Settling into the routine of chaos

It's Fall. Finally! For some of us, it means the return to academia. Let the chaos begin!

I recently read a blog that really spoke about ways to handle being pulled this way and that. She presented ways that she kept herself grounded. I enjoyed it, and so I thought I would create one of my own. I am not all-knowing, by any means. I just thing that we all must take time to realize our own limitations and our own needs. If we neglect ourselves, we will inevitably neglect those around us.

Develop a routine.... (if that's possible!) Sit down and look at the big picture. What are your needs and your "have to's", what are your "like to's", and what are your "don't need to's". Prioritize and develop a routine that balances your needs and wants. You do not have to give up everything just to fit in time for school, work, family, etc. You just need to be creative. Do what works best for you. Maybe you treat yourself to a movie after class some days. Or perhaps you have a "date night" with your significant other or your entire family. Those times will be sacred and much appreciated by all. Maybe you just want time alone, with no one around. That's fine to. Spend it however you want, just make time.

Nothing ever stays the same forever. Remember that on those days when it seems like you will never be finished with school. It will end, eventually! It may take you longer than you would like to, due to family obligations, finances, work schedules, etc. Like I said before, sit down and plan it out. See what you would like to do...and if reality will accommodate you. If you take 2 classes instead of 3 in a semester, it'll be OK. So it may push your graduation back some...but it's not a race. You need to make the most of the investment in yourself and your future. Finishing in 2 years versus 3 is not going to make you a better, or more satisfied nurse. Be patient with yourself. (This coming from someone who graduated with a bachelor's degree 7 years after high school.) But I know some who didn't earn theirs until much later...the point is they were persistent.

Learn as much as you can, ask a lot of questions, and share with others. That is how it works. We all have pieces of the puzzle. We must continue to collect the pieces and form them together as best we can, until the picture makes sense to us. It starts out looking like a big mess...chaos....but after a little work organizing the pieces....fitting them together....and stepping back every now and again....the picture becomes clearer and we can start to see how the "chaos" can bring order to our lives once again.

Thanks.
Steve

Share the Wealth

As I have said before...and will undoubtedly say again...Nursing has a wealth of information to share. We possess a great deal of scientific knowledge and artful skill that is unique to our profession. We have nurse scientists conducting research, nurse clinicians evaluating evidence-based practices, nurse educators instilling basic principles and practices of the profession into the minds of new practitioners, and we have an incredibly large amount of practicing nurses whose knowledge and experience is vastly important and vital to keeping patients healthy and safe. Yet with so many resources out there, we tend to rely on very few to guide us along the way. We all have something important to share. We cannot minimize our position within the profession simply because of our specific title or job description. We are professional nurses...every one of us.

I think that early on we view our role as nurses as an "assistant" of some sort: someone that serves an important function, but isn't necessarily "in charge". Well, I disagree. I do understand that when compared to the role of the physician, nurses are there to help coordinate and implement the various orders they receive. However, we are not technicians. We are not there to merely perform a task based upon a command. We have a unique knowledge base, and we are charged with keeping patients safe...we MUST use our brains and THINK critically. Nurses, like physicians, pharmacists, ancillary healthcare providers, and many others, are human...and humans are not perfect. No matter how hard we try, we will always be subject to error. Yet, at the same time, we are all creatures of adaptation, creativity, and higher forms of communication. We may not be perfect, but we can always be better! I believe that an unasked question is the only bad one. Without questions, we cannot gain knowledge. Without knowledge, we cannot progress. Without progression we will will fail. Only time will tell.

When I hear a person say "oh, yeah...right...right..." when they are being instructed on something which I KNOW they have no experience with, it drives me crazy! Now I do understand that we all have varying backgrounds and experiences that we bring to the table, and perhaps some things may be "understood", or better yet, "more familiar" than others....but you can't sit there and say "yeah....right....right" to everything. We ALL have something to learn. We are not stupid just because we do not know something, or let on that we don't know something. That is our own insecurity. We must be confident in our own knowledge and abilities. Please, please, please....stop saying "right....right...right..." all of the time. How do you know they are "right"?

Which brings me to my main issue....sharing information with others. It is not just a nice thing to do...it is a responsibility we all have. We must all accept that we will be asked (perhaps many times over) to share our knowledge with others, whether it be in the form of orienting a new student, a new employee, or even teaching a class to peers. Knowledge is absolutely worthless if it is not shared. I can't say that strongly enough. Why be the all-knowing bearer of all knowledge? What good does that do? It's merely a power issue. But is it real power? Are you really using your knowledge for the best? Who will really benefit from it if it isn't shared? Healthcare, in general, is very guilty of this....we tend to take really great knowledge and "proprietise" it. That way we keep it secret, for our own benefit, and charge others lots of money for it if we do share. That's ridiculous. I know there is the "business" side to almost everything...but when it comes down to patient safety and improving overall nursing practice, we need to be better at sharing our knowledge....across the board.

We were not born with all the knowledge we need...we had to seek it out, take time to understand it, and transform it into meaningful practice for ourselves. We learned from others, who learned from others before them, and so on. We have a vast amount of technology before us, and we are surrounded by innovations and changes every day. But nothing will replace the standard "oral tradition" we share with one another. Those "stories" and anecdotes are what helps us all connect and relate to one another...sometimes for laughs, sometimes to share in each other's pain. It is part of being human, and that will never change, or be replaced. We are, after all, in the business of helping people. No matter how much technology advances, and how many machines are involved in the care of a patient...the patient is always a human. If we stop being human, we stop understanding our patients. If we stop understanding our patients, we can no longer be a worthwhile profession. We need to share the "wealth": our thoughts, feelings, ideas, fears, laughter, tears, and most of all, a comforting touch on the hand to let them know they are human, and they are understood.

Thank you.
Steve

Teaching the next generation

We've all been there. That first semester of nursing school. Scared, excited, ambitious...no idea what really to expect, and a little curious to see what lies ahead. I remember one of my first days in nursing school, in fact, it probably was my first. Sonia, one of my first-level instructors, told us that many people that become nurses also considered being teachers at one time. This was true for me, anyway. (I had wanted to be a music teacher out of high school, and later a science teacher.) She went on to explain that this was not really surprising,and that if you didn't want to be a teacher, then nursing isn't for you, because nurses are teachers. I had no idea how much of my time would be spent teaching: patients, families, colleagues, new hires, and student nurses. A great deal of our time is spent educating others. Nurses really are teachers, like it or not. Now, some do a bit more than others, but you have to agree that nurses are the ones doing most of the teaching that goes on in an organization. So, if this is such an integral part of our job, why are many so resistant to this part of our profession? I think there are several explanations, and I will talk about a few.

Personality. This is an obvious one. Not everyone learns the same, and not everyone teaches the same...if at all. We cannot expect those that are "good nurses" to be "good teachers" as well. Sure, some may be, but not all will be. I think some of the best teachers may be the ones that really have to work to understand things. They know what it's like to need a bit of instruction, and time to let it soak in. Those that just seem to "get it" may understand things, but may not be able to articulate it well enough for others to understand in a meaningful way. It takes all kinds. Some have that perfect blend of understanding and skillfulness that makes them ideal teachers. There are some that love to teach others, and many that would rather slam their head in a door than have a student or new hire. Yet, I think we put new nurses with these people far too often, be it out of fairness to others, or perhaps out of belief that things will somehow "work out." There must be a conscious effot to place the right "personality" in the right situation if we ever hope to achieve any form of success. "Good enough" isn't acceptable, nor should it be.

Motivation. What "drives" you? What pushes you to achieve above expectations or minimum requirements? What makes you want to learn as much as you can about your clinical setting, and your professional role within it? The answer may vary with each individual...but perhaps more often than not, we may see themes such as "do what's best for the patient" or "need to know more", both of which are very important. We must always have that "need" to know more, to understand what it is we are doing, and moreover, why we are doing it. Additionally, whatever we do, we should have the patient in our focus, or we have lost sight of our ultimate goal. And to expand on that, in order for us to be effective, we must continually seek education and training in order to practice as we should. After all, not many people would want to go to a surgeon who stopped learning about his/her craft after becoming a surgeon. Why would we expect that patients would want a nurse that has failed to keep up on current evidence-based practice (EBP) and research? I wouldn't. In a previous blog post, I talked about nursing school being a "floor", not a "ceiling", and I truly believe that. Everything you need to know for the duration of your career was not provided during your time in nursing school...sorry to disappoint you. You are going to have to pick up a journal now and again if you want to be as effective as you think you already are.

Experience. Spend enough time in nursing, and you will most assuredly interact with an "experienced" nurse that loves nothing more than to eat you up and spit you out. And that's too bad. Why do we allow this? Why should we consider ourselves as anything less than professionals? Professionals do not tolerate this type of behavior. What good is education and experience if they are not shared? Not a lot, I can tell you. Those with a lot of "experience" may have just "punched the clock" a few more times than others, but that doesn't make them "valuable" resources, necessarily. Experience can be beneficial whether it is good or bad, especially when we opt to share it in a constructive and productive way. Otherwise, negative behavior is worthless, and is of no use to new nurses eager to learn from those before them. Share experiences, share stories, share your time. It is such a small price to pay for a world of difference.

Attitude. This one is key. If you have a great attitude, you will have a positive impact on others, even in the gloomiest of situations. A negative attitude often comes easiest, and most frequently, because it takes the least amount of thought or energy. Everyone has a bad day once in a while, but you do not need to share that with others. We must be much more conscientious of our actions and our interactions with others. Tearing others down to make one feel more powerful or in "control" is unacceptable, and should not be tolerated. We have all been there, new nurse in a new unit...new culture...and want nothing more than to "fit in" and "be accepted." "Eating our young" is what we have come to know and expect...and we need to break the cycle! We must speak up and take charge of our own career and our own ideas. We must be civil to one another, both as a colleague and as a human being. Everyone makes mistakes, EVERYONE. We are human, it's what we do. There are few things in this world that we can control, but our attitude is certainly one we can.

So, when you are asked to help train a new nurse or student, I hope you keep these things in mind. Please don't do it if you are not in the right mindset to be nice, be thoughtful, and be patient. If you are a new nurse, a student, or a seasoned nurse, make sure you never stop learning. We are not born with everything we need to know, and nursing school is definitely not an ending point for our training. Instructors, please create a culture of lifelong learning as a standard of practice, and nurses please continue this push in the clinical setting. These new nurses will be responsible for taking care of you and your families someday. They will train the generation following them, and so forth. A few extra minutes spent teaching is well worth the investment.

Thank you.

Steve

Know your role

Healthcare is comprised of numerous professionals and ancillary staff that are all essential to the care of a patient within a system, no matter how grand or seemingly insignificant the scale. Nursing makes up only one of these roles.... Or does it? If you have read Notes on Nursing: what it is and what it is not by Florence Nightengale, then you probably know that the practice of "modern" nursing actually consists of many different roles...all focused on the holistic care of the patient. Florence, a public health statistician, did not attempt to provide a manual for nurses of her time, nor did she profess that her book be the end-all reference for nursing practice. What she did do, however, was blend her "calling" to help others with her analytical thought process, and began to make keen observations on the health and welfare of "hospitalized" soldiers during the Crimean War. She noted that certain factors, or an absence thereof, seemed to play a part in the successful recovery of these soldiers, physically and emotionally. For instance, Nightingale offers her "tips" to would-be nurses as to what is important. Among these "canons" of nursing are proper ventilation, pure air and water, efficient drainage, cleanliness, light, noise, "variety", proper nutrition, and observation. This is not an all-inclusive list, only an example of common-sense practices that were not so "common" in her time. If you have not read Notes on Nursing, I strongly recommend it. Florence was a very intelligent and dedicated woman, who truly made a lasting impact on nursing and public health practice. We must learn all we can from our profession, both past and present. We must always seek knowledge through science and reasoning, always guided by ethical and moral principles, aimed to serve a those within our community and those we will never know.

What cruel mistakes are sometimes made by benevolent men and women in matters of business about which they can know nothing and think they know a great deal. ~Florence Nightengale

Florence recognized these varied factors to be very important to the wellbeing of patients and of the public. Take, for instance, the practice of handwashing. She recognized this simple practice to be extremely effective in the prevention of the spread of illness. Although she did not accept the "Germ Theory " as fact, she observed the basic principles of sanitation to be very effective in disease prevention. Today, ask any nurse about disease prevention, and they will tell you that handwashing is the number one way they can prevent the spread of disease from one patient to another. Nurses use to provide virtually all patient care duties: hygiene, meal preparation and assistance, cleaning floors, emptying trash, and even obtaining and evaluating laboratory specimens. Of course now there are many professional and ancillary service staff to provide these services...among numerous others. The point is, nursing has a very rich history, deeply seeded in the comprehensive care of patients. Nurses, and student nurses, truly use to "do it all". By today's standards, and with curent technological advances, it would be impossible-and unrealistic- to perform by the same standard as those before us. However, we should not soon forget what we are doing, and why we are doing it...for the patient. We can not know it all, we can not do it all, and we can not for one second think that we are capable of such a task. We are surrounded by a wealth of resources, there to assist in the care of the patient. We must know our resources, USE our resources, and coordinate all of these activities. After all, that is what professional nursing is all about: being the coordinator of care. Though we may not do it all, we should at least help ensure it gets done, all with the patient's best interest at the forefront of our minds. Florence was leading us in the right direction. It is up to us to maintain the course. So, was this about Florence and her contributions to patient care and organized medical and nursing care? Somewhat. The real reason I spoke so much of her is because in order to "know our role" we must understand what it is we do, and try and understand our beginnings. We must understand what we do and why we are doing it, otherwise we are not basing our professional practice in anything more than folklore and tradition. Evidence Based Practice (EBP) is what guides us today, and what we use to rationalize continuation or discontinuation of practice standards. We are a caring, intuitive profession guided by science and reasoning. If we lose this, we lose our identity as a profession. Observations guide research. Research provides evidence. Evidence support standards. Standards shape policy. Policy influences practice (among many other factors). In the end, we as nurses, are ultimately responsible for our own practice, and being knowledgeable of the various policies, standards, and legislational guidelines that both entitle an circumscribe our practice. Again, we must "know our role" or we may be not only endangering our patients, but our legal license to practice. I said this in a previous blog: "Nursing school is a floor, not a ceiling." We must not stop seeking knowledge simply because we are not in an academic setting. We must be current on recommended practices and what research is available. We must be able to find this information and make sense if it. We must not accept everything as being finite. We must own our practice and our profession, living up to our dedication to our patients. We cannot be afraid of asking questions, and furthermore, of seeking the answers. In her book Notes on Nursing, Nightingale even indicates that her work was not meant to tell nurses what to do; she wanted them to teach themselves, through the use of her "tips." We should continually teach ourselves about nursing, because after all, we have yet to attain all the answers when we do not even know all of the questions. I will leave you with another quote from Florence:

Were there none who were discontented with what they have, the world would never reach anything better.

Thank you. Steve

Leadership or Management?

It has been said, "You manage things....you lead people." I couldn't agree more.

There are a lot of "Managers" out there. Some manage processes, others manage groups of people. Being a manager means being "in charge", or perhaps, "responsible" for something, right? (some thing)? No doubt that there are many, many things that require someone to be responsible for: systems, budgets, workflow, logistics, information, etc. But what about the people? Do you manage people? I say no.

Sure, you can manage some situations that involve people, such as interactions/communications, environments, duties, or maybe even some aspects of behavior. Yet, no matter how complex of a machine or a system you may manage, it will never be as complicated or intricately-designed (or flawed) as a human being. For instance, a thing does not have thoughts, feelings, desires, hopes, dreams, emotions, or most importantly, a soul. You simply cannot manage these aspects. For that reason, you must have a completely different set of knowledge, skills, and talent: leadership.

A computer is programed to perform a certain set of tasks, given specific parameters, with identified variables and methods of input and output. And no matter how fascinating the process is, or how extraordinary the outcome may be, it will never be motivated to do more. And, to be honest, you really can't blame a computer for the outcome you get...because your results are precisely the end product of your specific instructions: you get out of it what you put into it. Yet, you will see managers repeatedly blame the output on others...an unfortunate hallmark of ineffective leadership. I believe it is a complete misnomer to identify a person in charge of other human beings as a "manager". You simply do not, and cannot, manage people.

It is by no fault of their own that some of the greatest leaders may have the title of "manager"...that is just our way of identifying a job duty or hierarchy of responsibility and influence within an organization. Anyone can put on a badge with "manager" in the title and be great at budgets and fiscal planning. But this person is not necessarily a leader simply due to the same qualifying identity. Again, "you manage things....you lead people." Emotion, personality, morals, and ethics are perhaps some of the biggest reasons you cannot manage people. People have goals, they have dreams, they have needs. They can be motivated. They can be made to feel worthless. They can trust and they can distrust. All of these factors require something much more effective than learning how to manage. You must understand how to lead.

I know that I will be much more likely to enjoy my job, work harder, and be more effective when I am motivated to do so. And to me, this occurs with positive reinforcement and opportunity to express ideas, thoughts, and concerns. Conditioning behavior within a workplace though negative reinforcement may provide short-term results, but it will pollute the very air it attempts to improve. If the main interaction you have with people is at the "giving-end" of a corrective action, then you will fail as a leader, even though you may manage a situation. You don't have to be friends, but you do not have to be the enemy. It doesn't have to be "us" against "them". Effective leaders know that to understand human behavior, you must be human. Humans are fallible. We make mistakes. It's a fact, and it cannot be ignored or avoided. We must learn form the mistakes, try to understand why we do what we do, and solidify our foundation upon that gained knowledge. We are human. It's time we treat one another accordingly.

Although I have talked about "people in charge" in terms of "superiors and subordinates", I think this would definitely apply to bedside nursing practice. Patients are not our "subordinates", but we do assume a great deal of authority and power over them whether we like it or not. We manage our care plans, our patients' information, and most of all, our time. But we will never manage our patients. We can manage symptoms, perhaps, by providing appropriate interventions, yet we cannot do the same with our patients' thoughts and fears. We must apply aspects of leadership to our everyday practice, understanding what drives people to do the things they do...what motivates them...and how we can use that knowledge to help them make more positive changes within their lives. Additionally, when we are working together as a team, we must understand that our coworkers will typically respond much more favorably if we treat them as humans and not things. A little communication goes a long way.

And, of course, there is a great lesson we can learn from the study of complexity science- actually there are a lot of lessons from it, but that's a different conversation. It is well known and observed that a single force, seemingly isolated and insignificant, can have a greater impact upon an entire system (small, large, near, or far) than we can ever predict. I am certain most of us can recall one or two individuals in our life thus far who have positively impacted us in ways we could have never known or understood. We all carry those people and those behaviors with us...we will never forget the way that person made us think or made us feel. It is because this person was a leader, and a leader leads people.

I am a nurse; I am a leader.

Thank you.

Steve

Back from Summer break!

Hey everyone! Hope you have had a great summer; and for some of us, I hope you managed to stay cool! It's been an eventful past few months, since my last entry in June. Of course one of the prevailing topics was the national budget, and the threat of defaulting on US debt. Well, as I had expected, an "eleventh-hour" deal was made and the US avoided default...but it earned a downgrade of it's AAA credit rating. Most recently, news of stock market instability has many in a state of panic, not only locally but globally. You can't hardly listen to the radio or watch the news without hearing about these issues...budgets are beingcut everywhere, at all levels. A lot of speculation an finger-pointing is taking place, with blame being passed around like a game of "hot potato". Well, I, for one, am trying to remain focused on the task-at-hand, and that is healthcare: the other huge mess....

Change in healthcare is common, and occurrs very frequently, whether you are monitoring vital signs, disease progression, technological innovation, or policies and regulations. I think there are certain instances when we must act urgently, such as when responding to a cardiac arrest, new findings of malignancy, or when our practice is threatened by policy changes. These instances require rapid, timely and skilled responses in order to achieve maximum benefit. However, there are some situations that may, at first, seem "urgent", but, in fact, may allow for more planning, thought and consideration before acting. When I hear about the stock market variability and the "knee jerk" reactions some have, it seems to apply to my job as a nurse. Although I do not deal in stocks and securities, I do deal with the greatest asset anyone can have: life. It's times like these when I am reminded that sometimes it is best to take a step back, gain broader perspective, and look at a situation from a "continuum", rather than an "episodic" standpoint.

Economic "health" is not episodic, and neither is that of human beings. We are constantly sliding along the spectrum of health, some moreso than others. Sometimes there are brief, but rapid shifts in the state of a person's health, and each situation should be viewed independently, as there are many factors that contribute to wellness and illness. For instance, if a relatively healthy individual falls and breaks an arm, the repair process is usually straightforward and uneventful. This represents a rapid shift among the spectrum, but overall the outcome is usually a trend back to a state of health. Now, take the same scenario, but make the person elderly, with osteoporosis, atrial fibrillation, and heart failure. Of course we would expect this situation to be worse than the previous due to the comorbidities present. This person is at much higher risk for major complications as compared to the first example. Additionally, this person may have been at his/her "usual" state of health prior to this incident, but it is doubtful the two individuals mentioned here shared the same position on the wellness spectrum. So, the person with multiple comorbidities would most likey drop further into illness, and recoup slower, and may not have the same likelihood of ever regaining his/her previous level of wellness. I am sure this is pretty basic knowledge to most of you. And my point is this: we must stop to look at the bigger picture sometimes, try to understand what we are looking at and begin to make sense of it, and move forward with interventions to change what can be changed, and make adjustments for what cannot.

The moment you stop seeing past your front door...or even the tip of your own nose, you have truly become impaired and must recognize an entire world exists beyond your field of vision.

You don't have to like what you see, you don't have to agree with what you see, and you don't have to act upon what you see. However, you should acknowledge what is in front of and all around you, and understand that everything is connected in some way, and whether you feel the effects of these connections now or later can only be determined by time...but it will happen. We should all be agents of change within our immediate environment, that of those we serve every day, and never become complacent with the seemingly complex situations we face. Remember, it only takes one. I hope you can be that "one".

Hope your summer was restful, and I look forward to blogging more frequently!!

Thank you.
Steve

Dads and Nursing

As the week draws to a close, and Father's Day approaches, I want to take this opportunity to wish all Dads out there a very happy Father's Day! As a father, I have new found respect for the important role fathers have in their children's lives, and ultimately in those of their children, and their children's children, and so on...

Fatherhood is a role that draws upon both shared and individual experiences, with cultural, ethical, social, political, and even economical influences. Many of us learned what we know about it from our fathers and our grandfathers. They have passed on their wisdom, experiences, and knowledge they have gained over the years, in efforts to help us be better prepared for life, and eventually, for fatherhood...if you can ever prepare for that!

An article I had published in Neonatal Network in 2008 expanded on this concept, including how male nurses can relate to fathers in the neonatal intensive care unit (NICU). I was a night shift nurse in the NICU at the time the article was written and published. I had spent about 1 1/2 years working in the NICU before my premature twin daughters were patients there in late 2004-early 2005. Before that time - which I refer to as "BC" (before children)- I enjoyed taking care of the tiny patients, and learning how they "tick", so-to-speak. However, after my daughters were born, and spent several weeks in our unit, my view changed dramatically. I realized I never really understood how it felt to take care of someone's child until that moment. Sure, I spent plenty of time taking care of the "patients", but to really know and understand what the parents were thinking, worried about, and what I knew about the truths and myths behind caring for premature babies proved very beneficial over time.

If you have ever watched the NBC TV comedy Scrubs, then this next reference will make sense...if not, well, you should watch the show...it's pretty funny (or at least is use to be - in my own opinion). Anyway, one of the main characters realized that he could not "see" any married women around him, because the fact they had wedding rings on made them "invisible" to him. In one scene, one of his friends assured him there were more women around him than he noticed. So, his friend proceded to call attention to the married women in the immediate area, asking them to remove their wedding rings, suddenly a roomful of women appeared. (Like I said, if you don't watch the show, or haven't seen this episode, then it may not make sense....but it's what popped into my head at this time, so I went with it...)

The point there is this: we may not really be aware of what (or who) is directly in front of us every day. Like the situation I just described, I never really "saw" the parents, or the dads, until after I became a NICU dad myself....it was then that the "rings were removed", and I could see the fathers all around me.

To be honest, I believe that a majority of the attention is focused on moms in the NICU, and for very good reasons most of the time. Mothers are going through a tremendous amount of stress during this time. They are healing physically, and trying to emotionally. And until I became a "father standing in the back of the room", I really never thought about how much some fathers can be "overlooked." As I talk about in my article, just because a guy doesn't express his emotions externally, it doesn't mean he does not have them...i.e., just because he doesn't seem stressed and worried, it doesn't mean he isn't. Quite the opposite is true. Men just worry about different things...their baby, their partner, their job, their home, etc. Not that women do not think of these things too, it is just that the men tend to be more focused on the "bigger picture", while the women are more focused on their child and being a mother.

Fathers love their children, and want to be involved with their care. Some may be a bit apprehensive to "touch" or "hold" the baby at first, as they may feel they are going to "break" them. It is my belief that having male nurses in the NICU offers a unique support system for the fathers. It provides them with a male role model, demonstrating that men can care for the smallest of babies without "breaking" them...and more importantly, that having a positive relationship "man-to-man" between the male nurses and the fathers could, in fact, lead to earlier caregiving behaviors, and therefore, earlier bonding opportunities. And that is where fatherhood really begins: seeing your baby for the first time, taking in all of the immediate senses around you. As nurses, we have a long-lasting impact on these fathers, and their first experiecnes with fatherhood. We are much more influential than we might believe.

I know that there are many of you with similar stories about being a nurse and a parent of premature infants...and just being parents in general. Some of you may have lost children at an early age, whether it be in infancy or in childhood. The pain you have felt is unknown to me, and to many others, and I can only say that my heart goes out to each one of you every day. And, in the end, that is what we are really offering to our patients and their families: our hearts. Nursing is the caring profession.We must think critically with our brains, act swiftly with our arms and legs, but we must always include our hearts in our daily practice. I know that there are days when patients and their families are on your last nerve, and have exhausted every last bit of compassion you feel you have left in your body. I've been there myself. But at the end of the day, when you are heading home...and they are staying there...just know that every act of compassion and caring are noticed and welcomed...even if they are not reciprocated. Anger is a manifestation of fear.

Help your patients and help their families. Healthcare is a continuum, and your patients are on varying aspects of that continuum. Some are realtively healthy, positive, and appreciative...while others...not so much. But we don't pick our patients, their diseases, or their families....but we did pick our profession, and that is just part of the package that we must accept. So, next time you are with a patient and their family, try to think about what I have said. Try to see what is right in front of you...you might just be surprised by what you discover.

Happy Father's Day!

Thank you.

Steve

Nursing theory and practice: who guides who?

I am no expert when it comes to nursing theory, but I do know a thing or two about it. For instance, I know that it is very complex, and that not a lot of nurses know or understand a great deal of it. I find that a bit disheartening because our practice should be "guided by theory", right? Perhaps the problem is that there are extremely diverse fields of nursing theories, found at many levels of complexity and practicality. Modern nursing theory is said by many to have evolved from the works of Florence Nightengale in the late 19th century. Since that time, there have been a multitude of nursing theorists who have thrown their proverbial hat in the ring. There are so many types of nursing theories out there, that they have been categorized into "grand theories", "middle range theories", and even "practice theories". It's no wonder nursing students have a hard time understanding nursing theory, and why professional nurses, for the most part, couldn't name many theorists...let alone a theory that "guides their pactice."

So what are we to do about that? How can we be professionals, "grounded in theory" and "based in science" if our practicing membership...our frontline representatives...do not understand the very essence that is their "profession?" I suppose that is a complex question in and of itself. So what about this: why can't practice guide theory? Perhaps it can be argued that it does, in many ways. Evidence-based practice (EBP),I think, is fairly close to this...even though the practice is still "guided" by something. Taking all of the evidence we have on a particular practice issue, such as family presence during resuscitation or palliative care efforts, helps to formulate how and why we should practice in a particular way. But could it also guide theory development too? What about Elizabeth Kubler-Ross' work with the stages of grief? Now, she wasn't a nursing theorist, but her work is most definitely found in nursing practice. It can be, perhaps, known by what is referred to as a "borrowed theory": non-nursing theory that has been adapted for use within the profession.

We incorporate so many "bits and pieces" of so many different theories into our practice, that perhaps we do it without even realizing it. I think that unless you work in a particular area of nursing, where one particular theory almost entirely supports your practice, it is difficult to pick just one and stick with it. As nurses we must adapt to our ever-changing environment. We must be able to learn-unlearn-relearn many times over, as our practice is constantly changing...yet our theories rarely do. Now some of you will recall that there is a nursing theorist who spoke about "adaptation": Sister Callista Roy. I'm not going to discuss any particular theorists here, just making observation.

So maybe you are mot familiar with any one particular theory, or maybe you combine many theories into your practice...either way your practice is guided by something. Maybe your practice will guide you to develop a new theory in nursing, or perhaps improve upon an existing one. I think where many nurses lose interest in nursing theory is when they begin discussing some of the grand theorists, such as Martha Rogers (not picking on anyone in particular). Rogers' theory is very abstract and difficult to follow, yet she touches on some very key adpects related to complexity, which is a big topic of today. She was truly ahead of her time, when compared with theorists contemporary to her day. But at what point do these theorists say, "I think I'm going to make up a nursing theory today, I have nothing better to do today..." my guess is probably never. I would imagine that their theories were formed out of experience and practice. So, who guides who?

I think that in the end, it will be up to us as individual nurses to identify with a particular theory or theorist. Maybe it's time we start looking at a theory that helps circumscribe our own professionalism and interpersonal relations (beyond the work of Peplau). What about achieving professional growth? Or one about nursing as a unique culture, and the many ways we tend to interact with one another (good and bad), and what we can do to improve. Do any one of us have the answer? I doubt it. Many times, the best things to happen are not from the "inventors", but the "innovators"- the ones that improve what was discovered by others. And, again, that's the beauty of complexity science: we can never predict the effect one thing has on another.

So, who guides who: nursing practice or nursing theory??? Are patients in a continuum of wellness or illness? I think we could argue either point.... But I will leave you with this: do your homework- find out about nursing theory, EBP, and complexity science. Find out what your profession has to say about your practice style, and more importantly, what it needs to say about it.

We need to be more aware of the "forces" that fuel our practices, and the practices that can lead to better, more effective theory.

Thank you.

Steve

Taking that next step

Every journey begins with one step....and then another....and another....

We cannot simply leap to our destination instantly- although I would find that helpful at times. Instead we have to take that initiative to begin the journey that will take us toward our destination. Now think about that: toward our destination. Notice I did not say to our goal. I believe there is a significant difference between these two statements.

First, toward, indicates "moving in a general direction which results in closer proximity to something", in my own words. I think we are always moving toward something, sometimes we know, and most of the time we do not. It is that unknown that often surprises us...or frightens us. Yet, there we are, every day, progressing toward something. What "thing"? Well, that depends greatly on the individual, and the situation, for that matter. Sometimes simply moving toward the end of a shift is all we want! However, I think you all know that I am referring to something much broader than that. I think that we are all moving toward becoming better nurses. I think we are moving toward more education, training, and career options. Sometimes we know we are on this journey, and sometimes we may not. We all have something to learn from one another, no matter where you are in your career. Some have great time management abilities, some great interpersonal communication skills, while others are very gifted with complex procedures. I think we all have something to learn. Each time we learn something new, or take a step toward improving our nursing practice, we are moving toward our destination. So what is our destination?

To me, a destination is waypoint along a continuous journey. A destination is not necessarily a "final" location, but merely a point at which we must reassess our bearings, reevaluate our options, do a bit of retrospective analysis of our path thus far....and then plot a course toward a new destination. So, where is this destination? Well, again, that depends on the individual. Some may choose career destinations, such as leadership positions within a company. Others may choose educational destinations, such as earning undergraduate, graduate, or post-graduate degrees. I think that as long as you are moving toward your destination you are where you should be. But the problem with all of this is that we cannot simply think of our journeys in preconceived, somewhat forced "linear" terms. We cannot always put our plan into a nice box and tie it up with a bow. There are far too many variables in life that can forever alter a journey in ways we cannot predict. For that reason, we must accept that we are not always in control (or in conscious awareness) of our destination, although we may be moving toward it.

For instance, I knew that I wanted to go back to school to get an advanced nursing degree. I have known this for quite some time. The only problem was, I had no idea which program I wanted. Do I want to be an advanced practice nurse??? Do I want to be in charge of something??? So I want to teach something??? Where do I apply??? Should I choose online or classroom format??? So I researched for a long time, "knowing" what I wanted to do was teach nursing students someday. I figured out I had no real desire to be an advanced practice nurse, so I eliminated that option. Then, after much agony, I had a moment of "clarity"...or what I might call, "intuition". I discovered a new nursing role called the Clinical Nurse Leader. This was to be an "advanced generalist" role, with advanced patho, pharm, and assessment....but with added courses in finance, leadership, and CNL role development. I thought "that's it!!" So I began my graduate education in a CNL program. Destination reached.

Then, during the course of the program, I was introduced to "complexity science" and "complex adaptive systems" in a leadership course. Learning about complexity science seemed to validate, somehow, my inner thoughts and feelings about how I perceived the world. And to know it had a name...and a whole field was dedicated to it! I became immediately interested in learning more. After the course was completed, I continued my research into the field, pulling as much information as I could from a variety of sources. The thought of healthcare (and healthcare organizations) being "complex adaptive systems" seemed to be a perfect fit for my thinking process. This proved to be a "turning point" in my career...and thus I was moving toward a destination. I began to get that "intuitive" feeling again, and have decided to change direction from the clinical aspect of nursing (the CNL role) and move to the "non-clinical" aspect of nursing informatics. I have therefore begun plotting a course from this destination (or waypoint) toward obtaining my graduate nursing degree in nursing informatics. I will start this Fall.

This is but one example...there are countless others. I "knew" what I wanted...but I am not where I thought I would be. I am more excited about nursing and my career now, than I was when I "knew" what I wanted. The point is, we can't "know" anything about the future. We can aspire, dream, "plan", and move toward it...but we can't "know" it or "predict" it. That is why linear thinking methodologies cannot apply to our future as nurses...or our future in healthcare. Healthcare is far too complex and interdependent on infinite variables to ever be reduced to linear terms. So, you see, we can only move toward a destination because there is never a straight line between points A and B...more like a general path, consisting of a variety of points and directional paths leading from these points. We always have a choice...but sometimes we need to think with our whole body...not just one side of our brain.

So keep moving...or get moving...and you will reach the next destination in your career's long journey. Maybe it's just getting through the next shift...maybe it's getting though a class or two...perhaps it's obtaining certification...it doesn't matter. Keep moving, keep learning, keep growing, and most importantly of all...KEEP HAVING FUN!!! We are all in this together, and we need to do a better job of supporting one another, instead of looking for ways to tear each other down.

Accept the present for what it is...learn from the past for what it was (and what it could have been)...and embrace the future for what it CAN BE (and SHOULD BE)! If we knew the end to every story, what fun would that be!?! Enjoy the mystery!

Thank you.

Steve

When the end is near

Most of us have dealt with end-of-life issues from our patients and families. Some of us have faced them within our own families. But how many of us have faced them individually? By this I mean actually coming to grips with our own impending mortality. I know that I have not, and I bet most all of you have not either.

Sure, I have thought about what it might feel like to be faced with those thoughts and decisions. But how accurate are my assumptions? What am I really going to be thinking about at that time in my life? I will never know until that time arrives. I may speculate and opine about what may be important to me, but that is all it really is right now...speculation.

My my grandfather is not doing well, and has been declining in health for some time now. I am certain he is not going to be here much longer, and I suspect he knows this as well. I can see him being more and more desperate to maintain as much control as he possibly can over his life. He is an extremely independent and stubborn man. Nobody can tell him what he needs to do, or what he shouldn't do...he knows far more than any of us. Or at least that what he wants us to believe. And I can't help but wonder who, exactly, is he trying to convince...us or himself?

When we are caring for someone who is facing their own mortality, we know there are a spectrum of emotions he or she is faced with. Elizabeth Kubler-Ross taught us that we typically transition through 5 stages of grieving: denial, anger, bargaining, depression, and acceptance. I can clearly see my grandfather in the first and second stages. And I think that, as a nurse, I want him to continue to express his emotions, and to work through the stages. Additionally, I recognize these stages exist, and anticipate that he may react this way. As his grandson, I want to tell him what a stubborn, irrational man he is being, and tell him to listen go his doctors and nurses. I know that wouldn't work, and would be extremely counterproductive. I know that he must make these transitions on his own, knowing that he has family at his side all the way. Some people will never say "sorry", "thank you", or "I love you." I believe my grandpa is one of them. But I know he doesn't have to say it to know that it exists.

I think that things happen in our lives very purposefully. Things seem to happen at either the "right" time or the very "wrong" one. It is really all a matter of perspective, and we all have heard that "hindsight is 20/20", illuding to the concept that the best perspective is perhaps the retrospective one. Maybe that is true. I believe that there are some, although not as many, that are known to us immediately as being very significant. It is how we react, it is the paths we choose at that crossroad, that can determine future events...and perhaps only hindsight will allow us to see them in more clarity. It's just that sometime we do not have the luxuries of time and retrospection at our disposal. It is at these times that what is "not" said may be more important than what "might have been."

I think that we, as nurses, are oftentimes faced with these situations. Sometimes we know that the most therapeutic thing you can do is listen. It may seem like we are doing nothing...and that would be absolutely correct. By doing "nothing", we allow our patients and their families to express their thoughts and feelings...sometimes for the first time. An open ear and a warm hand can provide more healing than we can ever know. We all know this to be true. It is what sets us apart as nurses. We should be proud to be in such an influential position in health care...even if we cannot see it at the moment.

Recognize every moment as being significant, for many times it is...just maybe not for you. Many times YOU are the turning point in someone else's life. I have said it before, and I am certain I will say it many more: you have an impact on many people, and you probably have no idea how important you are to this profession.

When my grandfather is in the hospital, alone at night, and he is being stubborn with the nursing staff, I can rest comfortably knowing they recognize his actions for what they are, even if he doesn't. I know that no matter what, he will be listened to, and be cared for indiscriminantly.

So, I say to each of you: the next time someone is angry with you, will not listen to your attempts to educate them on their disease, or just doesn't seem to want to accept the fact that "the end is near", please know that this person, this human being, is someone's mother, father, brother, or grandfather...and that they are resting comfortably at home knowing you are taking great care of their loved one, and that they are truly not alone.

Thank you for being there when no one else is. Thank you for the long, thankless hours you devote to others. Thank you for being a nurse. As this "Nurses Week" draws to a close, I want you to know that if no one else says it, I will: Thank You!!!!

Steve

Find the hat that fits!

Wow...it's been a while!
For those of you that have been following my blog, I want to say that I very much appreciate it, and hope you find sone good out of it. Also, I want to apologize for not posting in over a week...life gets busy, and you know the rest.

And, for a bit of an "FYI", I do blog from my iPod sometimes, which limits my editing and spellcheck abilities somewhat. So, if some of my posts appear a little rough, you know why. I will polish them up eventually, but please know my intent is well-meaning!!

Anyway....

So I have a lot of colleagues, friends, that are going through a bit of a rough patch in their careers. That is, they just aren't happy. I understand their feelings, I really do. I hate to see anyone frustrated with their jobs; especially in healthcare. As nurses, we are positioned in a very challenging, and very crucial, role. Or more appropriately, "roles." Hildegard Peplau felt nurses serve many roles, including technician, counselor, surrogate, and several more. Nursing is not a single act. It combines many roles together, each one unique, yet essential. As nurses, we often find ourselves performing many of these roles simultaneously...and not even know it...or perhaps not even understand its importance.

For example, as a NICU nurse, I often found myself wearing about every hat you could possibly wear...many times simultaneously. I could be speaking with parents of a premature baby, telling them about how their child adapts to his or her environment, how the ventilator is helping them to "breathe", assisting the parents with holding/changing a diaper, manipulating ventilator settings based on the baby's response to the stimuli, and listening to the parents' fears, concerns, and hopes. This all occurs in a matter of minutes, or even seconds, and yet I have "worn" many different hats. So what does that have to do with you??? Well I hope a lot!

If you enjoy your job, then that is awesome, and I hope you continue to do so for a long time to come. If you are at a point in your career/life where you are not so happy, then that is where my point comes in to play. Your environment does not define you or limit your options. Do not become quickly disillusioned that you are "stuck", or that you don't want to do it any longer. We all have those moments when we look at our jobs, at our daily routines, and feel "less-than-enthusiastic" about it. I believe it is in these difficult times we do our most important thinking and reflecting. What would make me happy? What would I be happy doing? Am I challenged enough...or maybe too much right now? The only person that can answer these questions is the one asking them.

We are very fortunate to be nurses. We are the most trusted profession in the nation...in the world! We are there for people at their worst, during critical times in their lives, using our skills, or training, or knowledge...but most importantly, we offer ourselves. There is no substitute for a warm touch or an open ear. Technology can never replace the tremendous impact one human being can have on another. It is because of the many hats we wear that we are so valuable, so important, so unique. We are adaptable creatures. We can take our skills just about anywhere and be fine. But what about our passion? What about the thing that motivates us to do our very best, to give our all everyday? Maybe some are better "technicians" than "counselors"...or vice versa. It is when we reflect back on our roughest days and say, "I still love my job" that we know we are where we are "suppose to be."

Maybe you have had some bad days at work. Maybe you are feeling like you are having more bad than good. Your body is telling you something; listen closely to what it is saying. We are capable of wearing many different hats...maybe you are not wearing the right ones. If your heart is not in it, it will show. How can we effectively connect with others if we first cannot connect with ourselves? And, very importantly, we must stop thinking in "linear" terms.

As nurses, we work in a very complex system, locally and globally. Connections and relationships do not behave in a predictable manner, as they often do in linear mindsets. The whole point of complex adaptive systems is that we cannot know the end result... we cannot k ow how one thing will affect the next. In more relative terms, we cannot see our career play out before our eyes. We never know what kind of opportunity the next challenge brings. We will experience those "turning points" in our careers that will have unforeseen impacts in your life. You never know where a day can take you.

So, if you find yourself unhappy, just switch hats, until you find the one that fits the best! And no matter what, please know that you do have an impact on a much larger scale than you may be aware. Hang in there, stay focused on the patient, and stay connected!

Thank you.

Steve

Nursing school is a floor, not a ceiling

"Everything I need to know I learned in Kindergarten"...or perhaps "nursing school", right?

Not quite.

One fundamental problems with some new graduate nurses is the fact that "they don't know what the don't know", and yet practice as if they have nothing else to learn. Being eager to step in there and get your hands dirty is an admirable quality. Experience is the best teacher, after all. But we must make sure we are careful not to overstep our professional boundaries when we pursue these great learning experiences.

For instance, a new nurse...on orientation perhaps...should probably not make independent adjustments to ventilators or other complex equipment. We gain some exposure to this sort of thing in nursing school, but it is not a "see one, do one, teach one" concept. Making adjustments to the ventilator does much more than change a few numbers here or there. It controls the patient's physiology...and anatomy. We must make sure that we know that some equipment surrounding a patient is actually an extension of that patient...and to manipulate the equipment is to manipulate the patient...and we must be ready to anticipate the effects of the changes we make. We have a duty to the patient, which extends far beyond the legalities of a patient assignment. We have an obligation to know what we are doing, why we are doing it, what the effects (good and bad) may be, know what we are monitoring (and why), and most important of all, know what we don't know.

Nursing school prepares you with basic education and training necessary to sit for the respective licensing exam. I prepares you with knowledge and experiences in a variety of settings, and with a variety of patient populations, so that you may begin practicing as a competent generalist nurse. Although some new graduates do enter specialty areas such as critical care or the emergency room, many start in a "med/surg" unit, where they will gain valuable experience in delegation, time management, communication, and organization....among others. Wearing a badge that identifies you as a "critical care nurses" or an "emergency room nurse" doesn't do anything more than just that. You do not gain immediate competence in the necessary areas of knowledge necessary to practice independently. It does not grant permission to "cut corners" and skip steps along the way. I am not picking on the CCU or ED by any means. I am using these highly specialized areas of nursing merely as examples of where new nurses may find themselves in situations they are not trained or experienced to handle alone... and must be readily aware of knowledge and training they do not possess just as much as that which they do. Of course, this applies to us all.

I say, seek out every educational opportunity you can. Learn as much as possible. Every tool you have in your belt will be necessary...only time will tell. You should never say, "I don't need that...I'll never use that..." How do you know? You don't. You never know when something you learned a while back...that seemed totally unrelated to your current job...could actually be of great benefit to you, but more especially to your patient. As nurses, we must accept the fact that our care is not as "siloed" as we might think. Patients carry everything with them at all times...their diabetes, respiratory disease, mental illness, social drama, etc... we don't get to pick and choose how we care for the patient...it's all or nothing. We could all gain from any education we can get. Do not limit yourself...and certainly do not wait for your employer to provide everything you need to know. They offer what they must so they can have documentation of training. That's it. Sure, they want to have safe patient care as well...but they are in a business, and they have limited funds. We must seek out the opportunities if they are not readily available to us where we are. Attend conferences, workshops, webinars, at-home study, etc. Read a journal! There's a wealth of information in there, you just have to start reading.

So, I say to everyone, young, old, novice, expert...keep on learning. If we truly want to provide patients with the safest care possible, we must take control of our own practices and be ever aware of what we don't know! Keep chipping away at it...you will be amazed at what you have to gain!

Thank you.

Steve

Guilty by omission?

If you haven't already picked up a theme among my blog entries, you soon will. I want us (every nurse possible) to work together. Now, when I say "work together" I am speaking in terms far beyond a shift or two...I mean really pull together as a profession and become a unified voice. There is no reason we cannot nor should not do this. Work in a rural area? A small clinic? A large university medical center? It doesn't matter. Neither our employer, our specific job description, nor or geographic location defines or limits our ability to interact with one another. Ever attend a national conference? If not, you should...at least once in your career...it is a wonderful opportunity.

Anyway, back to the topic of "omission". You can be guilty of not doing something just as easy as doing something. You can not give a medication or not perform an important procedure or intervention just as easily as you could actually do them. Being negligent due to omission can be a very important concept to consider in your practice. Do you pull up the blood administration policy every time you administer blood products? Sure, you may have administered it hundreds of times...but it only takes one incident to create a catastrophe. Don't get to comfortable in your routine...don't incorporate too many "workarounds", or shortcuts. There may be a time and place for them in some of your tasks, but when it comes to patient care and adhering to the 5 patient rights, there are no workarounds. You are busy...you have 10 things going on at once...you have 2 phone calls, 3 call lights, and a patient who wants to leave NOW. I get that. But the five minutes you save may be the most crucial five minutes of your shift...and you can't get those minutes back. Forget to raise a patient's head after restarting tube feeding because you are "busy"...the patient aspirates and quickly progresses into respiratory failure....then cardiac arrest...now you have a much larger problem on your hands. Maybe I am looking at this as "worst case scenario". Maybe. This is just an example, and this can happen to any one of us...and maybe something similar has. We have all been in similar situations...and if you haven't, more chances are you will at some point in your career. You can't get those minutes...those seconds...back. Just be careful.

Well, now that I have scared several of you from ever returning to work, let’s move on to another issue of "omission"....

Once again, lets "Google Earth" this topic out quite a bit, and gain a much broader view. In the recent issue of AACN Bold Voices (3(5), p. 22), AACN president Kristine Peterson speaks about our responsibility to seek out one another, use our available resources, and communicate with our policy makers (local and national), in order to ensure nursing's voice is heard at the table. Her article, "Will we let someone else answer?", is a great example of taking the initiative to pull our ranks together and do something. There is a wonderful quote by Goethe in this issue:

    

 Knowing is not enough; we must apply. Willing is not enough; we must do.

True. Very true. And this is what I mean by "guilty of omission": allowing policy to shape our practice instead of the other way around. We need to guide how policy is made. We need to be there when non-nurses and non-health-care-providers are at the table deciding what we can do, where we can do it, how we can do it, or even if we can do it. In the latest report from the Institute of Medicine, "The future of nursing: leading change, advancing health", released this past October, the IOM had four very direct recommendations:

• Nurses should practice to the full extent of their education, training, and licensure.
• Nurses should achieve higher levels of education and training. (Academic and other lifelong learning activities)
• Nurses should be full partners, with physicians and other healthcare professionals, in redesigning healthcare in the US.
• Effective healthcare workforce planning and policy making require better data collection and an improved information infrastructure, particularly as it relates to nursing's contribution to care.

These were restated from Peterson's article, and I would strongly encourage you to take a look at this report for yourself. (If you don't feel like reading hundreds of pages, you can read the Executive Summary, which provides a nice overview. The IOM speaks to the nation, saying, "let nurses do what they are trained to do...help them achieve higher standards of excellence in their training...hear their voices...let them be involved in health care decisions"...in my opinion, anyway. But the IOM is saying this to nurses as well. We need to be proactive in our approach to policy and procedure formation. We need to make sure we are present at the table when these decisions are made...we cannot afford to let someone else dictate our practice. We have an incredibly rich and diverse body of knowledge within our profession. We have nursing scientists that work very hard to encourage improvements and innovations. It would be a shame if we did nothing, and let it all go to waste. It would be a shame if we were guilty of omission.

Take pride in what you are. Take responsibility for your practice, and for those who follow in your footsteps. Leave it better than you found it. Nurses are not generally a quite bunch, so I think this should not be as difficult as it sounds. The only barriers we have are those we place on ourselves.

Thank you.

Steve

Message of appreciation

Easter is a time of remembrance and thankfulness. For Christians around the world, it is a time to remember the persecution and crucifixion of Jesus, and his majestic rise from the tomb. As we remember and give thanks to Him, let us also remember one another. Let the symbolism Easter brings allow you go reflect on your own lives and practices.

I often think back to the day I was sitting in, what was to be, my final nursing class. At the time, I had no financial aid available, and no additional resources of my own to support my last semester of nursing school. As I stared at the clock, counting down the minutes I had remaining in the inevitable end of my education, I remember closing my eyes, desperately wishing for a resolution. I was a nervous wreck. About that time, the financial aid advisor pulled me out of class to tell me the news I had been dreading all day. She proceeded to inform me that there had been an "anonymous" contribution to my account, and that I could continue my final semester as planned. I was absolutely speechless (which if you know me is quite a feat). I was overcome with emotion. To this day, I do not know who made the contribution to my account that day, and I have never asked. I have also never forgotten that act of giving and faith. Although there is no direct comparison between the story of Jesus' selfless act for all of mankind, and the story I described above, I cannot help but be reminded of that day in my life. It was a selfless act of giving and placing faith in another that has changed my life. I have been truly blessed, and I will never forget that.

Since then, I vowed to myself that I will use that chance, that generous gift, to make a difference in nursing. I don't care where I'm at, or what I'm doing, I want to use my practice to help as many people as I can. If that means giving up an aspect of nursing that I hold dear to my heart, then I will do it, because I know I am doing what I am suppose to do. Whether it is being part of an initiative that has a direct impact on a large number of people, or simply one person, what I do does matter. One life can impact millions, that's why every person is important and should be afforded the opportunity to succeed.

So, I say to whomever you are...known only to me as "anonymous"...I send you my sincere appreciation and gratitude for this gift you have given me. And I thank all nurses everywhere for their service to mankind. You are truly appreciated.

Happy Easter.

Steve

Career options

One of the things I enjoy about nursing is the vast amount of career opportunities that exist. If you love kids, there's a job for you...if you enjoy the adrenaline rush of trauma, there's a job for you...or if you would rather stay out patient care altogether, yes, there's even a job for you. The point is, no matter what motivates you and brings you satisfaction and fulfillment, there is a nursing job out there for you, you just have to look.

However, the career path you are on may eventually lead you to new opportunities and challenges that you had never expected. Perhaps what you had planned in nursing is not what nursing had planned for you. Now some of us will spend their entire career in one area, and I think that is wonderful. Others may explore several areas before settling into a career path. And, after all, if you don't see a job you like, create one you do!

"What do nurses do?" It has grown increasingly more and more difficult to offer a concise answer. Some care directly for patients, some serve as leaders, some review medical records, some conduct research, and some teach the next generation of nurses. They can do all of these things because nursing prepares them for these positions. Nursing is so diverse that you can pretty much do anything you want just about anywhere you want.

I have enjoyed my nursing career so far. I have worked in several different capacities, and have learned a lot about nursing, and myself. Nursing has as much to offer you as you have to offer it. Think about that. Are you a member of a nursing organization, such as your state nurses association? Have you ever considered becoming involved in something that has a direct impact on your current, and future, practice? Being active in organizations such as the ANA allow nurses to have their voices heard when policymakers threaten to limit your professional practice, and thus, your career options. Anyway, something to think about.

So, in a nutshell, nursing = opportunity. Don't worry if you don't know what you want to do or where you want to work. Don't worry about not being happy in one particular area. Nursing provides a vast sea of opportunity. All you have to do is set sail and see where the winds of chance lead you.

Thank you.

Steve

I am a nurse

I am a nurse.

More specifically, I am a registered nurse. I completed prerequisite coursework, applied to nursing school, worked my butt off, graduated, passed the NCLEX-RN exam, and can rightfully call myself a "nurse". I earned that privilege and right, along with all of the responsibility that goes along with it. Yes, I am a nurse and very proud of it. And one thing that really chaps my rear is to hear someone proclaim themselves to be a nurse, or allow themself to be perceived as such, and no right to be identified as such. That just sends the wrong message about what a nurse is, and moreover, who we allow "nurses" to be.

For example, it bothers me that some school districts have "nurses" render care for their students, when these "nurses" may only be CNAs...if that. That's pretty bad. But what is even worse, in my opinion, are these receptionists and nursing aides or medical office assistants that identify themselves as a nurse. That, to me, has far reaching ethical and legal implications not only for the individual, but potentially for the physician and his/her practice. Some may think this is no big deal, it happens all the time, and there's no harm caused by such practices. Really? Try referring to yourself as a "doctor", or lead others to believe you are...see how far that goes. Not the same comparison, you may say? I beg to differ. There would be real ramifications if you were providing medical advice or offering diagnoses or treatment only a licensed physician could provide. The same is true for nursing. It is a "licensed" profession, which means it is regulated and must abide by legislated rules and regulations set forth by a governing body.

It's a public health and safety concern first and foremost. Giving medical, or nursing advice, in person or over the phone should only be done be persons with the education, training, and license to do such. To have a receptionist triage phone calls or phone in prescriptions is absolutely intolerable, and physicians should not knowing allow it, and nurses should not knowingly, or passively, allow it either. It's not legal because it's not safe. Period.

Switching gears a little, and climbing down from my soap box a step or two, I'd like to share my thoughts on what a "nurse" is to me.

After you move past the legal mumbo jumbo about who has the legal right to call him/herself a nurse, you get down to the actual practice of nursing, and what it entails. Nursing practice is based on the diad of science and art...kind of like left brain and right brain concepts. It is important to have both aspects because there are infinite scientific, statistical, and methodological factors that contribute to nursing practice. Likewise, there is an abundant amount of emotion, self-exploration, and creative ability that is unique to the profession. It is the overall concept of quantifying and qualifying the practice of "caring" that is challenging. How do you capture "emotional and spiritual connectedness" on paper, or in a graph? How can you explain the intuitive sensation that overwhelms you when a patient is about to crash? Why do we have theorists whose life work surrounds such concepts as "expanding consciousness" or "unitary human beings"? Because nursing is more than the sum of it's parts: we are part of something that is greater that all of us, yet we are each an essential component. Nursing is as abstract as it is concrete.

I went to nursing school to learn how to start IVs, administer medications, perform assessments, and provide patient care. And that is what differentiates us from the rest of the the healthcare team. We are taught the importance of practicing the blend of science and art each day. I can care for a train wreck of a patient, code the patient when the body gives out, using all the science and evidence I have learned to try and save a life. And when my efforts ultimately succumb to the will of a much higher power, I will walk over to the patient's window and open it a little when they expire. Is it because the literature tells me that it is best practice? Is it because there is a scientific foundation behind it? No. It's because I know that underneath the tubes and wires that remain after our science has proven its limitations, there is a human being with a spirit that must be treated with dignity and respect. By opening the window, I feel I am somehow facilitating the spirit's peaceful transition.   That's what sets us apart from the others: care of body and spirit.

No matter where I go, what I do or how I do it, I will always be a nurse, and the patient will always be my focus. I worked hard for that privilege, and so did you. Take pride in what you do, stand up for what is right, and keep the patient at the helm of what drives your practice.

Thank you.

Steve

Time-lapse perspective of your nursing career

There are some amazing time-lapse photography images out there. Images of faces, landscapes, astronomical and meteorological phenomena captivate audiences around the globe, in all types of culture. We seldem stop to appreciate "life" as it passes us by. One trip on the ride is all you get.

As I look at these photo compilations, I am amazed at the patience and perserverance the photographer has with his/her art. Each picture is designed to complement the rest, in sequence. The overall effect is that of transition and transformation through paced progression. The artist captures the beauty and individual significance of each still moment, and combines these unique traits to form a pattern that yields an overall completeness. And this is what I think of as I see nursing.

Apply this to your individual nursing practice. Take a few "mental snapshots" of a few significant (and perhaps some more typical) events which occurred during your time as a nurse. Perhaps you started when you entered nursing school, or maybe when you were much younger, pretending as a child. In either instance the concept is the same. Continue this until present day. Now begin playing these events, one by one. Can you see the transition and transformation? See your career change... your life change... as you sequence through these images? Then take it a step further, and add your dreams and goals from this point forward. It takes on an entirely different feel. Now, imagine any one of these events not occurring, or maybe happening with a different outcome. Does the overall effect change? Maybe, maybe not. I think it depends on the event and the point in your progression it occurs.

Now "Google Earth" that image back a bit, expanding the view of nursing as a whole. Think about your career in nursing, the changes you have seen, and apply this individually to the profession as a whole. Our collective practices have a transitional effect on the whole of nursing. What we do matters. The problem is that we don't often stop to think of our contributions as being those "still pictures" in the overall "time-lapse" progression of our profession. We are part of something much larger than ourselves, or even our careers; yet our contributions remain significant to the overall success and vitality of the profession for generations to come. We know what we know because of those generations before us, learning from their "snapshots", and placing a relative interpretation pertinent to our current practice. What we need to do next, then, is to continue that momentum (applying a bit of complexity science fundamentals along the way), and imagine what we would see.

We should appreciate the moments we have now, embrace our individual "collections of snapshots", and know that we are part of something great. Every patient we touch, every life we welcome into the world, and every one we help transition out of it, they all have one thing in common: we were there to extend our caring hearts and skillful hands in assistance. What you do matters. Don't ever forget that.

What seems insignificant, or even life-altering, throughout our years adds up to a unique "time-lapse" presentation of nursing, and how these moments can combine to create a beauty that we all should hope to view someday...and perhaps someday we will.

Maybe some of our grand theorists saw this view of nursing, and each chose a different way of describing it? You never know.

Never lose sight of your hopes and dreams. Sometimes they are the clearest pictures we will ever see.

Thank you.

Steve

Maintenance?

This morning at work, I had the pleasure of running into a couple of nurses I worked with several years ago. We worked nights together for years. During this time, one of these nurses had mentioned something to me that really made me upset..." night shift was considered 'maintenance'". WHAT?! Now, before I go on, these were not the words of this particular nurse, but of someone else...someone paid to come into an organization and "turn things around"...someone who had a "model" to share. I don't know if this person was a nurse or not, and to be honest, I really hope he/she was not. After all, what nurse would actually say something like that, and think it is truthful? Seriously?!

I worked nights for the majority of my nursing career thus far. I enjoyed the shift, I enjoyed the people, I enjoyed the patients. Not everyone is made for "nights", but I was, as are many, many others who choose this shift. Working nights is not a "stepping stone", and is most certainly not ever to be referred to as "just not day-shift material". What exactly is that suppose to mean? I have heard that a time or two. Let me tell you what these nurses, and many other ancillary providers do at night...the same thing as they would during the day, but with less resources. On nights, you have to think through situations, as you do not have doctors, midlevels, and many other practitioners readily available. We usually worked as a team...a team...and used one another as first-line resources before making those calls at night...it's just what you do. Now, I have worked days as well, and I can say that some places may be better than others in regard to "teamwork". I can say this: in my opinion, the night shift workers tended to exhibit better "team" characteristics and better cohesion as a group. Not saying everyone was perfect, but we all never hesitated to lend a hand. I cannot say the same for day shift...as a whole. I don't want to create a divide here...I do not want to lead you to believe that one is "superior" to the other in any way. I am saying that I have respect for the work accomplished during each shift...along the continuum of care, and that each shift displayed differing team dynamics. That is all.

To hear someone refer to night shift as "maintenance" is pretty ridiculous, and could not be farther from the truth. Night shift does not just sit around, watching gauges, tweaking knobs, and waiting for the "real" workers to get there. The same skills, education, training, and patient-focused care goes on when the "lights are off". Sure, patients may be sleeping...but some are crashing, some are confused and trying very hard to get out of bed, some are having babies, and some are babies that have no concept of day or night. The point is, we should not discount our colleagues simply due to the hours worked. There are some damn fine nurses on each shift, and each one an extremely valuable part of the continuum of care, which we should be focused on.

We all have stories and anecdotes about each shift...and how "night shift did this" and "day shift did that". I have been guilty of this too, I admit it. But I have moved past that. We all have things to get over...so lets just do it. Get over ourselves...our egos...our pride, and put the focus back, once again, on the patient. We all make mistakes, that is a fact. We are humans, and by that very fact alone, are not infallable. Care that is safe, equitable, efficient, effective, timely, and patient-focused (as discussed by the Institutes of Medicine) is a priority for every nurse (or at least it should be).

Sunlight doesn't decide whether or not you are a competent nurse...you do.

Oh, and to the two nurses (who shall remain nameless, but you know who you are), it was nice to see you again, and "thanks for all you do!"  {;-)

Thank you.

Steve

Certification...what's in it for me?

One thing that I am very much in favor of is advanced certification. If you have taken the time, and energy, to pursue certification, it speaks volumes about you. It says that you have decided that time spent increasing your knowledge about a particular aspect of nursing is important to you, and that overall, delivering safe, effective, quality care is too. If you are a certified nurse, you understand the feeling of satisfaction, accomplishment, and the boost to your self esteem you received after passing your exam. It's a great feeling to know that you have put yourself out there, and succeeded in something far too few will ever try.

But is it for everyone? Probably not. And that's okay. "To each, his own." But what about you? What are your thoughts on advanced certification in your specialty?(If there is one, anyway.)

It was the hardest test I have ever taken; boards were nothing compared to my certifying exam. That is where the pride and honor come from. If it were easy, what significance would it have? Very little, if any. Becoming a certified nurse doesn't make you "smarter" or "better" than a non-certified nurse. It simply says that you have challenged yourself to. Level of expertise in your field, and that you are dedicated to delivering the best care you can, based on the advanced knowledge gained by achieving and maintaining your certification. Patients may never know who is and isn't certified, but wouldn't it be nice if they did? Maybe some would argue that patients may feel that ALL nurses should be certified. And that they may feel that care from a non-certified nurse may be, somehow, substandard. I think it's all how you approach the conversation.

To me, being certified was a personal choice, as much it was a professional one. What have you got to lose? You fell off your bike a few times, but you still kept on trying, didn't you? Or maybe you just said "forget it!" and walked away. Think about what you would have missed. The main issues I find with pursuing certification are the time and financial costs involved. But please know there is help out there! Surely you didn't learn to ride a bike, or to swim without help? Seek and ye shall find.

What about compensation? "Will I get paid more for being certified?" That depends on your facility. But when you receive raises, do you begin practing better only when you receive financial gain? I doubt that. Money does not (or at least it should not) dictate your standard of practice. Sure, it's nice to receive a little extra for your hard work and dedication, but then again, "why are you a nurse?"

Remember, nursing has been deemed over and over again as the most "trusted" profession. Think about that. That's huge! Trust doesn't come lightly, in fact, it bears quite a responsibility. We are not the "good enough" profession, or the "status quo" profession. No, we are far more than that, and we owe it to our patients and ourselves to be equipped with the best information we can, and hold ourselves to a higher standard than what is required. Do some research, talk to your certified colleagues...and if no one is certified, be the first one!

A few links to get you started:
ABNS position statement for certification
ANCC website
Wikipedia list of certifications*
* I typically steer away from wikipedia, as it is not the best source of information, but it does at least point the way for further review. Also, please note that among the many certifications available, there are several such as "TNCC" which are not "specialty certifications", more like "practice certificates", and although valuable, are not concidered "valid" specialty nursing certifications.

Thank you.

Steve

Turning points

There are certain points in your life, and your career, that have a significant impact on you personally and/or professionally. Remember the first time you had a patient die? Or how about a time when you made an impact on a patient, and helped them overcome a struggle they had? Remember when you held your child for the first time? Tell me that didn't change your life forever! Each of us has these moments in our life. They are who we are and why we are where we are today.

We have to accept what happens to us, because we can't really control it. About the only thing we can control is how we respond...how we interact. You can't make your patient's colostomy bag smell any better...but you can refrain from making that "sweet-mother-of-pearl-what-died" face, and act like you notice nothing. We can work alongside someone who just likes to swing on our very last nerve, and choose to ignore their efforts to elicit a response. You see, WE are in control of us...even if we feel like we aren't. I'm not saying pretend the colostomy smells like fresh baked cinnamon rolls, or that the person next to you is your BFF. These things are what they are. Just let them be, and carry on about your day. You have things to do, and these are but small pieces of gravel in a long unpaved road that is your day...and your life.

I remember the first time I had a patient pass on in the NICU. It was devastating. I did my best to hold back my tears. The baby's father- who was a very large "prize-fighter-looking" guy was an emotional wreck, reduced to the very essence of sadness and grief. He was crying for the both of us. I'm not saying what I did was the "right thing" to do...I know many others would have been a mess. But I chose to remain as calm as I could, and offer him and his wife all of the support I could...allowing them this private moment to hold their baby, without having to share this with me. That was my choice. That was a turning point.

Having kids makes as different...it just does. There is no other love on this Earth that compares to the love you have for your child. To see a parent grieve over the loss of their own child is heart wrenching, and I cannot even begin to imagine the pain that they feel. I know, for them, that will be a turning point. The patient who comes very close to death, experiencing powerlessness and loss of hope, can persevere and live to appreciate life a little more afterward. That is a turning point for them.

What about professionally? What have been your turning points? My time spent in the NICU was definitely one of mine. That is a whole different world all in its own. My thoughts about caring, sharing, learning, and leading have been shaped by certain events and people through the years. I have never forgotten one man who taught me that having a positive outlook is my choice, and moreover, why wouldn't I have one? He used the comparison of driving a Pinto or a Ferrari. He asked me, "if you could choose either car, which one would you drive?" Of course, I said Pinto! (just kidding, I went for the Ferrari...) He said, "OK, so when someone asks 'how are you today?', what do you say...'okay' or do you say 'GREAT!'" I have never forgotten that. Those who know me will understand this story, because every time someone asks me how I am doing, my response is either "great!" or the ever popular "fantastic!" Why would you have a negative attitude, when you could just-as-easily have a positive one? It isn't anyone else's fault (or problem) that you may be having a bad day...you don't need to spread that kind of energy around.

I do firmly believe that everything happens for a reason...even if it seems pointless at the moment. Change is inevitable, and we must embrace it, because there is no use in resisting...it will consume all of your energy, only it will happen much faster! You don't have to like it, but you must accept it for what it is...change. It goes both ways, good and bad. I can say that I have failed at a lot of things in my life, and I have learned a lot too. I appreciate who I am and what I do now more than ever. And I appreciate all of the people I work with too. It's not easy being a nurse, and perhaps that's why I love it, and respect it. Trying to influence change in nursing is like attempting to steer the Titanic with a spoon. It may seem impossible, but you will never know until you try. And when you get knocked down, sit there for a minute...think about what happened...get back up on your two feet...put on a big smile and say, "thank you, may I have another!?!"

You don't get to control what life brings you. You don't get to control how people treat you.

When your life is at a turning point, you will definitely know it. You will find yourself re-evaluating your inner self, your career, your hopes and dreams...everything. And when you are at that crossroads, look carefully at your choices...choose the unpaved road...full of bumps and uneven surfaces. That is where you will find adventure and experience true discovery (hopefully of your self). And remember...

Have a GREAT day!

Thank you.

Steve