Notes on Nursing:
So, I've been an RN for thirty years, come June. Done patient care for 35 years, and cared for children for 45 years. It seems like yesterday I was so anxious about going to community college at the ancient age of 21, with a 1-year-old son and having JUST learned to drive that I actually turned around and walked back to the car two times before going up to Admissions and Records and picking up a copy of the catalog. And even then, it took me 5 years and a second child to actually apply. And yet here I am, lo these many years later, still excited by nursing, still learning. It's awesome.
I have occasion right now to be re-reading some nursing theory stuff, because I need to make a case for the lad's care being more complex than it appears on the surface. It'd be easy to dismiss him as 'retarded' and his family as 'troublesome', but that's the cheap way out. Any of you who have care-giving situations in your families, or who have chronic conditions, know that most of what you need to take into consideration is nearly invisible on the surface, until something goes wrong, and that's not the time to be trying to explain things to the people you need to help you sort it, especially if they're not going to be able to hear you because they're not listening with the right vocabulary.
So: Nursing Theory. The bane of nursing students, because so many people dismiss it as make-work and pseudo-intellectual crap. Yeah, some of it is. Most of it's not. A lot of it has analogs in or developed from work done in other fields: systems theory, human development theory, adaptation theory, conservation theory, to name a few.
I use a variety of nursing theories all day, every day, both at work and in ordinary life, and find them very helpful in organizing data on the way in and organizing my response to it on the way out. In my experience, nursing's not a set of tasks but a continuous process (and here I would argue- hell, have argued! -strenuously with cost-cutters and administrators and third-party-payors who chop nurses up into Full-Time Equivalents and Efficiency Statistics); a continuous process conducted in real time on (at least) three levels: physically, with constant patient assessment and re-assessment; intellectually, with constant application of science-based nursing knowledge and evaluation of the results obtained; and emotionally, with constant attention to "Is it well with my patient?" Implicit in this is the well-being of the nurse: making that explicit is, I think, where a lot of the difficulties in the field lie, these days. But that's another story for another post.
This one's about nursing theory, and nursing theories.
Modern Western science-based nursing came into being when Florence Nightingale used carefully gathered and presented statistics to prove to that preventing disease and injury, and providing support to regain health and function to those ill or injured, was far less expensive than writing people off. It is better to keep mothers healthy and babies well, workers uninjured, soldiers well-cared for, communities clean and safe, than to decry the costs of public health and health education. (This is still true. She expected a level of interest on the part of the ill or injured in regaining their well-being, which, when supported, would motivate them to take care of themselves. Nowhere in her writing that I'm aware of- granted, I've not read all of it- does she say that everyone is born healthy, lives healthy for a long time, and has a right to perfect health until they die of old age in their sleep, which is kind-of the illusion we Westerners have, now, about health and what health-care owes us. Again, a story for another day.)
She puts it well in Notes on Nursing: What it is, and what it is not. (1860), 1912. Remember that she initially wrote before antibiotics, before a treatment for TB, before practical x-rays, before the incredible understanding that we have of how infectious disease spreads, before microbiology labs, before comprehensive study of how the mechanism of injury affects recovery, before gas anesthesia, before running water in every town and electricity in every home became a standard (and is not, in so much of the world), before closed buildings with forced air heating and cooling systems, before automobiles and paramedic ambulances and gas autoclaves. For Florence, a nurse first and foremost paid attention to what she was doing, with the good of her patient foremost in her thoughts. Yes, modern Western nursing is more complex now- and no, it's not. There is no monitor in the world that makes up for the nurse's attention to the basics, and no doctor's order or hospital protocol that saves as much suffering as careful nursing.
As Afaf Ibrahim Meleis says, nursing theory can be a mirror, a microscope, or a telescope. I work consciously with a number of theories, probably unconsciously with many more. I use Betty Neuman's Systems model as a relatively simple assessment model when looking at what each person in the family is up against, and capable of, at any given time. I use Imogene King's Goal Attainment theory almost without thinking about it, now, but I'm well aware that every interaction I have with my patient and the family is a transaction, that there's something being negotiated between us with the goal being looking after the patient's best interests.
Aaaaaaaanyway. Rambly post is rambly. What this is about tonight is how to gently but firmly point the new day nurse in the direction of paying attention to the lad and his family in an organized, interested, compassionate manner, instead of focusing on how little (relative to hospital nursing) she's being paid, how 'boring' his care is (it's only boring if you can't see what's going on: this kid can't protect his own airway, or move for himself, and has only the most rudimentary use of his voice for communication. You miss a lot if you assume he's mostly stable, mostly not-there), and how she's being shut out of the job she really wants (get over it).
It'd be easy to just say, The parents said the school called and had this that and the other complaint about you, so shape up or ship out. But that's stupid, cruel, and wasteful. I knew this woman when she was a tech in the OB dept at my last hospital- she went to LVN school during that time, then to RN school (associate degree) and graduated in May as an RN. She's got what a lot of people have when they graduate from an ADN program- a sense of entitlement, and an abnormal fear of being sued, coupled with reasonably good basic nursing education and just enough clinical experience to pull off safe nursing care of uncomplicated patients in a supported setting. Now, I'm not saying ADN programs are no good. I graduated from the same one she went to, and went straight to work in a step-down ICU/progressive telemetry unit, 23 beds, 17 monitors on the floor, 6 beds in the step-down with ventilators, arterial lines, we put in temporary pacemakers on the floor under fluoro, and did most of the pre-op teaching for the cardiac surgical patients. It was scary and demanding I learned a fuckton of stuff, and the most important thing I learned was that there was no way I was ever going to notice everything, so I'd better pay attention to as much as I could and think about it. I think the most important question I ask, after "How are you feeling?" is to myself: "What does this mean?"
So, what does it mean, that he can't protect his airway? What does it mean, that he can't move for himself? What does it mean, that he's got very limited communication ability (notice, not that he's not trying, just doesn't have most of the tools we take for granted). What does a right temporal lobe brain infarct translate to, in practical terms? I've got 30 years of experience, most of it in various critical care settings, and I'm constantly thinking it over, mulling over what this all means, and looking things up. There's no monitor doing the 'baby-sitting' for me, no computer taking notes, no doctor just down the hall, no comprehensive history and physical with recent labs and so on to help guide me: just my attention, and my ability to think.
So. So. So, so I need to write her a note today (we miss each other by 30 minutes, because I can't start work later than 11pm, and she has to start at half past 7 am, so that she's not getting too much overtime on school days) that says as clearly as possible, "Please don't do these things with him at school, and this is why", without saying "What the fuck were you thinking?" which certainly has never helped me think about anything except "Shut up shut up shut UP!" He's only JUST gone back to school this fall after two years' absence; the people who remember him keep saying 'but he's like this' when he's not like that anymore (special ed program, has its own nurse, then some kids come with their own nurse too) I need this note to be short, clear, friendly, and unmistakeably about "This is what it's like, learning on the job: You're an RN now, you need to infer, you need to derive a plan from data, you need to think from everything you've studied: anatomy, physiology, micro, pharmacology, everything you've studied has to go into everything you do for this kid all. day. long, because that's what being an RN is. It's not starting IVs, it's not running codes, it's not working in the ICN, it's not Mercy or Three Rivers or ER or Scrubs or Grey's Anatomy, it's paying attention, it's thinking about everything you do, and it's thinking about it because you're giving care.
And now it's time to close up the lappie and do morning stuff with the lad, because that's what I'm actually here to do. Mulling stuff over can go on in the background, per usual.
Blessings on your heads.
I have occasion right now to be re-reading some nursing theory stuff, because I need to make a case for the lad's care being more complex than it appears on the surface. It'd be easy to dismiss him as 'retarded' and his family as 'troublesome', but that's the cheap way out. Any of you who have care-giving situations in your families, or who have chronic conditions, know that most of what you need to take into consideration is nearly invisible on the surface, until something goes wrong, and that's not the time to be trying to explain things to the people you need to help you sort it, especially if they're not going to be able to hear you because they're not listening with the right vocabulary.
So: Nursing Theory. The bane of nursing students, because so many people dismiss it as make-work and pseudo-intellectual crap. Yeah, some of it is. Most of it's not. A lot of it has analogs in or developed from work done in other fields: systems theory, human development theory, adaptation theory, conservation theory, to name a few.
I use a variety of nursing theories all day, every day, both at work and in ordinary life, and find them very helpful in organizing data on the way in and organizing my response to it on the way out. In my experience, nursing's not a set of tasks but a continuous process (and here I would argue- hell, have argued! -strenuously with cost-cutters and administrators and third-party-payors who chop nurses up into Full-Time Equivalents and Efficiency Statistics); a continuous process conducted in real time on (at least) three levels: physically, with constant patient assessment and re-assessment; intellectually, with constant application of science-based nursing knowledge and evaluation of the results obtained; and emotionally, with constant attention to "Is it well with my patient?" Implicit in this is the well-being of the nurse: making that explicit is, I think, where a lot of the difficulties in the field lie, these days. But that's another story for another post.
This one's about nursing theory, and nursing theories.
Modern Western science-based nursing came into being when Florence Nightingale used carefully gathered and presented statistics to prove to that preventing disease and injury, and providing support to regain health and function to those ill or injured, was far less expensive than writing people off. It is better to keep mothers healthy and babies well, workers uninjured, soldiers well-cared for, communities clean and safe, than to decry the costs of public health and health education. (This is still true. She expected a level of interest on the part of the ill or injured in regaining their well-being, which, when supported, would motivate them to take care of themselves. Nowhere in her writing that I'm aware of- granted, I've not read all of it- does she say that everyone is born healthy, lives healthy for a long time, and has a right to perfect health until they die of old age in their sleep, which is kind-of the illusion we Westerners have, now, about health and what health-care owes us. Again, a story for another day.)
She puts it well in Notes on Nursing: What it is, and what it is not. (1860), 1912. Remember that she initially wrote before antibiotics, before a treatment for TB, before practical x-rays, before the incredible understanding that we have of how infectious disease spreads, before microbiology labs, before comprehensive study of how the mechanism of injury affects recovery, before gas anesthesia, before running water in every town and electricity in every home became a standard (and is not, in so much of the world), before closed buildings with forced air heating and cooling systems, before automobiles and paramedic ambulances and gas autoclaves. For Florence, a nurse first and foremost paid attention to what she was doing, with the good of her patient foremost in her thoughts. Yes, modern Western nursing is more complex now- and no, it's not. There is no monitor in the world that makes up for the nurse's attention to the basics, and no doctor's order or hospital protocol that saves as much suffering as careful nursing.
As Afaf Ibrahim Meleis says, nursing theory can be a mirror, a microscope, or a telescope. I work consciously with a number of theories, probably unconsciously with many more. I use Betty Neuman's Systems model as a relatively simple assessment model when looking at what each person in the family is up against, and capable of, at any given time. I use Imogene King's Goal Attainment theory almost without thinking about it, now, but I'm well aware that every interaction I have with my patient and the family is a transaction, that there's something being negotiated between us with the goal being looking after the patient's best interests.
Aaaaaaaanyway. Rambly post is rambly. What this is about tonight is how to gently but firmly point the new day nurse in the direction of paying attention to the lad and his family in an organized, interested, compassionate manner, instead of focusing on how little (relative to hospital nursing) she's being paid, how 'boring' his care is (it's only boring if you can't see what's going on: this kid can't protect his own airway, or move for himself, and has only the most rudimentary use of his voice for communication. You miss a lot if you assume he's mostly stable, mostly not-there), and how she's being shut out of the job she really wants (get over it).
It'd be easy to just say, The parents said the school called and had this that and the other complaint about you, so shape up or ship out. But that's stupid, cruel, and wasteful. I knew this woman when she was a tech in the OB dept at my last hospital- she went to LVN school during that time, then to RN school (associate degree) and graduated in May as an RN. She's got what a lot of people have when they graduate from an ADN program- a sense of entitlement, and an abnormal fear of being sued, coupled with reasonably good basic nursing education and just enough clinical experience to pull off safe nursing care of uncomplicated patients in a supported setting. Now, I'm not saying ADN programs are no good. I graduated from the same one she went to, and went straight to work in a step-down ICU/progressive telemetry unit, 23 beds, 17 monitors on the floor, 6 beds in the step-down with ventilators, arterial lines, we put in temporary pacemakers on the floor under fluoro, and did most of the pre-op teaching for the cardiac surgical patients. It was scary and demanding I learned a fuckton of stuff, and the most important thing I learned was that there was no way I was ever going to notice everything, so I'd better pay attention to as much as I could and think about it. I think the most important question I ask, after "How are you feeling?" is to myself: "What does this mean?"
So, what does it mean, that he can't protect his airway? What does it mean, that he can't move for himself? What does it mean, that he's got very limited communication ability (notice, not that he's not trying, just doesn't have most of the tools we take for granted). What does a right temporal lobe brain infarct translate to, in practical terms? I've got 30 years of experience, most of it in various critical care settings, and I'm constantly thinking it over, mulling over what this all means, and looking things up. There's no monitor doing the 'baby-sitting' for me, no computer taking notes, no doctor just down the hall, no comprehensive history and physical with recent labs and so on to help guide me: just my attention, and my ability to think.
So. So. So, so I need to write her a note today (we miss each other by 30 minutes, because I can't start work later than 11pm, and she has to start at half past 7 am, so that she's not getting too much overtime on school days) that says as clearly as possible, "Please don't do these things with him at school, and this is why", without saying "What the fuck were you thinking?" which certainly has never helped me think about anything except "Shut up shut up shut UP!" He's only JUST gone back to school this fall after two years' absence; the people who remember him keep saying 'but he's like this' when he's not like that anymore (special ed program, has its own nurse, then some kids come with their own nurse too) I need this note to be short, clear, friendly, and unmistakeably about "This is what it's like, learning on the job: You're an RN now, you need to infer, you need to derive a plan from data, you need to think from everything you've studied: anatomy, physiology, micro, pharmacology, everything you've studied has to go into everything you do for this kid all. day. long, because that's what being an RN is. It's not starting IVs, it's not running codes, it's not working in the ICN, it's not Mercy or Three Rivers or ER or Scrubs or Grey's Anatomy, it's paying attention, it's thinking about everything you do, and it's thinking about it because you're giving care.
And now it's time to close up the lappie and do morning stuff with the lad, because that's what I'm actually here to do. Mulling stuff over can go on in the background, per usual.
Blessings on your heads.