most people that there are few assumptions made about what I do and don't need in those spaces, so I can set the timbre.  I tell people frankly that I need to vent the bag or that the loud, wet sound they heard was "just my ostomy," to normalize it a bit more, sometimes for myself.  Melvin also gives me an excuse to go to the bathroom--I can tend to Melvin with little internal discussion when I had successfully ignored my bladder for the last several hours, which means that it is also a good time to pause for some water and otherwise take a few mindful breaths while I'm at it.  

Just a normal bathroom, for our version of normal

Melvin makes me pause, both to my frustration and relief.  Melvin humanizes me to both my patients and my peers.  Melvin does not define me, but it definitely does frame my experience significantly to the degree that I cannot separate myself from my disability.  Living with an ostomy means that I always have to be checking in with my body in certain ways and have contingency plans for different situations, which can turn into experience I share with patients all over again and reasons to further self-advocacy.  It is a continuous journey of self-acceptance, grief, and resilience, overlapping corners with other challenges and the needs of the moment.  And the only visible marker of all these things hides under my shirt.  

Fledgling Nurse, Part 5: Not Knowing

Since NaNoWriMo has wrapped up, I've been trying to restart some books that I had been reading and a couple of series that I had been watching on Netflix and Amazon Prime.  At any given time, I tend to have somewhere between three and eight books that I will swap around between, though one will likely be my major focus at the moment.  There are a number of reasons for this, including recognizing different moods--something fluffy and comforting compared to something that is denser and requires a certain attention compared to something else that is purely for learning purposes that I'm trying to half-memorize as I go through.  I have a couple of books that I want to get through but are hard for various reasons, requiring a titration of sorts (read a small bit, recover for a week, repeat).  Specifically what comes to mind for this group is An American Sickness:  How Healthcare Became Big Business and How You Can Take it Back--it is highly informative in the same breath that it is absolutely soul-crushing and/or rage-inducing, particularly when I have been on the medication that was used as a talking point in the first chapter and experienced those points first-hand.  

Other people would probably put some of these books down.  Anything that I only read a chapter here and a chapter there, that takes months to work through, well, it probably means that I'm not necessarily enjoying it as much as I could be, that I am muscling through it.  There is no small measure of stubbornness involved.  And yet, I also just want to know how it ends.  For An American Sickness, I know it gets to a point where it will outline a solution.  I have also read books where I knew I was turned off either from how it was written or enough flaws in the structure that I was pulled out of the story...and yet, I still wanted to know the ending.  

That's happened several times over, actually, with TV series and books where I had the realization that I was not enjoying the experience necessarily but that was outweighed by my need to know how it ended.  For TV series, I have gone to Wikipedia to read episodes' synopses, to save myself literal hours of watching in order to know the ending, but usually a book I will muscle through (and then read the synopses for the rest of the books in the series if need be).  Even if I'm only mildly invested in the characters, I still want to know what happens.

...and so let's consider, then, how I might feel after spending twelve hours with a patient.  A patient I had to research regarding their past medical history, allergies, medications, and other quirks.  A patient that I have gotten to know, having specifically listened to their emotional needs in the day.  A patient that has suddenly taken a strange turn in their condition over the course of the day.  They are a person to me, AND my curiosity is piqued.  

And then I go home at the end of the day.  I may never find out what happened to them.  I could have had a patient over four different shifts that discharges or transfers on a day I'm not working and then never see them again.  It is possible to look up their chart in the computer, sure, but it is also a violation of HIPAA to do so, because I am not looking up information on them with regards to their current care.  In other words, satisfying my own personal interest is not a valid enough reason to delve into someone's private health data.  A peer might know if they went into home hospice or if they were transferred to another facility, but there's still not much of a conclusion.  Even someone that was well-ish when they discharged, I do not get to know what happens to them after the fact.  Do they keep their physical therapy appointments?  Do they have questions about their diet changes?  Are they being adequately supported by their family members for dressing changes and emotional needs?  Are they able to go back to work?  How are they considering their own mortality after this interlude?  

I have to find a way to come to terms with never knowing.  I have to let go of the patient when I clock out at the end of the day or when I transfer their care.  That not-knowing is just going to be a thing.  I do not get the satisfaction of resolution.  And I'm not specifically entitled to it, either.  It's a brief intersection of different lives and nothing more.  

There is no resolution.  There is no closure.  Some cases will bother me on that count more than others, but with all of them that is something I'm going to have to figure out how to live with and let go.

Fledgling Nurse, Part 4: Ingenuity

One of the most time-consuming parts of my day in the hospital is finding things.  I have stared at the wall of supplies in the storage room, suddenly blind to the piece I need.  I have searched all corners of the room trying to find the thermometer, and I have scoured from room to room looking for a recliner I could steal.  I have popped to another floor to borrow a bladder scanner or snag an armful of blankets when we ran out.  I have sent many, many requests to pharmacy for the one medication that is missing and wait for it to be sent up because a dosage was changed last minute or another piece had just been added.  

It takes time.  Sometimes it requires several phone calls and traipsing around the hospital to check in a couple of individual spaces.  There are occasions where it is better to beg forgiveness than ask permission...or at least sneak it back up into place before anyone seemingly notices.  There are also places where trades happen, the you can borrow X if we can borrow Y secret-handshake-swaps in the hallway (temporary exchange of bladder scanner for vein finder was one from a few weeks ago).  And if the room that you need it for is a room that requires specific PPE (personal protective equipment, such as a gown and an N95 mask as opposed to a normal procedure mask), then there is a lot of putting on and taking off and back again, and suddenly it is forty-five minutes or two hours later and you are behind on all of the morning meds.  

That, of course, is assuming that you know exactly what you're looking for.  Let's say that you are not trying to find a particular something but instead you are aiming to solve a particular problem.  Then, staring at the wall of supplies becomes a different problem.  Here's a hypothetical:  a patient cannot have a certain set of medications, they are in pain, and the best immediate solution seems to be attempting a warm compress of sorts, but the warm blankets cool off too quickly and keep sliding off in any case.  I ended up taking two ice packs, filling them with warm water, tying them together, wrapping a warm blanket around those, and then wrapping another around the body itself that held the specific limb in place.  It wasn't elegant, but it was functional while we were sorting out other details and other options.  There have been many, many times when I have walked into a room and thought "what is this hot mess?" only to untangle a pocket of genius that I could refine as the day went along.  Other times, it is just a hot mess, and we can scrap the idea to then try something else.  Techs, nurses, and other members of the team can find some glorious, creative solutions to so many interesting situations.  There are simple questions (How do I take blood pressure on someone whose arms we can't put a cuff on?  Use a leg.), there are daily questions (this man's anatomy does not work well with the external catheter--use the other kind but backwards), and there are some that will likely never happen again but still help inform how we approach adjacent questions in the future (too specific to mention here).  

This is also assuming that one has the capacity to well identify a the right problem.  It's a particular skillset to look at a situation, to take a vague discomfort and turn it into something actionable.  Turning a generic frustration into something that you can do to directly address it, that takes a certain amount of critical thinking combined with active listening--it's easy to latch on to one part of the conversation while ignoring the core.  This also takes time, to suss out a series of complaints into steps.  The real secret, though, is that the core has to be identified, even if it cannot be acted on directly.  It needs acknowledgement.  Solving a couple of the smaller pieces can help, but simply acknowledging the core tends to help much, much more.  A very common one I see in my patients is that they feel out of control in the situation.  If I interrupt the first part of the tirade where the patient complains of being cold by offering a blanket, then we might not get to the real reason of the frustration.  It's important to listen fully, and it's difficult to be patient enough to do so.  I tend to let them list out everything and then repeat back parts with "So what I'm hearing is..." to check for clarity, allow for additions, and then end the conversation by validating their feelings and repeating the list of actionable steps we have made.  As long as I can fulfill my verbal contract or keep them updated on ways it could not be, I have earned their trust.  

Now, in addition to solving an already existing problem, there is an additional skill--preempting potential or even related issues.  This is an entirely different skillset and frankly it is an artform.  It is a very helpful one to have in nursing, most certainly.  Can I deescalate a patient's feelings of lack of control by offering small choices, like whether they would like their door open or closed?  I can also call them before I go into the room to see if there is anything else I can bring with me before I go in, saving myself a trip in addition to allowing them voice into the situation.  They keep asking for water when I go in, so maybe I can bring a fresh one in with me anyway.  Again, it takes a certain kind of mental energy, intentional forethought to put myself through possible hypotheticals of what I might need and then see if they might also fit for the patient's circumstance.  I should also be considering potential issues in the room, such as whether the path to the bathroom would be clear if they had a sudden emergent need.  Is their phone charger plugged in and in reach?  

All of these facets are using different levels of critical thinking, on top of that other critical thinking that I need to do, like watching trending vital signs for new potential issues.  

So, long story short, at the end of the day, my brain hurts.

Fledgling Nurse, Part 3: Language

There is a different way of talking out on the floor.  Yes, there is a fair bit of jargon floating around, but that doesn't encapsulate the full flavor--no one I speak with on the floor sounds like a textbook to my ears, at least.  

My coworkers are also starting to realize that I 
come with catchphrases...

Brevity is not my strong point.  You may have noticed.  My brother told me once that I speak in essays, and I think about it from time to time, even in how I draft things I want to say and write.  It's not impossible for me to tap into brevity, but it does take a level of intentionality--the ideas tend to wind to a point at the end, coming together through various explorations of thought and verbiage.  This is more for deeper discussions and playing with hypotheticals, but there are still places that it crops up in "normal" conversation.  So I have my voice, which goes through various filters depending on the needs of the moment.  There is a dominant influence from my English major brain paired with a few successful NaNoWriMos.  In fact, the first scientific paper that I wrote and turned in for research--a completely different kind of writing--was veritably covered in red ink, slashing out my descriptive phrase, adverbial clauses, and all other facets designed to add flow.  The work was stripped to choppy sentences of only the essentials.  It was a jarring but important lesson:  the creativity came not in the wording but instead in the ideas behind the research.  I needed to consider words differently, and I'm finding that I might need to again.

As such, I have been paying attention to how people speak on the floor and I have identified three facets of communication between nurses, in no particular order:

1. Brief:  When giving report, my impulse is to frame it like a narrative, to describe the story.  Odds are the nurse receiving report would be very grateful if I spit out the specifics without the color commentary.  After all, they have four other nurses that they have to tackle to get report on four other people before than can get going on their day.  Their phone is also already going off because one of them needs to go the bathroom and the tech is helping another patient with the same already.  There are always additional irons in the fire, whether they're immediately visible or not.  We're even taught in nursing school to start with the point and then fill in the background, the whole design of the SBAR format in making a question.  When communicating with doctors, I try to tell myself that it needs to fit in an original tweet length.  Keep it simple.  Be direct.  Spit it out.  Add additional information when asked.  
2. Morbid:  Those in fields close to death tend to develop (or already have) an altered sense of humor.  It's a defense mechanism, to help release some of the pressure and otherwise to protect oneself.  We were having a conversation at the front desk one day about what happened to larger persons when they die, specifically how could someone be cremated if they didn't fit into the machine.  It was a bit uncouth from the outside, but it was fueled by genuine curiosity and something that needed levity in the midst of the stresses of the day.  As with many things, stories traded around are hilarious in retrospect but terrible in the moment, adding evidence to the axiom that tragedy + time = comedy.  As a hypothetical, discussing how a confused patient ripped out their IV or central line, in the moment there might be a chorus of "ohshitohshitohshit" and a few other choice words going through my head while deciding what to do next, but that certainly wouldn't be how I tell the story later in the day--it would become more of an epic on how my patient looked like an extra from a Halloween slasher movie.  The emotionally difficult pieces can't all be processed immediately--there are other patients that also need care that day--but there are tiny outlets to take a breath of air before diving in again.  That small gasp of air is the brightest moment in a bleak storm of terrible things.  So, no, it's not a joke for polite company to talk about blood or vomit or death or dismemberment, but the laughter is needed.  And one finds it where they have to.  
3. Constantly interrupted:  Maybe the group is talking about what happened over their vacation, but then an alarm goes off.  Or someone might be venting about something when the tech walks up with some important patient information.  Or maybe one nurse is seeking advice from another and both of their phones go off at the same time, they resume conversation and another phone goes off again.  The point is there are many conversations that start but the majority are interrupted and never resumed.  Some days, your phone truly does not stop ringing.  Pieces that need an answer--sounding board kinds of conversations--are easy to resume or start with a new body, yet there are many conversations where we're supporting our peers as people or talking about other life things that are important to us that never have an opportunity to continue.  In the beginning, I tried to wait for parts of the conversation to naturally ebb before interjecting important information.  However, then I found there never was a chance unless I just throw the information out there.  As a result, I've seen two major effects in how I approach staff conversations:  I feel an increased pressure to speak in conversation the less urgent it is, lest the opportunity fizzle out immediately, and I interrupt a hell of a lot more if there's any kind of actual urgency.  

So, yes, there is a veritable alphabet soup of acronyms, jargon, and all else floating around, but there's also a style.  There are moments to breathe and moments to laugh and moments to vent and moments to see your peers as people.  There are also spaces where we're just surviving at the moment, "eggshell fine," if you will.  I'm adjusting my scripts as I go, finding what pieces I'm going to keep and refine.  

Definitely going to work on the brevity thing.  Eventually.  

Fledgling Nurse, Part 2

I was asking another new grad the other day what surprised her most in the transition between nursing school and nursing practice.  For some reason, I didn't have my own answer prepared when she reversed the question to me, which means I have specifically paying attention in a few places.  As such, I have been starting to catalogue some of the observations and victories--big or small--that I have noticed along the way.  

Fashionista of the year, yo

Time to deploy the bulleted list!

• My grip strength has gotten a bit better--I can take off the cap of the end of an IV tubing with one hand sometimes, instead of reaching into my pocket to grab out my hemostat (clamp) to quickly twist it off with a tool.  
• I have finally developed the habit of putting on my goggles before going into patient rooms, hooray!  And whenever we're in public and I cross a doorframe, I immediately look for the hand sanitizer as another habit.  
• My short term memory is improving.  Really.  The kinds of pieces that I am remembering between rooms isn't perfect, but I am retaining numbers and which medications my patients are taking when I go to collect them from the right spaces and when I gave X medication to a patient last.  I might do an assessment on a patient in the morning but get pulled in so many different directions that I cannot chart it until four hours later, but I'm retaining parts better than I thought I would and learning what kind of notes I need to take otherwise or normalizing rechecking with a patient when I don't feel certain in my memory.  Yet, I've been startled by how much I do remember, partly as I now have a flow in how I like to do my assessments.  
• I'm allowed to message doctors directly with questions.  It's encouraged, even.  And, achievement unlocked, I have already pissed off a doctor by asking reasonable questions, which means oddly enough that I feel I have "arrived."  
• Sometimes the patients we have on our floor are not in their right minds or are not capable of making their own decisions, for a great number of possible reasons.  This may permanent or temporary.  Trying to explain to someone that is confused why they can't just leave or walk around unescorted does not always go smoothly.  Recently, we had one particular patient that I was wondering if I was going to get shoved or punched by standing between them and the door.  We can try to explain and redirect, but in the end we may need to call for additional hands.  I've been reflecting on a particular experience with this patient and making decisions for what boundaries I will set next time.  
• We have hospice patients on our floor.  Honestly, I've considered going into hospice nursing specifically, so I'm grateful to have some of this experience.  I'm not afraid of grief (familiar with it in my own experiences), and I can push through places where people feel awkward.  I am glad to have dedicated space to listen and simply be present with families as they work through those spaces.   So far, I have been a part of declaring two people dead.  Both of them, however, I did not have much of a chance to meet the family, meaning that I was decidedly more of an "extra" in a pivotal moment of their shared experience.  This was surreal to me in a number of ways.  I felt my role as "accessory" and supported that as well as I could by tending to the physical and encouraging them to take any time they needed to feel what they needed to feel.  It was strange to feel adjacent to death, if that makes sense.  And then I had to turn around and be cheerful in another patient's room and overly polite for the next patient's room based on previous interactions.  There was no time--just turn around and move on, think about it later, maybe.  
• There are a lot of terms that I'm accepting and speaking that I was not so fluent in a year ago.  I might through out "peds" instead of "pediatrics" or look at my notes to see that I've written "20 G R AC, NS @ 80/hr; 22 G L FA, SL" and it makes perfect sense to me.  I mentioned as part of an explanation one day that a patient has the right to leave AMA and forgot that not everyone knows what that acronym means, let alone what some of their hypothetical patient rights might be.  
• I'm starting to find rhythms, find patterns in how I work through my day and what pieces I need to do.  Every day is different, with the various needs that my group of patients that I have.  There's that balance between setting a general pattern in the day and reacting to patient needs that crop up, from trips to the bathroom to major crises.  I come in, check my assignments, start filling out some basics about those patients on paper for my own reference, get report from the night nurse to fill in a lot of important specifics, compare that against both procedures and tasks set in Epic, gather an idea of where to start, and begin on those morning meds after prioritizing accordingly.  Every morning I need to assess my patients, to form my own opinion of how they're doing and what goals we might have for this patient today.  The song is different but the genre is the same.  There are patterns and certain things that need to be done by X point or Y point in the day.  I pick my battles and am finding which ones are worth picking.  
• I am noticing my different feelings of urgency and finding my balances between what needs to be done by X time for Y reason and what is feasible to do--when I have five different people with medications due at nine, I cannot physically be in all places at once.  Inevitably, I will walk into a patient's room for a quick thing and get stuck there for an hour, either because of a series of "well, while you're here..." or needs revealing themselves (e.g. going to deliver an IV medication and finding that their IV doesn't work anymore) or whatever else.  There are guidelines and certain things that must happen at specific times, and there are many things that should happen by a certain time and are going to happen as soon as I can and there are a few things that need to be recorded by the end of the shift (e.g. any patient education components discussed today, which I tend to sprinkle in anywhere).  
• There is so much variety in the patients that we see on our floor.  On the one hand, this can be very intimidating because there isn't a certainty to land into with enough time.  On the other, there is always something new to learn, which I find thrilling.  Additionally, there is freedom in knowing that I won't be able to know everything so I don't have to, which in turn takes the pressure off of trying to know everything.  There is peace in that.

Certainly more to come soon, but that's a happy smattering to start with.  What the biggest surprise will be in another few months time, that'll be an interesting question all over again.

Fledgling Nurse

Whelp, I've been working toward this goal for literal years, walking the path to RN.  Andy and I have been working toward being financially able to make the move, assessing what our best choices were, and determining our most appropriate timings.  It was a lot of calculating, prioritizing, and a fair bit of luck to get to where we were, able to make this kind of leap.  

My view walking into work the other day

And here we are.  This is real.  I have a license and a job in a hospital and a coach and days scheduled and a direct deposit setup completed.  It's strange to me to accept the benefits of the hard work after working toward it for so long.  It's almost like same feeling as a book hangover, that the absence of having something to look forward to, to be working toward, there's a strange void there.  It's time to construct a new goal.  

In the meanwhile, my goal is to absorb as much as I can.  I've learned a LOT as a CNA, regarding how the hospital works in general and how my floor "moves" specifically.  My role and its pace will change--I think probably the most difficult part of that transition might be delegation, figuring out how to best utilize team resources.  

There is so much to learn, but the real trick as I see it is trying to feel out two important things:  my own independence and the balance in transference I feel with my patients.  

Let's dig into those.  

Independence:  I now have the power to administer medications without someone over my shoulder approving them.  There are administrative and procedure powers, sure, but I can give people medications that are within their orders without double-checking each one with another body, allowing me to create a blending between my time schedule,  my judgement, and the verbal contracts I have made with my patients.  I can reach out to their doctor on the patient's behalf with their concerns.  I can ask the client what goals are important to them today and with what I know about their case.  I decide what order to do different tasks.  And yet, there are still places where I need to have my coach present, partly for my own safety and partly as they are gauging where I need additional hands and insight.  This leads to some waiting times, where we have to find a place that lines up between tasks.  In other words, there are places where I am asking a lot of permission that are necessary for a number of reasons, which does then impact how much independence I can grow at once--not a complaint but a recognition of what simply is.  

Transference:  I remember what it was like to be a patient, in very vivid detail in some places and otherwise some important, formative moments.  It is VERY easy for me to see myself in a lot of their situations, to want to fight for them in the way that I wanted people to fight for me.  I now have the power to do some of those facets, but I do not have the time nor resources to be all things to all people.  I can ask the doctor questions; I can encourage the patient to ask questions; I can help connect the patient with different referrals and resources; I cannot, however, take all of their urgency unto myself nor can I be overzealous and take pieces of their autonomy with me.  The solution will be finding balance between hearing the patients' concerns to then turn them into actionable pieces but also not pulling on more empathy than I have available, to ensure that I don't make it personal to me.  I have to be mindful of what and where my boundaries are.  I also need to demonstrate self-compassion in enforcing those boundaries.  

There are many, many other pieces to sort through:  I am finding a groove in some spaces; I am stumbling my way through others; I am adjusting to the crisis that needs addressing, which means I have to re-adjust my whole day; I am providing emotional support, even when I have other tasks that need doing; I am learning that one more thing that was policy that I was hitherto unaware of and adding that to the mental list of things that need attending; I am refining my scripts; I am starting to get to know my teammates.  

And walking around with all of this uncertainty as I do explore these spaces is exhausting and fulfilling and terrifying and encouraging and a number of other adjectives all at once.