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Slightly Shitty Superpowers…What’s yours?

I was in the middle of a reasonably-under-control shift the other day and suddenly was struck with a feeling that fans of Monty Python will recognise as “wanting to be…A Lumberjack!“

Except that wasn’t quite all there was. Or rather, the feeling I was experiencing was that despite my work performance, the only person able to appreciate the day I was having was me.

We don’t build, or repair, or leave a mark on society. We work with colleagues as a team, but despite that, once our particular shift had gone off, the next shift would have no knowledge of our experiences and challenges. Jokes and anecdotes might filter through handover, but nothing of the details.

Of course, this is how it should be. The purpose of handover is to put the patient first, to ensure safety and continuity of care.

But then a fellow nurse asked me to help her with a patient needing a nasogastric tube. It had been inserted by the ENT fellow and needed replacing.

I have rather an extensive history of placing these. I’m pretty good at them. I called the ENT fellow, who told me of the challenges of placing an NG on this particular patient and wished me well. Call me again if you can’t do it, he said, half-joking.

Now, I’m not perfect and I did not place it the first time. The tube went into the patient’s larynx, curled beautifully at the carina and came back up the bronchus.

But the second time was perfect. I realised this was what I was missing in my day – I hadn’t appreciated my Slightly Shitty Superpower!

We all know how to perform the technical aspects of our roles as nurses. But we know, secretly, we are incrementally better at some roles or procedures than we are others. We might even be slightly better than our peers at a particular “thing” – and here’s the rub – WE ALL HAVE A “THING” – a Slightly Shitty Superpower.

It might be containing faeces in a pad on cleaning an incontinent patient. Or changing bed linen in record time. Maybe you can always hit that vein? Is ABG interpretation your thing? What one thing would you show off or smile to yourself about when you’ve done it well, reliably, every time?

We need to relish and delight in Slightly Shitty Superpowers when we find them. We need to share them with our colleagues, to pass on the tips, the methods and the tricks, and to have just one more “thing” we can appreciate about the uniqueness that we bring to every shift.

What Is The Most Medically Accurate TV Show?

I always nominate a two shows: MASH from the operating theatre perspective and Scrubs for the best overall realism (yes, realism!) in Intensive Care.

I have been a nurse for 14 years now in Theatre and Intensive Care. I don’t watch many medical shows as I get paid for that kind of thing, you just want to leave work at work (people never get this bit – have I seen this show or that show – probably not).

I knew of a doctor who worked on a locally produced medical drama. They’d ask him to nominate a particular procedure/condition that would fit with the story line. Then he’d stand by and watch as the producers/scriptwriters would change fundamental aspects of his input for dramatic effect. It’s hard to respect that kind of TV show, and when you see those kind of changes it’s kind of hard to keep watching.

A big example of this (without giving everyone an education into two specialist areas of healthcare) is when a patient on a TV show is INVOLVED in the drama – you get the patients fears, thoughts, love and wise words for the forlorn or over involved staff member. Some of the ways TV staff get involved can actually be illegal or unethical and subject to sanction by professional or licensing authorities. Great way to lose your job (and ruins your plots for future episodes!)

In the big metropolitan ICU I work, we rarely get to speak to our patients – not a ‘conversation’ anyway ( because of airway tubes and ventilators), and except for our long term tracheostomy patients, it is rarer still to get to know them. We communicate with our trachy patients by lip reading (it takes practice) and charades (most are too weak to write clearly). You can get to know people but we try to keep them socialised not institutionalised – we want them to go back to their lives. TV seems to be the other way round. As it is, most of our our long termers need to be reassured that the rest of the hospital knows what they’re doing – they get quite dependant on the feeling of safety from 1 on 1 nursing. It can be harder still to reassure the relatives!

We do experience our patients through their family and friends. Given it’s often a life threatening experience for our patients, it’s rare to hear anything bad about anyone. I’m realistic and know I’ve looked after some ratbags (or scum and villainy- to quote the wise man.)

We get prisoners with prison guard escorts (and the occasional escape) but most of us never want to know what a prisoner patient has done (I tell myself it’s fraud – if the guards are armed then it’s tax fraud), so we don’t ask. Our professional requirements don’t allow us to judge our patients or change our care, so it’s easier not to know.

Family members pick a number on a monitor and focus on that, and some go and talk to Doctor Google and think they have the answers. Others point all information to a nurse friend or family member who (as an insider into healthcare) just wants to be a friend or family member. Lots of friends and family refer to TV shows as a touchstone “I saw this in House/on ER/Chicago Hope/etc” and then refuse to see the uniqueness of their own situation – “it’ll go how it went in that neat hour long episode and we’ll all learn something”.

All of this can provide drama enough. I had to leave for six months and get counselling related to my experiences in my current job (I’m back now). I’ve known nurses to leave the profession for similar experiences. I can’t talk about them to my colleagues (who all understand anyway).

Unfortunately, it’s hard to translate that into a TV drama. People want details, but don’t need those kind of details. So that doesn’t make for good TV.

There is a succinct example of why it’s MASH and Scrubs that get all the of the everyday workplace experiences right. I’ve never yelled at the TV when those shows are on. I can watch them over and over and tellingly, I still cry at the episodes that remind me of my own experiences – the everyday cycle of life and death they show, and the staff using all the skills they have to do a job that is just not in most people’s idea of normal experience. Especially if they get their ideas from any other medical show I’ve ever seen.

This post originally appeared on Quora.

What advice Would I give an RN Student Whose Final Practicum Was In ICU?

Three things:

Remember you aren’t there to learn how to be an ICU Nurse. If you like the environment and choose to apply for ICU when you are a Registered nurse then education starts from the beginning. Take the pressure off as a student in ICU. It’s stressful enough…
Learn as much about the pathophysiology of the patient as you can. This will help you in working out what is actually going on, goals of care, and how well the patient is responding. This will draw on ALL the knowledge you have ever covered at university.
Practice assessment skills. Look, listen, feel. Become confident in listening to your patient’s chest sounds, feeling all pulses, looking at colours, pupils, etc. You can take your newfound confidence in your skills into any clinical area.

Enjoy!

This post originally appeared on Quora.

Every Day is R U OK? Day…

Gavin Larkin was an advertising “creative” whose father, Barry, committed suicide nearly 20 years ago. He found himself trying to stop the pain of grief his family endured, and decided to do this by asking one question – “Are you OK?”.

In 2009, he established the R U OK? foundation to enable everyone, in all levels of society, to encourage and ask “Are you OK?”

Based on the work of Dr Thomas Joiner, who describes at risk people as having three dominant forces – a feeling of being a burden on others, a belief they can withstand a high degree of pain, and a disconnect from others.

Gavin used his advertising and marketing skills to establish R U OK? Day, an annual day give society permission to ask. He sadly passed away in 2011.
Sometimes we need reminding that health care workers are no different from the rest of society, and that in healthcare, Every Day is R U OK? Day…

Healthcare is hard

So here’s the thing. This is personal. Apart from many useful links, this post is almost entirely anecdotal. And my chest is a bit tight contemplating writing it – so I know it won’t be easy.

I work in a really supportive workplace, which is surprising for the number of staff. In fact, the whole hospital is like that. Nodding acquaintances, people you don’t know, but who you know you’ve seen and will undoubtably see again. You nod hello in the corridor or elevator.

Occasionally, we hear of a colleague from another department who has taken their own life. Usually it is someone you don’t know, like the nodding acquaintance, but someone you do know is connected to them in some way. We wonder what happened, how we could have helped…

In my workplace, we have a loose collection of nurses who take on the role of “Peer Supporter” (I am one – the little sticker on my ID badge identifying me as such is one of the qualification badges I am most proud of). We choose ourselves, or are identified as “the right kind of person” and asked to think about taking the role.

The right kind of person to be a peer supporter is approachable and discreet (when it counts) and has undertaken a short course covering how to encourage someone to obtain help, where to direct someone to help, self-care, and limits of expectations (you can’t save everyone yourself, don’t try).

As stated in the picture above, healthcare is hard. It asks a lot from us. We see things, we do things, we know things. We can’t un-know. And we cope. We have humour. We all know the jokes about going to dinner with a group of nurses (we are apparently the worst at this but I suspect there’s a bit going on in the other professions) and the conversation quickly turns to work. We sometimes find ourselves describing things at the dinner table in company with civilians and everyone goes silent at something we’ve said.

We normalise the abnormal, the difficult and the things that are unknown to everyone else.

Some of us found our way into the industry by accident, we didn’t know what else to do with ourselves, via a calling, family expectations, as many reasons as there are practitioners. But whatever the reason, we know if we wanted easy we would have done something else.

We feel we can deal with what our jobs ask of us. Any pain we experience isn’t the same as our patients’ pain, they’re the injured, the ill, we can give them medications, analgesic modalities from pills to subcut or IV boluses, to PCA’s to epidurals or local anaesthetic infusions, dissociative medications, we can use distractive therapies with them, validate their feelings, ventilate their emotions…

We can have a high degree of pain tolerance. But we might not be equipped to know we even have pain. Ours might not be physical pain but psychic pain. The pain of seeing the same physical pain every day. The pain of coping with what we do.

Then to complicate things, we have the disconnect from others. This can be can be any kind of disconnect. The obvious disconnect in healthcare is the shift work. We work different hours. We work with different people, each of us having our own schedule across the week.

The disconnect can be as a result of the knowledge that we are aware of things about life that others don’t know, and don’t really want to know, despite their curiosity at dinner parties.

Pain and the disconnect can be in any area of our lives and from any area of our lives. Look again at Dr Joiner’s risk factors for suicide. Pain and the disconnect. If we include a feeling of being a burden on others – I don’t want to bother my spouse, my family, my friends, my colleagues…my patient is the one with the problem, I’ll just carry on…

This is personal.

I was that person. I had a run of several difficult situations involving a particular type of patient at work. I had a very high tolerance for pain – I was as capable and as professional as I have ever been in my career. I was working my ICU job, I was working agency in anaesthetics, and I was working in tourism to relax.

Then, one day while completing my bed area checks in my role as an ACCESS nurse, a colleague asked me a surprising question.

“How are things? Are you OK?”

I surprised myself by telling her that I wasn’t. I really was not OK. I was in danger of becoming the one everyone wondered about. I had a plan, I had most of what I needed, I was consciously avoiding certain patients, I was socially isolated due to family dynamics, I was grieving for a family member who had died almost exactly a year earlier (and who was responsible for propelling me into nursing in the first place).

My colleague referred me to one of our Peer Supporters. I saw a work provided psychologist that afternoon. I took three weeks leave, I had six months away from my workplace, but was supported in another role in a different area on reduced hours.

I took up educating (one door closes, another opens). I worked university terms looking after students, and worked clinically back in my chosen area around the university year. When I went back to Intensive Care I undertook a performance appraisal from one of the ICU educators (at my own request) to help me with my confidence. I worked hard to get back to where I was, and I knew I was supported. I’m still trying to get that balance.

But I learned something…

After working 8 years as a theatre nurse, I knew my emotional resilience was good.

After working 4 years in ICU on top of that I knew my emotional resilience was very good.

After having looked after a disabled family member since I was 13 years old (the year I learned how to place NG tubes), with a hospital in the home situation (we had an oxygen concentrator, pulse oximeter, and suction, and my sister would occasionally require IV drug administration via a hickman catheter) I knew my emotional capacity was as good as anyone I worked with.

And still I needed help…

You never know. Until you ask.

R U OK?

If this blog has highlighted issues for you or someone you know please do not hesitate to obtain help. Or call Lifeline 13 11 14.

Do you or a loved one need help? Find help now.
R U OK? is a not-for-profit organisation dedicated to encouraging and empowering all people to ask “are you ok?” of anyone struggling with life. Our vision is a world where everyone is connected and is protected from suicide. This year, R U OK?Day is Thursday 11th September.
Find out more: ruokday.com

Nursing Student 101: What Am I Supposed to Learn Here?

A Nursing Student on Reddit recently asked the r/nursing sub reddit for advice on how to manage an ICU placement as a third year student. They were understandably scared, and uncertain as to what they could achieve that would be useful for them in their future career.

I have helped guide nursing students through placements throughout a large, tertiary referral hospital in the role of Clinical Facilitator. Most of these wards have some kind of specialisation (ie, not a “surgical ward” but an “organ-system surgical ward”). Even our rehabilitation units are specialised.

This was the perspective I tried to give the nursing student on the ICU prac, but it could be helpful for anyone undertaking a specialist placement and who is finding it challenging to see the point…

You need to take these concerns to your facilitator/preceptor for context specific advice on what you should do regarding your fears for this placement. With so many different nursing systems and cultures on r/nursing it will be hard for answerers to assist you in a meaningful way.

On the other hand, as an undergraduate nursing student remember you aren’t there to learn How To Be An ICU Nurse 101. (This is the first point I started my undergraduate students in ICU on every time. Gives permission for a big relaxing breath).

You say the nurses are used to having students – they really aren’t expecting you to be an ICU nurse at the end either. Maybe to have an interest and want to come back, but that’s about it.

‘So what am I there for?’

To learn to be a NURSE. And in ICU you have a unique and peerless opportunity to take advantage of.

‘Why?’

Let’s start with What Does the ICU do…

It looks after really sick people. Medications, ventilators etc. the scary stuff.

From a healthcare system viewpoint it does a few things.

It supports them through critical illness and multiple organ failure or serious injury. It generally doesn’t admit patients on its own – all the patients will be under a treating team. (Usually the speciality of the patient’s primary issue: this might not be the same on discharge from ICU as it was at admission).

It also acts as a safety net for the whole hospital.

The ICU primarily coordinates care between the specialities that need to communicate and work together for the benefit of the patient. That means the ICU staff (nursing and medical) have to know at least a bit about EVERYTHING.

Aside from admitting to other higher level ICU’s it doesn’t generally have it’s own safety net.

All this make it the perfect place to see/hear/experience all the patients you could hope for as a student.

‘So how do I make the most of this opportunity then? I don’t know even a bit about everything?‘

Easy. Ask yourself what you CAN learn that you can use WHEREVER you end up. If you don’t yet really know where that is (even if you liked medical ward nursing, that’s no guarantee of a career there) then look globally.

Despite the monitoring, observations don’t record themselves. What happens if the power goes out? Practice taking all the BPs, pulses (ALL the pulses), looking at pupils, describing colours, warm or cool, and listen to chests.

‘All the pulses?’

ALL the pulses. And ALL the chests. Find out as much as you can. Listen before a suction. Listen after a suction. Listen before and after Physio. Listen before and after turns. Listen to bowel sounds, and maybe listen to heart sounds. Get a library of remembered sounds going. Look at wounds. Do dressings. Take ECG’s. Ask for help.

Ask for descriptors.

Make descriptors up yourself. Practice writing them in notes.

Get comfortable with how to do a manual blood pressure (yes, even in ICU). Not simply a non-invasive BP, but one where you listen. Learn why the automatic BP cuffs are a silly waste of money (and why at 3am the doctor wants you to do a manual one before they get out of bed to see your patient). And when you get the stethoscope out for the BP, Listen to the patients chest again.

‘Er, I did obs in first year…?’

Ask your buddy nurse to relate all that to the disease or injuries of the patient. Then when you get the idea, practice relating all the obs to the buddy nurse. Anyone can take obs. It’s knowing what they mean that’s the hard part.

‘And then?’

Do the same thing with medications, even the IV. Doesn’t matter if you can’t give them. You’ll have to know them. Most of the ones in ICU are used in medical wards anyways. (Ok, there are obvious exceptions to that). But this will help your future practice by increasing your knowledge of pharmacology and physiology.

Oh, and do the obs again after medications have been given or titrated.

See? The drug works!

‘And you said I’m not studying ICU 101?’

But you are learning how to be a nurse. These skills, all this knowledge is transferable. Remember the ICU as safety net bit? If you call for help as an RN, how much more helpful, how much earlier are you going to notice changes, how much more comfortable will you be.

Instead of ‘Er, um, can you come see Mr So-and-so, I’ve got a feeling…’ you will be able to say ‘he sounds like a bowl of Rice Bubbles on his lower right lung, and his sats drop when he’s laying on that side, … … …etc”

Much more helpful. And much more confident.

Enjoy the rest of the prac.

You aren’t psychic. Neither is anyone else.

When I started in Anaesthetic nursing I was preceptored for one and a half shifts. I was task-oriented, which was good as I had demonstrated I could undertake the tasks expected of the role but had no real idea of how much I did not know.

Donald Rumsfeld, the former US Defense Secretary and ground-breaking educational theorist, defined this as the known unknowns. I knew there had to be more to learn, I didn’t know what, and at that time I didn’t know where to start.

The environment in which I was working was an operating theatre suite in a very busy metropolitan hospital. The theatre and the hospital itself were both going through an organisational “down-swing” of morale. I’m sure we’ve all experienced the type: a kind of a “sink or swim” environment, where the old hands are sick of introducing new staff to policies, procedures or even themselves and where the unspoken rule of sink or swim is “just do it quietly, we’re busy”.

So it was as a junior nurse I learnt to ask questions. Many, many questions. I would introduce myself, informing the Anaesthetic consultant or senior registrar that I would ask them questions while we worked. The junior registrars and residents seemed relieved I was offering myself as the person who knew the least, a role some of them must have thought they would never grow out of.

I discovered about the joys of gas dissolvability, of nitrous oxide as a carrier gas (with caution in bowel surgery and never in cranial neurosurgery), of Mean Alveolar Concentrations and the differences between and induction doses of the non depolarising muscle relaxants, in addition to myriad other details.

I continued asking questions when I changed hospitals, moving to a smaller regional hospital with a large obstetric casemix. I learned about the anatomical and physiological changes wrought by pregnancy, about ergometrine, syntocinon, syndometrine, and successfully diagnosed a Mallory-Weiss oesophageal tear in a patient post-epidural hypotension induced nausea. I worked stupid hours.

Eventually I moved out of the public health system and into private healthcare. I was lucky, as by this time I had a fair grasp of the theory behind practice and there are no junior doctors in private practice to use s cover for my learning. Of course, I had long lost my fear of asking questions.

A regular Anaesthetist was on holiday. An anaesthetist no-one had worked with arrived to cover his list, and although we had never worked with her we had heard of her. She was no nonsense, pragmatic, experienced, and seemed to have skipped all the CRM (Crew Resource Management) and communication and conflict theory. It was obvious that there would be no zen-bubble today.

We had paediatric patients on the list. This was new.

I decided I would continue with my usual strategy. I introduced myself, she told me what she wanted, I informed her I had no experience with children, and I would like to know what the major differences were in order to properly anticipate potential issues.

No dice. “Hurry up, we need to get started.”

I’d met the patient and Mum earlier, when waiting for the anaesthetist to arrive. We led them in, got the child monitored, breathed down via a sevoflourane induction. Mum went out, and the child was intubated for surgery.

It was not unsafe, but nor was the process smooth, cool, calm or as controlled as I would have liked. Good learning, I thought.

The anaesthetist was livid. “Damned incompetent anaesthetic assistants who don’t know what they’re doing…waste of effort…” (Just two of the comments I remember hearing). I felt humiliated and frustrated.

Between cases, I gathered my composure and decided this was a conflict worth having. “I told you of my inexperience and asked you what I needed to know to work with you. If you’d worked with me with an adult patient you’d never have dared to call me incompetent. If you answered my questions, all that would have been much smoother. Is this my issue because I didn’t know or yours because you didn’t teach me when I asked?”

The anaesthetist said nothing, and part of me felt I should stop, but a small part was…exhilarated. If this was going to bite me at least it would be worth it.

I continued “So, let’s try again. I’m not psychic, I can’t read minds and I’ve never pretended to. When working with paediatric patients, how do you think, and what do I need to know?”

More silence, and then she actually smiled (well…grinned?). “In twenty years no-one has ever told me that. Usually they’re scared of me. I guess it’s about time…”

I got to learn a great deal about paediatric anaesthesia that day. And I became her anaesthetic nurse of preference when she worked at that hospital. We ended up having some rather good conversations, and a normal working relationship. I learned a lot more working with her after that.

And one afternoon she thanked me for challenging her, as it was “nice to work with someone who was not scared.”

So here is the point:

Healthcare is difficult at the best of times. Working as part of a team is hard, doubly so without effective communication. There are many impediments to communictation, but by far the silliest and most inexcusable obstacle is to assume that the person you are working with can read your mind, and yet we all have colleagues who seem to do just that.

It’s something we all need to remind ourselves of occaisionally.

You aren’t psychic.

Neither is anyone else.

NB: for the uninitiated, a zen-bubble is a bubble of calm created around an urgent or emergency situation by a experienced heathcare professional. They exude a calmness that is infectious and calmer the closer you get. It remains my aspiration to be known for my zen-bubble. You never see them on medical shows on television.