Joan is smart, funny, warm, and engaging, and I liked her from the start. Hospitalized after her homemaker found her unconscious on the floor and subsequently diagnosed with a small stroke, Joan was doing better and eager to go home when I met her in my role as hospital-to-home liaison. Ultimately, though, she was persuaded to postpone her discharge and accept a ten day stay on the inpatient rehabilitation service to gain strength and work on the balance deficiencies that seemed to contribute to her history of multiple falls. That she had abused alcohol in the past also was noted, but waking up in the Emergency Department and learning she had suffered a stroke had startled and scared her, so Joan had been receptive to abstinence counseling and remarked many times that she didn't miss drinking and wasn't about to resume her old ways.
I followed her as she progressed through rehab, and accepted her as my own patient when she finally did go home. For weeks she stayed sober, and I discovered that she was well informed about issues of the day, highly articulate, and strongly committed to work with the homeless, once having been homeless herself. Indeed, one of her pressing objectives was to regain strength sufficient to resume work at a local shelter, either as an employee or volunteer, depending on the shelter's need and budget at the time. Her "no nonsense" attitude coupled with her ready smile and quick wit struck me as a uniquely winning and effective combination, and we talked about her ability to offer both academic insight and the wisdom of personal experience in her work on the problem of homelessness. And every time I saw her she smiled and affirmed that she was "done with the booze." As time went on I saw no hint of alcohol in her home, and her air of practicality and bottom-line realism led me to believe that while not out of the woods, her prognosis was good.
Until today.
I knocked and knocked on her door, but heard only a television or radio inside. Confident that Joan wasn't yet able to go out, I knocked longer and more loudly, until a muffled voice seemed to answer from within. I waited. And waited. And then knocked some more, and called out, "Joan, it's Sue. Are you in there?"
"I'm in here. Where else would I be?" came the slow, familiarly sarcastic, . . . and unfamiliarly slurred response. "Let me drag myself up."
"Take your time and be safe," I answered. And I waited.
All grew quiet, and I debated leaving ("Has she fallen back to sleep," I wondered) or calling for help ("Is she on the floor?"). But then came shuffling, silence, stumbling, more shuffling, fumbling with the lock, and, after the handle had spun helplessly while the door didn't open, finally, a slurred command, "Open it and come in."
I did, and there she was, dressed only in an oversized t-shirt, balancing precariously on legs she did not seem to recognize as hers, and breathing alcohol fumes in my face. She staggered against the adjacent bathroom door frame and tried to look casual as she leaned on it for support. "I went to the store for the first time yesterday, all by myself. . . . All. by. my. . . . self!" she said with a forced, crooked smile.
"And what did you buy?" I asked, knowing the answer.
"Tons of food," she said, "Tons and tons and tons and tons of food." She stumbled to the refrigerator, opened it, and repeated, "Tons and tons of food." Collapsing onto a chair she looked up at me as though expecting a response to a profound pronouncement.
"Did you also buy some booze?"
"A little," she slurred, attempting with small success to make a pinching gesture with one thumb and forefinger.
"Let's have a look at you, Joan," I said, beginning a cursory exam, because there's truly nothing to be said to a drunken drunk. "Do you have any of that booze left, or did you drink it all?"
"A . . . LOT. I have a LOT left!" she announced with a sloppy smile.
"You did well for quite a few weeks, Joan, and tomorrow's another day. You can start again. One day at a time."
"Yeah. One day at a time."
Peddling away on my bicycle a short time later I felt a profound sadness that permeated my being from head to heart to toes. And I realized that after forty years of practice there's been nothing sadder in my repertoire of experiences than the people doing themselves in with alcohol. And there's not a thing I can do for them until they hit that proverbial bottom and make the decision to help themselves.
If a patient is dying of cancer I can act to control pain, prevent tissue breakdown, maintain hydration, and more. In the face of fear and fever, of multiple trauma in the middle of a street somewhere, of a disease with no cure, of a body whose vital organs are failing irreversibly, of confusion and dementia, of ignorance and inability to learn, and more, I can offer some means of aid. At the very least, or perhaps the very most, I can be present to stand, sit, or walk with another who treads a dark road that perhaps none understand. But the inebriated alcoholic may not even know I'm there; indeed, tomorrow Joan may tell her Physical Therapist that she wonders why she didn't see me this week, never knowing that it was what she put in her mouth that blinded her eyes and her memory to my presence.
I'm glad I was the one who found Joan today, because I know the intelligence, sensitivity, passion, warmth, and hardship of the human being behind the booze. And I'm a seasoned warhorse who knows what I saw and what can and cannot be done at this point in Joan's journey. A younger, greener nurse might have set herself up for unnecessary failure; I could peddle away with sadness, yes, but also with understanding.
Joan needs to meet some friends of a fellow named Bill W., and she probably knows that. I will see her once more, hope she is sober, and if so will suggest an introduction and tell her where in her neighborhood that introduction can happen. And then it's up to her. I told her booze-smitten self today that I'd see her only once more, because there's nothing more I can do for her . . . although there is a great deal she can do for herself, and much support to be had once she makes that commitment.
The world needs Joan and people like her, desperately. She understands the problem of homelessness from every perspective and has the smarts and the skills to communicate with everybody from the badly beaten single mom with no place to go to the policy makers. Few can do that. We need her. But today she drinks.
I write this from a corner lounge overlooking the driveway to the Emergency Department of the hospital where Joan goes, where EMS would bring her if she called 911 or someone else made that call on her behalf. I see ambulances coming and going, and wonder if one of them carries a smart, funny, warm, engaging woman who was found on the floor today with a fractured [fill in the blank]. Or I wonder if she is alone in her tiny apartment finishing off "a LOT" of booze tonight.
And I feel the most profound sadness possible, because there is nothing to be done . . . until Joan takes action herself. Bill W.'s friends reach a point of making amends to those they have harmed whenever possible, except when doing so would cause further harm. Sadness isn't the worst thing in the world, and mentally healthy people know how to handle it and gently let it go. But when people like Joan become acquainted with people like Bill's friends I wonder if they ever truly know not just the overt and subtle harm they may have caused themselves and others, but also just how very sad those who care have been, and how the practice thought to bring pleasure actually is perhaps the most isolating one possible. For in a drunken haze not even the connection of another quiet presence is possible, and no matter how lively the bar or how many people at the party, the alcoholic always drinks alone.
Now in this festive season, as I watch ambulances come and go, I wonder how many times in the guise of fun and celebration
Isolation Toasts Sadness.
Thursday, December 4, 2014
Saturday, May 3, 2014
You Had a Chance to Be Kind Today
You had a chance to be kind today. I wish you'd taken it.
I didn't mean to usurp your parking space. My new patient's husband, "Charlie," called while I was en route to their home to let me know there was a lot behind the building where I could park. Parking is particularly challenging in your neighborhood, as you well know, so this was good news. However, when I arrived I was concerned to note that although there were many vacant parking spaces, all of them were numbered, and I shared this concern with Charlie, who was sitting in his motorized scooter waiting for me. "Nurse? Are you the nurse?" he'd called out, and I'd addressed him by name and affirmed my identity. When I mentioned my concern about the numbered, and therefore possibly reserved, spaces he told me, "You can park "back there," so I chose a spot where he pointed, pulled in, gathered my computer and supplies, and followed him to the elevator.
It was a long visit, as initial visits usually are. But there also were unusual problems in this case. Charlie's wife, Delphine, was diagnosed with cancer "about a month ago," and just two days ago returned home from a second hospitalization where the cancer had been found to be particularly aggressive, already spreading to other parts of her body. Yesterday I hadn't been able to reach her to schedule a visit; as it turned out, she was back in the emergency room because of severe, unrelieved pain. When I arrived today Delphine still was in pain, didn't have her medicine, and the hospital bed and wheelchair that had been ordered for her had not arrived. It takes some time to sort out such issues as these, with calls first to identify exactly what the problems are, and then more calls to solve them. And my physical exam and everything I do happens in slow motion, because the patient is hurting and moves gingerly, and her ability to hear and understand instructions is compromised. So my car sat in your parking space for quite awhile.
Again settling into his scooter, Charlie escorted me back to the parking lot when I was ready to leave, and there we met you. Oh, my, but you were irate! My car was in your parking space, you shouted, and, "We called the towing and it is coming now." Well, I'd say I arrived just in time, I thought, although clearly that wasn't what you wanted to hear, so I held my tongue. In fact, it didn't take long for it to be obvious that you didn't want to hear anything. And it didn't take much longer than that for anyone around to realize that there was nothing that could be said or done to help you feel better. You were puffed up with righteous indignation, and letting it rip.
I apologized, identified myself and my reason for being there, explained that I had been told I could park there while visiting my patient, emphasized that I now understood I had been misinformed and that I would not do it again, and assured you that I would remove my car at once. "You should have called ME!" one of you said, although I had no idea who you were or how to call you. If you are the janitor or a staff member who can authorize parking I surely would like to know it and would be happy to call you next time, but you weren't about to disclose anything like that. No matter that until moments before I'd had no idea you even were on the planet and that I still didn't know who you were except the wronged probable leaseholder of the parking space in question, I should have called you, you told me, and at a high decibel level. "I came back from SHOPPING," the other one of you announced indignantly, "and couldn't park my car!" While I feel quite sure my car was where it should not have been and that you were inconvenienced as a result, I couldn't help but be struck by your ability to draw yourself up and spew forth righteous entitlement befitting a setting far more well-heeled and exclusive than the asphalt lot behind the modest building where many residents, probably yourselves included, live on public aid. I don't know your life story, but you have the Rodeo Drive air down pat. Well done.
I apologized again, but you told me, "Sorry is no good!" Ah. Having established that my car was in the wrong place and feeling confident that it was not in my power to rewind the clock and make a different decision about where to park it, and quickly coming to a clear understanding that you didn't care that I had made every effort to park properly and truly regretted my error, it took no genius to realize that there was no point in continuing the conversation and every advantage to be gained by my removing my vehicle and being on my way. The tow truck you called arrived and left; my sense was that you were most angry about having been denied the satisfaction of watching my face as my car was towed away. I'm afraid I'm not sorry to have deprived you of that!
Interestingly, before I could leave the parking lot I needed to wait while you pulled your car in front of mine and carefully blocked my way as you adjusted your seat belts and did whatever else you were doing before driving off. I followed you down the road until we turned in opposite directions. It seems you had no intention of using your parking space. Evidently you arrived home from shopping, found your parking space occupied, and simply took another of the many that were vacant. Perhaps you unloaded your purchases and called the tow truck in the process. You may or may not have noticed the sign in my window identifying my car as belonging to a visiting nurse who was on site providing healthcare; if you did, it didn't matter.
My heart is sad for you. I wonder if you know that your 51 year-old neighbor would love nothing more than to be able to go shopping, but she doesn't even have medicine, much less other purchases, and can't so much as roll over because of severe cancer pain and because the hospital bed that would make movement easier has not arrived. I wonder if you noticed your other neighbor who must travel by motorized scooter because he can't walk and doesn't have a car, much less a place to park one. I believe on the basis of your presentation, your particular accented English, and the location of your modest apartment that you may have come to this country as a religious and/or political refugee and may be here at the expense of a charitable sponsor and of the US taxpayers, and that you may have come from a country where the only way to have your basic needs met was to get in someone's face and loudly demand satisfaction. I wonder if you took time to relish being able to peaceably acquire what you bought today, as well as having the money in your pocket to buy it. And I wonder if you enjoyed your ride to wherever you went as you drove off in front of me, if you amused one another with stories and jokes, or sang along with the radio . . . or if you spent a precious evening, of which your 51 year old neighbor probably has few remaining, complaining bitterly about the errant ways of a misguided nurse who borrowed your parking space without permission.
I will see you again. Or someone like me will. I will see you in the ER when you arrive with your chest pain, your stroke, your hemorrhaging gut, your fierce headache, your uncontrolled pain . . . from the effects of the stress hormones that all too often course through your body. You may arrive with stab or gunshot wounds if the next person who meets your rage responds in kind and your mutual anger escalates. I will see you through your hospital stay, and I will be on your doorstep (albeit with my car parked elsewhere) when you arrive home to begin your arduous rehab, after which, I fear, you will be left with significant permanent deficits. You see, rage is deadly, and far more so for the perpetrator than the recipient.
My evening shaped up quite nicely. Since your neighbor had needed more of my time than I'd expected, my plans to meet a friend for dinner were postponed. So I enjoyed nice dinner at home in front of a DVRed episode of Masterpiece Theatre I'd not had a chance to watch, figured out some new computer software and enjoyed a head start on some work, read a bit, and soon will turn out the light and sleep like a baby. I think you may have returned home from wherever you went and relived your anger as soon as you saw your parking space. Unfortunately, your body doesn't know the difference between the memory of anger and stress and a new occurrence of those all over again, so just parking your car probably set off your "fight" response anew. Your poor bodies! I would guess that you may sleep poorly tonight and many nights, or use drugs to ease yourself into a relatively unhealthful slumber; this is another factor that will contribute to your meeting me, or someone like me, again one day.
I am sorry I inconvenienced you by parking in your space. I don't knowingly park in places reserved for others. I'm glad to have avoided a tow, and to know not to park in that lot in the future. But I didn't do anything wrong . . . and neither did you. I asked, I followed the instructions I was given, I double-checked to be sure I had made a correct choice. You pay rent for a parking space, found it occupied by an unauthorized vehicle, called a towing company, and conveyed your displeasure to the offending driver when she appeared.
But you had a chance to notice the sign in my window identifying my car as belonging to a nurse temporarily parked for a home visit. You had a chance to see my cell phone number and call it instead of the towing company. Since you did not need your parking space at the moment anyway, you had a chance to leave a note on my windshield pointing out my error and to take no other action. You had a chance to park elsewhere long enough to unload your purchases and then be on your way, exactly as you did. You had a chance to accept an apology, allow amends, correct a misunderstanding, meet a neighbor, and perhaps even make new friends. You had a chance to forgive, to build bridges, to feel peace, to heal. But you chose rage instead, and that rage seemed to take hold of you and not let go. It is the kind of rage that will harm you one day. It already may have poisoned your relationships with family, neighbors, coworkers, and others. And one day it may kill you. It almost certainly will be a contributing factor to whatever does.
I'm the one who parked in the wrong place today, and all I suffered for it was a bit of unpleasantness from you, which, frankly, doesn't matter to me one way or another. You were the one wronged, however unintended that wrong may have been, and you then wronged yourself all the more by stewing in anger over something that could not be changed and by refusing to accept an olive branch of peace and healing. I will see you in the ER one day, and in the hospital, in rehab, and at home as you struggle to recover from the consequences of your choices, such as the unfortunate one you made when
You Had a Chance to Be Kind Today.
I didn't mean to usurp your parking space. My new patient's husband, "Charlie," called while I was en route to their home to let me know there was a lot behind the building where I could park. Parking is particularly challenging in your neighborhood, as you well know, so this was good news. However, when I arrived I was concerned to note that although there were many vacant parking spaces, all of them were numbered, and I shared this concern with Charlie, who was sitting in his motorized scooter waiting for me. "Nurse? Are you the nurse?" he'd called out, and I'd addressed him by name and affirmed my identity. When I mentioned my concern about the numbered, and therefore possibly reserved, spaces he told me, "You can park "back there," so I chose a spot where he pointed, pulled in, gathered my computer and supplies, and followed him to the elevator.
It was a long visit, as initial visits usually are. But there also were unusual problems in this case. Charlie's wife, Delphine, was diagnosed with cancer "about a month ago," and just two days ago returned home from a second hospitalization where the cancer had been found to be particularly aggressive, already spreading to other parts of her body. Yesterday I hadn't been able to reach her to schedule a visit; as it turned out, she was back in the emergency room because of severe, unrelieved pain. When I arrived today Delphine still was in pain, didn't have her medicine, and the hospital bed and wheelchair that had been ordered for her had not arrived. It takes some time to sort out such issues as these, with calls first to identify exactly what the problems are, and then more calls to solve them. And my physical exam and everything I do happens in slow motion, because the patient is hurting and moves gingerly, and her ability to hear and understand instructions is compromised. So my car sat in your parking space for quite awhile.
Again settling into his scooter, Charlie escorted me back to the parking lot when I was ready to leave, and there we met you. Oh, my, but you were irate! My car was in your parking space, you shouted, and, "We called the towing and it is coming now." Well, I'd say I arrived just in time, I thought, although clearly that wasn't what you wanted to hear, so I held my tongue. In fact, it didn't take long for it to be obvious that you didn't want to hear anything. And it didn't take much longer than that for anyone around to realize that there was nothing that could be said or done to help you feel better. You were puffed up with righteous indignation, and letting it rip.
I apologized, identified myself and my reason for being there, explained that I had been told I could park there while visiting my patient, emphasized that I now understood I had been misinformed and that I would not do it again, and assured you that I would remove my car at once. "You should have called ME!" one of you said, although I had no idea who you were or how to call you. If you are the janitor or a staff member who can authorize parking I surely would like to know it and would be happy to call you next time, but you weren't about to disclose anything like that. No matter that until moments before I'd had no idea you even were on the planet and that I still didn't know who you were except the wronged probable leaseholder of the parking space in question, I should have called you, you told me, and at a high decibel level. "I came back from SHOPPING," the other one of you announced indignantly, "and couldn't park my car!" While I feel quite sure my car was where it should not have been and that you were inconvenienced as a result, I couldn't help but be struck by your ability to draw yourself up and spew forth righteous entitlement befitting a setting far more well-heeled and exclusive than the asphalt lot behind the modest building where many residents, probably yourselves included, live on public aid. I don't know your life story, but you have the Rodeo Drive air down pat. Well done.
I apologized again, but you told me, "Sorry is no good!" Ah. Having established that my car was in the wrong place and feeling confident that it was not in my power to rewind the clock and make a different decision about where to park it, and quickly coming to a clear understanding that you didn't care that I had made every effort to park properly and truly regretted my error, it took no genius to realize that there was no point in continuing the conversation and every advantage to be gained by my removing my vehicle and being on my way. The tow truck you called arrived and left; my sense was that you were most angry about having been denied the satisfaction of watching my face as my car was towed away. I'm afraid I'm not sorry to have deprived you of that!
Interestingly, before I could leave the parking lot I needed to wait while you pulled your car in front of mine and carefully blocked my way as you adjusted your seat belts and did whatever else you were doing before driving off. I followed you down the road until we turned in opposite directions. It seems you had no intention of using your parking space. Evidently you arrived home from shopping, found your parking space occupied, and simply took another of the many that were vacant. Perhaps you unloaded your purchases and called the tow truck in the process. You may or may not have noticed the sign in my window identifying my car as belonging to a visiting nurse who was on site providing healthcare; if you did, it didn't matter.
My heart is sad for you. I wonder if you know that your 51 year-old neighbor would love nothing more than to be able to go shopping, but she doesn't even have medicine, much less other purchases, and can't so much as roll over because of severe cancer pain and because the hospital bed that would make movement easier has not arrived. I wonder if you noticed your other neighbor who must travel by motorized scooter because he can't walk and doesn't have a car, much less a place to park one. I believe on the basis of your presentation, your particular accented English, and the location of your modest apartment that you may have come to this country as a religious and/or political refugee and may be here at the expense of a charitable sponsor and of the US taxpayers, and that you may have come from a country where the only way to have your basic needs met was to get in someone's face and loudly demand satisfaction. I wonder if you took time to relish being able to peaceably acquire what you bought today, as well as having the money in your pocket to buy it. And I wonder if you enjoyed your ride to wherever you went as you drove off in front of me, if you amused one another with stories and jokes, or sang along with the radio . . . or if you spent a precious evening, of which your 51 year old neighbor probably has few remaining, complaining bitterly about the errant ways of a misguided nurse who borrowed your parking space without permission.
I will see you again. Or someone like me will. I will see you in the ER when you arrive with your chest pain, your stroke, your hemorrhaging gut, your fierce headache, your uncontrolled pain . . . from the effects of the stress hormones that all too often course through your body. You may arrive with stab or gunshot wounds if the next person who meets your rage responds in kind and your mutual anger escalates. I will see you through your hospital stay, and I will be on your doorstep (albeit with my car parked elsewhere) when you arrive home to begin your arduous rehab, after which, I fear, you will be left with significant permanent deficits. You see, rage is deadly, and far more so for the perpetrator than the recipient.
My evening shaped up quite nicely. Since your neighbor had needed more of my time than I'd expected, my plans to meet a friend for dinner were postponed. So I enjoyed nice dinner at home in front of a DVRed episode of Masterpiece Theatre I'd not had a chance to watch, figured out some new computer software and enjoyed a head start on some work, read a bit, and soon will turn out the light and sleep like a baby. I think you may have returned home from wherever you went and relived your anger as soon as you saw your parking space. Unfortunately, your body doesn't know the difference between the memory of anger and stress and a new occurrence of those all over again, so just parking your car probably set off your "fight" response anew. Your poor bodies! I would guess that you may sleep poorly tonight and many nights, or use drugs to ease yourself into a relatively unhealthful slumber; this is another factor that will contribute to your meeting me, or someone like me, again one day.
I am sorry I inconvenienced you by parking in your space. I don't knowingly park in places reserved for others. I'm glad to have avoided a tow, and to know not to park in that lot in the future. But I didn't do anything wrong . . . and neither did you. I asked, I followed the instructions I was given, I double-checked to be sure I had made a correct choice. You pay rent for a parking space, found it occupied by an unauthorized vehicle, called a towing company, and conveyed your displeasure to the offending driver when she appeared.
But you had a chance to notice the sign in my window identifying my car as belonging to a nurse temporarily parked for a home visit. You had a chance to see my cell phone number and call it instead of the towing company. Since you did not need your parking space at the moment anyway, you had a chance to leave a note on my windshield pointing out my error and to take no other action. You had a chance to park elsewhere long enough to unload your purchases and then be on your way, exactly as you did. You had a chance to accept an apology, allow amends, correct a misunderstanding, meet a neighbor, and perhaps even make new friends. You had a chance to forgive, to build bridges, to feel peace, to heal. But you chose rage instead, and that rage seemed to take hold of you and not let go. It is the kind of rage that will harm you one day. It already may have poisoned your relationships with family, neighbors, coworkers, and others. And one day it may kill you. It almost certainly will be a contributing factor to whatever does.
I'm the one who parked in the wrong place today, and all I suffered for it was a bit of unpleasantness from you, which, frankly, doesn't matter to me one way or another. You were the one wronged, however unintended that wrong may have been, and you then wronged yourself all the more by stewing in anger over something that could not be changed and by refusing to accept an olive branch of peace and healing. I will see you in the ER one day, and in the hospital, in rehab, and at home as you struggle to recover from the consequences of your choices, such as the unfortunate one you made when
You Had a Chance to Be Kind Today.
Tuesday, April 1, 2014
A Good Nurse
Good nurses practice in accordance with the Nurse Practice Act of the state in which they are licensed and working, and in so doing carry out all of the components of the "nursing process," and they do this well. That's all there is to it.
Yet among the thousands and thousands of patients who receive nurses' services every day, and the thousands of organizations that employ nurses, precious few folks seem to know what a "good nurse" truly is or how to spot one.
A nurse can be kind, compassionate, considerate, friendly, thoughtful, smart, funny, and able to change a bandage or administer an injection without causing pain, yet still not be a "good nurse." A nurse can be a conscientious employee who is well-liked, responsible, and loyal, yet not be a "good nurse." And most of all, a nurse can be "nice" (Lord help me if one more person tells me how "nice" a nurse is!), while being a professional disaster at the same time.
The problem is that state laws and professional standards of practice just aren't typical recreational reading for most people, and the essence of good nursing practice often is concealed in mundane activities. So it's all too easy for the public, and for business people who own and/or administer healthcare organizations, to assume that handing out pills and applying cool cloths to fevered brows is professional nursing, and that people who hold RN licenses and do those things well are "good nurses." 'Tain't necessarily so.
Some years ago a recruitment ad running in professional journals showed a nurse standing at the bedside of a patient who was sitting up in bed with a meal tray on the table in front of him. They were smiling at each other and obviously enjoying a pleasant exchange. The caption read something like, "He thinks they're talking about green jello. Actually she's halfway through 146 assessments." That would be true, if she were a good nurse, and the point of the ad, directed to good nurses whom the sponsor hoped to recruit, was that this is the sort of nurse sought and valued by that hospital.
A nurse indeed could merely banter about food with a patient and then head off to hang the next IV, having noticed and learned little. But more probably the nurse at that bedside noticed whether, what, and how much nutrition the patient was taking. She knew if he was enjoying his meal or if eating was a struggle or a chore. She recognized if he seemed to be in pain or to be having difficulty eating, from trouble swallowing to challenges manipulating utensils to inability to see clearly the things that were on his tray. She noticed his color, his breathing, and his speech. She could estimate his level of literacy, and had a sense of his willingness to engage with her and other providers. She had a sense of his communication style and whether he tended to be blunt, evasive, or something in between. She noticed his position and if he favored or guarded any body part, or if he just seemed more comfortable being "crooked" in the bed. She could tell if he was likely to engage, ask questions, and want to be an active participant in his care, or if he preferred a passive "wake me when it's over and I'm all better" approach. The nurse noticed any hearing deficit, if the patient seemed light-headed or dizzy, or if he was confused, forgetful, hallucinating, or demonstrated impaired cognition. She recognized effects, intended or otherwise, of the medications the patient had taken, and whether he might need something more, less, or different. She had a sense of how eating was affecting his stomach and entire GI tract. She noted sensory impairments he might have, such as not realizing that coffee was hot or that a glass was placed too close to the edge of the table. She saw if he had trouble grasping objects or tended to drop them, and if this involved one hand or both. She noticed if he did not move normally, and if he was tired, or tired quickly. She saw how he coped with whatever health problems he had, and knew the approaches to which he likely would be most receptive. She knew if his IV was running properly, if his bandages were intact, and the significance of displays on the monitor over his bed. And more.
The nurse also knew what to do with all of this information. She used it to formulate diagnoses, plan treatment, evaluate the effectiveness of treatment, prepare to teach the patient, include supportive others and exclude others, plan his discharge, and give other team members heads-ups about the patient's status, needs, and actual and potential problems. She knew what to disregard for the moment, and what warranted prompt action. She knew what questions she still had, and had a plan for pursuing their answers.
But when the phone rang and she excused herself from the bedside as the patient answered it, chances are she overheard him saying, "Hi, Honey. I'm having lunch and just was talking with Jane about the jello. It's green! Yeah, Jane's very nice; she's a good nurse."
More sobering are the administrators and executives of healthcare organizations who don't know what good nursing is, or even what nurses are required to do to be in compliance with the law. Recently I spoke with a Clinical Manager of a home healthcare agency who lamented the unnecessary and time-consuming documentation that many nurses new to home healthcare wrote. "All they need to write is what regulators and payors require," she said, "The rest is superfluous and unnecessary."
Wrong.
Those new-to-homecare nurses indeed may have been including unnecessary information in their notes, but they are required by law and by the standards of their profession, to which they would be held accountable in any court of law, to perform and document the entire nursing process, not just the parts that satisfy the specific requirements of regulators and payors. One would hope that Clinical Manager would help new employees ferret out irrelevant information while fleshing out a complete clinical picture of each patient and of the nursing process as it is carried out in each case. I fear that was not the case in this instance.
Employers can be so focused on their business needs that they fail to be mindful of the larger responsibility of professional healthcare providers. If executives hold business degrees rather than professional licenses they may not even know the standards and requirements for which a nurse, or other licensed professional, is accountable. They may even, unwittingly, I hope!, encourage employees to flout the law: "Just document the patient's homebound status, the skilled services provided, and compliance with the treatment plan that the physician signed and be done with it." But business needs cannot be allowed to trump professional standards or the law.
Because an employer gives a directive does not absolve a nurse from the duty to practice in accordance with the law and with professional standards. If a manager told a nurse, "It's ok, you don't have to file a tax return this year," you can bet the IRS still would go after that nurse and would have no sympathy for what the boss had said. If a director told a nurse to reach a destination as quickly as possible, without regard for speed limits, it's a sure thing that flashing lights in the rearview mirror and a speeding ticket would be in that nurse's future, boss's directive or not. Similarly, when a manager or executive tells nurses how to practice and what to document, it is incumbent on those nurses to be sure that their practice and their documentation both satisfy the needs of the employer and those of the law and of the profession.
It's a wonder more nurses don't seem a little schizophrenic from time to time, given that so many of our patients don't realize even a small portion of what our practice with them truly entails and that so many of our employers are focused on the bottom line to the exclusion of good practices and of compliance with the law. But the next time you encounter a nurse and a dish of green jello, please don't be quick to confuse personality with professionalism. Because before you can down the jello that nurse will have completed 146 assessments, formulated diagnoses and a treatment plan, evaluated what has been done and how you have responded so far, and determined with whom she or he next needs to confer to help you take the next right step towards better health. . . if he or she is
A Good Nurse.
Yet among the thousands and thousands of patients who receive nurses' services every day, and the thousands of organizations that employ nurses, precious few folks seem to know what a "good nurse" truly is or how to spot one.
A nurse can be kind, compassionate, considerate, friendly, thoughtful, smart, funny, and able to change a bandage or administer an injection without causing pain, yet still not be a "good nurse." A nurse can be a conscientious employee who is well-liked, responsible, and loyal, yet not be a "good nurse." And most of all, a nurse can be "nice" (Lord help me if one more person tells me how "nice" a nurse is!), while being a professional disaster at the same time.
The problem is that state laws and professional standards of practice just aren't typical recreational reading for most people, and the essence of good nursing practice often is concealed in mundane activities. So it's all too easy for the public, and for business people who own and/or administer healthcare organizations, to assume that handing out pills and applying cool cloths to fevered brows is professional nursing, and that people who hold RN licenses and do those things well are "good nurses." 'Tain't necessarily so.
Some years ago a recruitment ad running in professional journals showed a nurse standing at the bedside of a patient who was sitting up in bed with a meal tray on the table in front of him. They were smiling at each other and obviously enjoying a pleasant exchange. The caption read something like, "He thinks they're talking about green jello. Actually she's halfway through 146 assessments." That would be true, if she were a good nurse, and the point of the ad, directed to good nurses whom the sponsor hoped to recruit, was that this is the sort of nurse sought and valued by that hospital.
A nurse indeed could merely banter about food with a patient and then head off to hang the next IV, having noticed and learned little. But more probably the nurse at that bedside noticed whether, what, and how much nutrition the patient was taking. She knew if he was enjoying his meal or if eating was a struggle or a chore. She recognized if he seemed to be in pain or to be having difficulty eating, from trouble swallowing to challenges manipulating utensils to inability to see clearly the things that were on his tray. She noticed his color, his breathing, and his speech. She could estimate his level of literacy, and had a sense of his willingness to engage with her and other providers. She had a sense of his communication style and whether he tended to be blunt, evasive, or something in between. She noticed his position and if he favored or guarded any body part, or if he just seemed more comfortable being "crooked" in the bed. She could tell if he was likely to engage, ask questions, and want to be an active participant in his care, or if he preferred a passive "wake me when it's over and I'm all better" approach. The nurse noticed any hearing deficit, if the patient seemed light-headed or dizzy, or if he was confused, forgetful, hallucinating, or demonstrated impaired cognition. She recognized effects, intended or otherwise, of the medications the patient had taken, and whether he might need something more, less, or different. She had a sense of how eating was affecting his stomach and entire GI tract. She noted sensory impairments he might have, such as not realizing that coffee was hot or that a glass was placed too close to the edge of the table. She saw if he had trouble grasping objects or tended to drop them, and if this involved one hand or both. She noticed if he did not move normally, and if he was tired, or tired quickly. She saw how he coped with whatever health problems he had, and knew the approaches to which he likely would be most receptive. She knew if his IV was running properly, if his bandages were intact, and the significance of displays on the monitor over his bed. And more.
The nurse also knew what to do with all of this information. She used it to formulate diagnoses, plan treatment, evaluate the effectiveness of treatment, prepare to teach the patient, include supportive others and exclude others, plan his discharge, and give other team members heads-ups about the patient's status, needs, and actual and potential problems. She knew what to disregard for the moment, and what warranted prompt action. She knew what questions she still had, and had a plan for pursuing their answers.
But when the phone rang and she excused herself from the bedside as the patient answered it, chances are she overheard him saying, "Hi, Honey. I'm having lunch and just was talking with Jane about the jello. It's green! Yeah, Jane's very nice; she's a good nurse."
More sobering are the administrators and executives of healthcare organizations who don't know what good nursing is, or even what nurses are required to do to be in compliance with the law. Recently I spoke with a Clinical Manager of a home healthcare agency who lamented the unnecessary and time-consuming documentation that many nurses new to home healthcare wrote. "All they need to write is what regulators and payors require," she said, "The rest is superfluous and unnecessary."
Wrong.
Those new-to-homecare nurses indeed may have been including unnecessary information in their notes, but they are required by law and by the standards of their profession, to which they would be held accountable in any court of law, to perform and document the entire nursing process, not just the parts that satisfy the specific requirements of regulators and payors. One would hope that Clinical Manager would help new employees ferret out irrelevant information while fleshing out a complete clinical picture of each patient and of the nursing process as it is carried out in each case. I fear that was not the case in this instance.
Employers can be so focused on their business needs that they fail to be mindful of the larger responsibility of professional healthcare providers. If executives hold business degrees rather than professional licenses they may not even know the standards and requirements for which a nurse, or other licensed professional, is accountable. They may even, unwittingly, I hope!, encourage employees to flout the law: "Just document the patient's homebound status, the skilled services provided, and compliance with the treatment plan that the physician signed and be done with it." But business needs cannot be allowed to trump professional standards or the law.
Because an employer gives a directive does not absolve a nurse from the duty to practice in accordance with the law and with professional standards. If a manager told a nurse, "It's ok, you don't have to file a tax return this year," you can bet the IRS still would go after that nurse and would have no sympathy for what the boss had said. If a director told a nurse to reach a destination as quickly as possible, without regard for speed limits, it's a sure thing that flashing lights in the rearview mirror and a speeding ticket would be in that nurse's future, boss's directive or not. Similarly, when a manager or executive tells nurses how to practice and what to document, it is incumbent on those nurses to be sure that their practice and their documentation both satisfy the needs of the employer and those of the law and of the profession.
It's a wonder more nurses don't seem a little schizophrenic from time to time, given that so many of our patients don't realize even a small portion of what our practice with them truly entails and that so many of our employers are focused on the bottom line to the exclusion of good practices and of compliance with the law. But the next time you encounter a nurse and a dish of green jello, please don't be quick to confuse personality with professionalism. Because before you can down the jello that nurse will have completed 146 assessments, formulated diagnoses and a treatment plan, evaluated what has been done and how you have responded so far, and determined with whom she or he next needs to confer to help you take the next right step towards better health. . . if he or she is
A Good Nurse.
Saturday, March 15, 2014
We'll Take the Watch from Here
Although he uses the moniker only with tongue squarely in cheek, "Internet Sensation" Chief David A. Oliver of the Brimfield Police Department has created an engaging Facebook page that brings an international community of "crazy cousins" into informative, humorous, and thought-provoking dialog with those who serve and protect a small Ohio town (https://www.facebook.com/BrimfieldPolice). Now over 141,000 followers strong, Chief Oliver and the BPD offer fans a look at the inner workings of a department that is redefining what it means to be public servants. My mornings are not complete until I read the Chief's daily message, as well as any updates from the "Brimfield Triangle" and any Chief's "rants" or "babbles" that may have appeared in the preceding twenty-four hours.
A post that always touches my heart is a tribute to a fallen officer anywhere in the country. Chief Oliver notes what happened and links to a local news report, extends sympathy to the family, and bids his brother or sister in blue "Rest in peace," adding, "We'll take the watch from here." Having known and worked with many fine police officers over the years I can imagine a public servant not quite able to rest, even from the Beyond, without knowing that his or her watch is covered. I am grateful, and struck that a police chief in a little Ohio town thinks to offer that reassurance: "Your watch is covered; be at peace."
Why is it that we can't seem to cover our watches in healthcare, even when they span only the relatively small group of patients entrusted to our care in whatever setting we happen to practice?
"Maria" was an elderly patient of mine last year. She had heart disease, high blood pressure, diabetes, kidney issues, and all the degenerative processes that so often accompany advanced age. As she recovered from a complicated post-surgical course and neared the time of home healthcare discharge, her husband "Frank" was scheduled for surgery himself. He had been told to anticipate a five-day inpatient stay and then a period of recuperation at home that would last some weeks. His planning for this surgery included lining up relatives to assist Maria in his absence, however, I was concerned. In the many months I had seen Maria at home, no family ever had appeared. Greeting cards were displayed at holidays, and now and then Maria and Frank mentioned that someone had visited during the previous weekend, but these visits were infrequent, and no one had shown interest in Maria's health needs or offered to help with her care. So I wondered if they would step up to provide the level of support that she would need while Frank was away and later recovering. Fortunately Maria had enough ongoing issues with her various health problems that I was able to extend my visits to the time of Frank's surgery.
Frank was admitted to the hospital on Monday, for surgery that same day. He underwent a five hour procedure, and spent Tuesday in Intensive Care. Wednesday I was able to reach Maria at home and schedule a visit with her for Thursday, as Frank was doing better and she would not be going to the hospital that day.
My wait on their doorstep Thursday morning seemed interminable. Maria and Frank live on the second floor of a two-flat, and I wondered which family member was so slowly making his or her way down the stairs to admit me. Imagine my surprise when Frank opened the door, breathing heavily, a large surgical dressing covering much of his face and neck, and looking like he was about to fall over. He had been discharged home, alone, Wednesday, the day after leaving intensive care. "They didn't tell me it was going to be like this," he said, breathing hard and grasping the handrail for support. "And I'm supposed to take the bandage off today, but I don't know how. And what do I do about what's under there?" I asked if he had been given fresh bandages or other supplies; he said no.
Somehow Frank and I made it back up those stairs, after which he barely managed to walk several steps to all but collapse in a chair. Maria sat on the couch with her walker nearby, able to move about the apartment herself only with difficulty and certainly unable to provide physical assistance to him. No one else was there.
Frank was not my patient. I was not privy to his treatment plan or to information about his surgical procedure or hospital stay. There were no orders for home healthcare; Frank had not signed a consent for me to lay a hand on him or provide any kind of service. In short, his problems and needs were not my business. Or were they?
Certainly Frank's welfare was material to Maria's, and she indeed was my patient. Perhaps on that basis I could justify a bit of emergency assistance. But ethically there was no question what needed to be done, orders, proper referrals, legal consent forms, or not.
"Frank, would you like me to help you with that bandage?" I asked.
I don't know if the tears or the gratitude in his eyes were greater.
The details of his case aren't important now. The incision under the bandage was healing well and could be covered with a much more simple and easily managed dressing. I could tell Frank generally what to expect, how to take care of himself, what pitfalls to avoid, and what might happen that would warrant a call to his surgeon or, God forbid, an emergency trip back to the hospital. Maria was fine, well, as fine as an old woman with multiple chronic problems and a basket-case of a husband could be, and needed little attention just then. Whether family had risen to the occasion earlier in the week was a moot point: Frank and Maria had food and could manage adequately in their little home without any more trips down the stairs. They knew to call 911 in an emergency, and family or me for anything else.
But what had happened at the hospital?
The surgical team did its job on Monday, the critical care team did likewise on Tuesday, and Frank was handed off to a general surgical floor on Wednesday, determined no longer to be in need of inpatient care, and discharged home. Harsh as it may seem, that might not be unreasonable. Hospitals are dangerous places, with potential for infection of new surgical wounds and much bustle allowing for possible confusion of patients, orders, and needs. If a person does not absolutely need to be there, often it's best for him or her to go somewhere else. Insurance companies and hospital bean-counters wound agree, albeit perhaps for other reasons.
I wonder, though, if anyone asked Frank where he was going (home to a second-floor walk-up apartment), who was available to help him (no one), or if he understood, less than forty-eight hours after general anesthesia and with a load of narcotic pain relievers and other medications on board, what had been done, what he would need to do for himself, how to do that, how safely to maneuver about, what measures to take to build strength, and under what circumstances it might be necessary to seek help, or what that help would be. If anyone did ask those things, under those circumstances, I wonder what was wrong with that person's brain. Frank was an old man two days out of surgery and full of brain-altering drugs!
Frank was a Medicare beneficiary who qualified for home healthcare, yet no one referred him. I wasn't looking for more work to do; truth be told, I was looking forward to discharging Maria because their home was out of the way for me and I had tired of the extra driving. But I, or someone like me, would have seen Frank in a heartbeat. Two or three nursing visits and a session or two with Physical Therapy to see that he moved up and down those stairs safely would have done the job nicely. But it seems that when each hospital team finished its own job, it sent Frank to the next setting on his road to recovery and washed its hands of him. I do not believe there was one iota of malicious intent, and I'd bet money the hospital was busy and its workers harried, striving to do the best they could for the charges in their care, with little time even to think about consequences beyond the next "hand-off."
Yet even when a police officer dies, when his or her tour of duty is ended for the last time and there is no more work for him or her to do ever again, colleagues such as Chief Oliver and thousands of others step up to take over, ever mindful of the need to serve and protect twenty-four hours a day, every day, regardless of circumstances.
Healthcare providers could stand to take a page from the Brimfield Police Department and public servants everywhere, and not rest without knowing that when their work with a patient is done someone, an appropriate party receiving the "hand-off," has said,
"We'll take the watch from here."
A post that always touches my heart is a tribute to a fallen officer anywhere in the country. Chief Oliver notes what happened and links to a local news report, extends sympathy to the family, and bids his brother or sister in blue "Rest in peace," adding, "We'll take the watch from here." Having known and worked with many fine police officers over the years I can imagine a public servant not quite able to rest, even from the Beyond, without knowing that his or her watch is covered. I am grateful, and struck that a police chief in a little Ohio town thinks to offer that reassurance: "Your watch is covered; be at peace."
Why is it that we can't seem to cover our watches in healthcare, even when they span only the relatively small group of patients entrusted to our care in whatever setting we happen to practice?
"Maria" was an elderly patient of mine last year. She had heart disease, high blood pressure, diabetes, kidney issues, and all the degenerative processes that so often accompany advanced age. As she recovered from a complicated post-surgical course and neared the time of home healthcare discharge, her husband "Frank" was scheduled for surgery himself. He had been told to anticipate a five-day inpatient stay and then a period of recuperation at home that would last some weeks. His planning for this surgery included lining up relatives to assist Maria in his absence, however, I was concerned. In the many months I had seen Maria at home, no family ever had appeared. Greeting cards were displayed at holidays, and now and then Maria and Frank mentioned that someone had visited during the previous weekend, but these visits were infrequent, and no one had shown interest in Maria's health needs or offered to help with her care. So I wondered if they would step up to provide the level of support that she would need while Frank was away and later recovering. Fortunately Maria had enough ongoing issues with her various health problems that I was able to extend my visits to the time of Frank's surgery.
Frank was admitted to the hospital on Monday, for surgery that same day. He underwent a five hour procedure, and spent Tuesday in Intensive Care. Wednesday I was able to reach Maria at home and schedule a visit with her for Thursday, as Frank was doing better and she would not be going to the hospital that day.
My wait on their doorstep Thursday morning seemed interminable. Maria and Frank live on the second floor of a two-flat, and I wondered which family member was so slowly making his or her way down the stairs to admit me. Imagine my surprise when Frank opened the door, breathing heavily, a large surgical dressing covering much of his face and neck, and looking like he was about to fall over. He had been discharged home, alone, Wednesday, the day after leaving intensive care. "They didn't tell me it was going to be like this," he said, breathing hard and grasping the handrail for support. "And I'm supposed to take the bandage off today, but I don't know how. And what do I do about what's under there?" I asked if he had been given fresh bandages or other supplies; he said no.
Somehow Frank and I made it back up those stairs, after which he barely managed to walk several steps to all but collapse in a chair. Maria sat on the couch with her walker nearby, able to move about the apartment herself only with difficulty and certainly unable to provide physical assistance to him. No one else was there.
Frank was not my patient. I was not privy to his treatment plan or to information about his surgical procedure or hospital stay. There were no orders for home healthcare; Frank had not signed a consent for me to lay a hand on him or provide any kind of service. In short, his problems and needs were not my business. Or were they?
Certainly Frank's welfare was material to Maria's, and she indeed was my patient. Perhaps on that basis I could justify a bit of emergency assistance. But ethically there was no question what needed to be done, orders, proper referrals, legal consent forms, or not.
"Frank, would you like me to help you with that bandage?" I asked.
I don't know if the tears or the gratitude in his eyes were greater.
The details of his case aren't important now. The incision under the bandage was healing well and could be covered with a much more simple and easily managed dressing. I could tell Frank generally what to expect, how to take care of himself, what pitfalls to avoid, and what might happen that would warrant a call to his surgeon or, God forbid, an emergency trip back to the hospital. Maria was fine, well, as fine as an old woman with multiple chronic problems and a basket-case of a husband could be, and needed little attention just then. Whether family had risen to the occasion earlier in the week was a moot point: Frank and Maria had food and could manage adequately in their little home without any more trips down the stairs. They knew to call 911 in an emergency, and family or me for anything else.
But what had happened at the hospital?
The surgical team did its job on Monday, the critical care team did likewise on Tuesday, and Frank was handed off to a general surgical floor on Wednesday, determined no longer to be in need of inpatient care, and discharged home. Harsh as it may seem, that might not be unreasonable. Hospitals are dangerous places, with potential for infection of new surgical wounds and much bustle allowing for possible confusion of patients, orders, and needs. If a person does not absolutely need to be there, often it's best for him or her to go somewhere else. Insurance companies and hospital bean-counters wound agree, albeit perhaps for other reasons.
I wonder, though, if anyone asked Frank where he was going (home to a second-floor walk-up apartment), who was available to help him (no one), or if he understood, less than forty-eight hours after general anesthesia and with a load of narcotic pain relievers and other medications on board, what had been done, what he would need to do for himself, how to do that, how safely to maneuver about, what measures to take to build strength, and under what circumstances it might be necessary to seek help, or what that help would be. If anyone did ask those things, under those circumstances, I wonder what was wrong with that person's brain. Frank was an old man two days out of surgery and full of brain-altering drugs!
Frank was a Medicare beneficiary who qualified for home healthcare, yet no one referred him. I wasn't looking for more work to do; truth be told, I was looking forward to discharging Maria because their home was out of the way for me and I had tired of the extra driving. But I, or someone like me, would have seen Frank in a heartbeat. Two or three nursing visits and a session or two with Physical Therapy to see that he moved up and down those stairs safely would have done the job nicely. But it seems that when each hospital team finished its own job, it sent Frank to the next setting on his road to recovery and washed its hands of him. I do not believe there was one iota of malicious intent, and I'd bet money the hospital was busy and its workers harried, striving to do the best they could for the charges in their care, with little time even to think about consequences beyond the next "hand-off."
Yet even when a police officer dies, when his or her tour of duty is ended for the last time and there is no more work for him or her to do ever again, colleagues such as Chief Oliver and thousands of others step up to take over, ever mindful of the need to serve and protect twenty-four hours a day, every day, regardless of circumstances.
Healthcare providers could stand to take a page from the Brimfield Police Department and public servants everywhere, and not rest without knowing that when their work with a patient is done someone, an appropriate party receiving the "hand-off," has said,
"We'll take the watch from here."
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