The Intensive Art

My first thought was, “I have been incredibly jinxed with urine output lately!” It was getting to the point where I was more surprised if my patients actually peed an appropriate amount. The doctors were getting used to my frequent pages begging for boluses for my dry patients.

Yes, my patient’s urine output was only 200cc for the entire shift. I resigned myself to this fact after about ten minutes of manipulating and milking the tube, and falling short only of pushing on my patient’s bladder and begging. I had no choice, it was time to call the doctor for another bolus.

What luck! The doctor was standing by the nursing station flirting with the young nurses. Granted, he his young and devastatingly handsome, but do the girls really need to giggle like that?

I hesitantly walked over to him, taking deep breaths, attempting to overcome my absolute fear and intimidation of talking to doctors. Causing the most trepidation was having to interrupt his “professional” conferencing with the nurses.

“errr…hi….I…ahhh…have a question.” I hate the way I sound so nervous when I talk to doctors.

“What is it?” He went from flirtatious to serious, bored, and bordering on annoyed. Sometimes it just doesn’t pay to be a male nurse!

“My patient has a low urine output. Mr. Smith that is, no! Sorry! Mr. Elliott!” I’m stammering. I’m getting more nervous. Why can’t I just be confident like everyone else?

“Tell me his story.” He said, not looking at me.

This is approximately the moment I panicked. I just expected him to ask about cardiac history, and order a bolus of Normal Saline.

“Errr…well….unresectable tumor of the panc…no liver….geeze…” I point to my abdomen and the doctor gives me a look that most definitely accuses me of being a complete idiot. His eyes ask who the hell let me take care of his patients. “His pelvis, it was in his pelvis.”

“I can see you don’t know anything about this patient, just get me his chart.” He sighed. I gave him the chart and ran away embarrassed. The truth was that I had been caring for this patient for days and knew him inside and out. I had read his chart front to back and knew his entire medical history. I had assessed him numerous times and knew every wheeze and bowel sound.

The patient got his bolus, but I had completely failed at my report to his doctor. As I lay in bed at night reliving the moments of the day (we all know this is a nurse’s favorite past time, and is potentially what leads us to insanity), I asked myself, “tell yourself honestly, did you know this patient.”

The answer was a definite yes. Where I had failed was in my preparation in giving report to the doctor. I didn’t organize my thoughts and the patient’s situation/needs into an organized presentation for the doctor. I failed to use my communication skills properly, and I failed to project confidence in my patient’s needs.

My hospital has begun teaching the SBAR method of reporting a situation to a doctor. Never until this moment have I fully understood exactly why it was necessary. SBAR stands for Situation Background Assessment Recommendation.

I had a Eureka moment as I lay there in bed desperately trying to find a way to improve myself. When I need to talk to a doctor, I just need to stop, organize my thoughts using SBAR, and then proceed. If I had done this, my side of the conversation would have looked more like this:

“Mr. Elliott had an output of 200cc concentrated urine for my shift. He had a laparotomy on Wednesday for an unresectable tumor with a colostomy creation. He has had a low output for the past 72 hours and has received two 500cc Normal Saline boluses, the last one at 23:00 yesterday evening. He has a history of hypertension and a MI in 2004. His vital signs are all stable and unremarkable. I think he would benefit from another bolus.”

I couldn’t help but wish I were the type of person that could just roll words off of my tongue with no effort at all. While earning my degree, I had more than one professor tell me that I sounded very confident and intelligent in my writing, but verbally I struggled. It’s true!

The next morning during report I was told that Mr. Elliott had been causing problems overnight. His lungs sounding worse, his Sats were dipping low occasionally, and he felt short of breath.

Not a problem, I gave him some ventolin for the wheezing, lasix for the crackles, ordered a physiotherapy chest assessment, taught him breathing/coughing exercises, and kicked him out of bed for some walking. He had none of the problems night shift experienced.

During morning rounds, one of the doctors (the same one that caused me to stutter my words in nervousness) had a hunch that Mr. Elliott was having cardiac problems and ordered an ECG and Troponins.

Oh what joy! The ECG shows a block, and the Troponins were sky high!

Moments later, a severe looking women entered the room. She was definitely high on intimidation factor! She introduced herself as a cardiologist here for a consult.

“Can you tell me about your patient?” She said, in a way that told me she was completely bored with the situation. You could tell she would rather be elsewhere. And seriously, how did she get here so fast. And OH CRAP, I need to talk to a doctor again!

“84 year old male for unsuccessful laparotomy to remove abdominal tumor, diverting colostomy created. Low urine output times four days, chest has wheezes and course crackles, at 05:00 this morning he experienced episode of decreased Sats and shortness-of-breath, oxygen delivery was increased, and Lasix and Ventolin were given. All vital signs have been stable since. His ECG showed a block, and Troponis were 0.28” I rattled off with definite confidence. I liked the way it all sounded! I forgot to use SBAR, but I think my bedtime talk with myself had worked a little bit.

“OK” she said, and went to assess the patient. I didn’t receive one condescending look from her!

Nursing is a reflective practice. We learn how to do our jobs by examining our performance, and critically thinking in order to find ways to improve. In nursing school we called them “Reflective Journals,” and we all dreaded them. But I really do understand why the practice is important.

My conversation with Doctor McFlirty kept me up late at night because I knew that I could do better. I knew that I was not happy with my performance. I laid there in the dark, picking apart my performance until I discovered a method to improve the way I communicate with doctors.

Sure, my performance the next day was not perfect, but it was a vast improvement. With practice and reflection, I will develop the confidence I feel my patients deserve from me.

I love the quiet solitude of the world that welcomes me as I take the bus to work at 10:30pm for night shifts. Wrapped in my favorite fuzzy jacket, backpack beside me, iPod soothing me, and Tetley tea in hand, I watch the dark world zoom by. The hospital rises above its citadel overlooking the blackened lake as I get closer, the empty scaffolding from the half done expansion is lit only by the bright sign that advertises, “Emergency.”

The unit is dim as I arrive; someone has turned off most of the lights to help patients sleep. Peace, and an obvious lack of chaos greet me. I begin focusing on tasks. As I approach the end of my degree, I have noticed just how much nursing is about tasks. The main concern as I start my shift is what I will be doing, when I will be doing it, and how I will be doing it. I have a peace of paper on a clipboard that I diligently fill out with patient information. I make lists on it of what I need to do overnight–little crooked boxes are drawn beside each task, waiting for my checkmark that signifies it has been done.

But I know my task list is a little more flexible at night. During day/evening shift, time is an extremely hot commodity, and everything must be carefully timed and prioritized to ensure that nothing is missed. Something is always missed. Time always seems to run out. You always feel as though you have twelve hours of work to fit into an eight-hour shift.

I think prioritizing is one of the hardest skills to learn as you transition from student nurse to RN. As a student we have such different expectations. We have no “wiggle room” for prioritization; we are expected to do everything by the book, no omissions, and no short cuts. We miss breaks because we have four bed baths to do when most nurses would delegate to nursing attendants, we stay late because our charting needs to be four times more detailed than an RN’s. Every moment of our shift is scrutinized and judged, every action is expected to be perfect beyond imagination.

But on night shifts, I feel free of these pressures. I feel that I can be creative in how I go about my duties. I can bathe patients, take them for walks, get them food, but none are expected of me. I need to do vital signs and assessments, but I can judge when is the most appropriate time–before bed, or in the mornings. There is freedom, and within this freedom is power. There is nursing as I pictured it before I began my degree, because for some reason I did not foresee nurses as slaves to clocks, schedules, and routines.

I suppose I am saying that during the days and evenings nursing feels like a job while during the night nursing feels much more like an art.

I always like to do an assessment and a set of vital signs when I start my night shift, particularly if this is my first time caring for a patient assignment. This first round of checks is slower on nights. I take my time to check all the IV bags and lines, I restock, clean, and organize.

As I went about my duties this particular night, I was stopped in my tracks by a patient after finishing my assessment and vitals. He simply stated that he was glad that the doctors had finally planned a procedure for him. I hadn’t mentioned the doctor’s decision to perform a certain procedure because I wasn’t sure that the doctors had discussed it with him at this point. So, I probed further, asking him to tell me about the procedure. I was interested in knowing how well he understood the process so I would know what I could help him with in terms of teaching and preparation.

But as he began to talk, I realized that he wasn’t talking of facts or treatments, but of emotions and feelings. He described the events that began his time in hospital and how it progressed. He described his family’s reactions and his own. He told me how his wife was coping, and how she helped him during the ups and downs of the process.

After about fifteen minutes, I began thinking about my other patients and tried to break away from the conversation. It wasn’t easy to put closure on our conversation since every time I thought I was free to leave he would begin talking again. I began getting increasingly frustrated.

At this point he started talking about how scared he was and about his wife’s fears regarding his long-term prognosis. My thinking and feelings were changed entirely. I remembered that it was a night shift, and thankfully it offered me the chance to be creative—to practice the “art” or nursing. My frustrations melted away as I began to understand my true priorities better.

I grabbed a chair and sat down. The unit was dark and quiet except for a soft light above his bed and the sound of his voice as he told me his “story.” I stopped thinking about my other patients, knowing they would be fine if I took half an hour to listen. I knew that my schedule and list of tasks wouldn’t be jeopardized. I knew that by sitting and listening I was doing something that was potentially more important than making sure there was an extra bag of IV fluids in the room.

In nursing we are so incredibly focused on tasks that we forget that nursing is NOT a job. It is a career, and it is (I truly believe) an art form. Night shifts remind me of what I want nursing to be. I feel so strongly that day and evening shifts should have the same feeling of freedom and creativity. I have yet to finish nursing school and I feel burnt out by the regimented style of most shifts. I am crushed by overwhelming expectations to complete tasks that seem to take priority over taking true time to “be with” patients.

My feeling toward nursing is that each patient does not have a diagnosis or a treatment. Instead, they have a story (or what I have heard called an “illness narrative”). The patient’s story must be put at the centre of our practice with effort put toward discovering how the patient perceives the story’s characters (nurses, doctors, family) and events. Being able to understand the differences between each patient’s experiences, and knowing how to treat each patient differently as a result really is the art (and the heart and soul) of nursing.

The challenge is learning how to let go of the details and “busy work” that fills the day, reprioritizing, while still living up to our expectations as members of our team. An even bigger challenge is leaving the hospital proud of the work we did on a shift, knowing we made a true and positive difference in a patient’s story, and letting go of our need to feel validated by compliments from other nurses. If I did not have time to restock towels and IV bags in the patient’s room, and the oncoming nurse is upset, but the patient had time to talk through his hopes and fears regarding his upcoming surgery—I will make no apologies.

On this particular night shift, I left feeling incredibly proud of my work, and my new understanding of nursing.