On becoming a nurse

Stuff I've read lately

2011-02-12T12:19:00.000-08:00

That was worth reading.

Yet another valuable Atul-Gawande-penned _New Yorker_ article contributing to the body of knowledge on healthcare dollars & how and where they're spent:

http://www.newyorker.com/reporting/2011/01/24/110124fa_fact_gawande

Thoughts on obstacles to evidence-based practice in medicine:

http://bengoldacre.posterous.com/why-is-medicine-often-not-evidence-based

And I finally read Abraham Verghese's _Cutting for Stone_. Lovely, mostly believable paean to medicine and surgery despite a maddeningly 2-dimensional female foil whose only existence is to let the protagonist's destiny unfold as needed in the book.

Soapbox: Permanent Novice

2011-01-27T14:03:00.001-08:00

In my psysch nursing class the other day, our instructor got on her soapbox for a moment about nursing. She said nurses are in the privileged position of always being a novice, for each patient, every time. Patients know if you are pretending to listen to them, so we have to learn how to really listen, so that we can learn from the patient. The patient is the expert on herself, and the nurse is there to listen and learn. I like this.

Nursing Defined (self-plagiarism)

2011-01-20T09:59:00.000-08:00

About a week ago, I sat down & whipped out a short essay for a 1-credit class, in response to two articles we had to read regarding nursing. I didn't do a fabulous job, but because of the self-referential nature of the assignment, it seems worth re-posting here.
****

Nursing Defined

Defining is a process that involves deciding upon criteria for inclusion and exclusion. Providing a definition of nursing, or listing the criteria that one must meet to be called a nurse, reminds me somewhat of the activity of declaring who is a Christian. Any licensed practical nurse (LPN) or non-bachelor-prepared registered nurse (RN) would be insulted—and rightly so—were I to tell them that Luther Christman (1998) thinks that what they spend their time doing cannot, or should not, properly be called nursing, since they were not prepared by a four-year university education. While most of the Southern Baptists in the Alabama town where I was raised would swear up and down that Mormons are not Christians, Mormons I know say that they are. The members of a group make up the group’s inclusion and exclusion criteria, and outsiders, those who do not think of themselves as belonging, usually could not care less about such internecine controversy.

I agree with Christman that nurses’ image in the public eye could be better (1998), and a combination of the public’s experience with point-of-care delivery and what they see on television is likely the source of this image. Nonetheless, the “solution” he offers to this problem is impractical and naïve, not merely because there are so many entrenched interests opposed to it. Demanding that all nurses spend even more time and money on their educations will simply mean that Christman’s “real nurses” will be more expensive to hire, so current trends will continue: Certified Nursing Assistants and LPNs will be trained to stretch the bounds of their scope of practice in ever-more creative ways so that they can take over most of the tasks that RNs do, and healthcare facilities won’t have to budget so much for personnel [1]. And their patients still won’t keep straight who can properly be called a nurse, because they won’t care. Patients will only know or notice who is caring for them at bedside, and whether this person does so in a way that makes them happy. As for Christman’s complaint that more educated nurses eventually move out of the realm of patient care (1998), this could be solved in a number of ways that do not involve his never-to-be-realized pipe dream of a 100% BSN-prepared nursing staff, including “lateral” promotion whereby someone gets meaningful salary increases without being asked to leave bedside nursing. Likewise, his important critique of nursing instructors often being many years out of practice of bedside nursing could be accomplished by having educating institutions require that faculty spend a minimum number of hours per month working in bedside nursing, which presumably many of them require already.

Rozella Schlodtfeldt’s (1986) description of nursing seems nearly orthogonal to Christman’s. She barely touches upon nurses’ education or preparation. Rather, she addresses nursing practice and scholarly inquiry. She fears that the American Nursing Association’s definition of nursing in its 1985 Social Policy Statement, and nursing diagnoses themselves, will induce nurses to focus on human sickness and abnormality, rather than human health and health-seeking behaviors. This seems unreasonable to me, given that the _Nursing Diagnosis Handbook_ contains plenty of diagnoses that relate to wellness and health-seeking behaviors, and “deficient knowledge” diagnoses that require assessing what the client already knows and treating them as a health-seeking agent. Her definition of nursing as “the appraisal and the enhancement of the health status, health assets, and health potentials of human beings” (Schlodtfeldt, 1987, p. 67) certainly approaches sickness and health from the direction of health, but I do not think it would cause a change in the diagnoses present in the Handbook, unless someone took the time to tortuously reword them to provide for this slight change in emphasis at the cost of clarity.

When I studied comparative religion, I approached religion from an anthropological perspective. I was much less interested in what a particular religion’s canon declared that the religious practitioner was, or should be or do, or could not be or do. Rather, I was interested in the actions of those who called themselves believers and practitioners. Likewise, while I find studies of what practices and medications prove effective in healthcare settings interesting, I am far more interested in when, how, and why these evidence-based procedures are and are not implemented. I think the entire field of healthcare would benefit from relatively more research on factors that affect the (non)implementation of interventions proven to be effective, rather than looking for new interventions.

A nurse, to me, is someone who has undergone a specific amount of training to become a nurse, and who calls herself a nurse, as do her coworkers and clients. She engages in tasks that touch upon human dignity and are often quite high stakes, require an enormous amount of organizational ability, can employ analysis but don’t necessarily, and likely has to work hard. This is different from an ideal nurse. An ideal nurse is an effortless multi-tasker and communicator, endlessly compassionate, intellectually curious, intolerant of inefficiency in the healthcare system while tolerant of the humans who create the inefficiencies, prompt to adopt evidence-based changes in practice, a tireless worker, and kind and sociable without imposing her own emotions on any situation. Much like Jesus, the ideal nurse is a model we can carry in our heads and hearts as we carry out the tasks we have to do, and to which we can compare ourselves, hopefully with compassion, as we fail to do exactly what the Ideal Nurse would have done in the same situation. Certainly I hope that a drive for self-improvement, and for improving the system in which humans experience sickness and health, is a part of every nurse, but even this cannot be declared the sine qua non that makes a nurse a nurse.

[1]
As a teaching “assistant” at University XXX, I taught 300-level Spanish courses on my own. I was far cheaper to UX than faculty or even assistant professors would have been. I was a competent and well-prepared instructor, but I could not have been, and UX still would have been saving money. As a further example of outsiders’ indifference to rank and role inside groups they don’t belong to, students often called me professor and were confused when I corrected them.

References

Ackley, B., & Ladwig, C. (2011). Nursing diagnosis handbook: A guide to planning care ( 9th ed.). St. Louis: Mosby.

Christman, L. (1998). Who is a nurse? Image: Journal of Nursing Scholarship, 30 (3), 211-14.

Schlotfeldt, R. (1987). Defining nursing: A historic controversy. Nursing Research, 36(1), 64-
67.

3rd quarter and all is well

2011-01-20T09:34:00.000-08:00

My program has some bizarre & distressing organizational issues, but I'm still inspired by all my various clinical instructors/preceptors and my class instructors, by how they practice, teach, and manage and think about their own lives. I'd say 90% of the (very large amounts of) time I spend doing school-related clinic, work, class/clinic preparation, follow-up, writing, reading, etc. is enjoyable and thought-provoking in the best ways.

Nursing school has been good at really teaching me to prioritize, by example and by necessity. Necessity: I just have less time, so I'm making sure I spend not-school-related time doing exactly what I want or need to be doing, which turns out to mostly be hanging with my family. Example: nursing is all about teaching patients/clients in various compromised states of health to prioritize so they can "conserve energy" and use their time in the ways most important to them. As a classmate of mine said to me the other day, someone with COPD (chronic obstructive pulmonary disorder) has to choose between having sex with their spouse and going to the grocery store that day, and needs help adjusting to the idea of planning accordingly. And that's ok. One cannot do it all, one shouldn't try to do it all, and it's a waste of precious energy to even spend time worrying about the "all" one isn't doing. I also find that I'm enjoying the time I spend with my daughter more and more--in part, this is because she is 3, and everyone says 3 is "such a great age, watch out for later." But it's also because of how precious this time with her feels to me.

All the things I'm learning, and strategically "thinking like a nurse" in terms of assessment, prioritization of my time and client'/patients', and provision of care, have been the final nail in the coffin, for me, of the Cartesian mind/body distinction. The distinction had started to erode years ago through a combination of lots of yoga and being humbled by how birth control hormones affected what I thought of as my stable self and personality. But pharmacology, therapeutic-nursey thinking, my own experiences with therapy and couples workshops, and some profound meditative experiences in yoga, have finally taught me it's a useless distinction to make.

One other cool revelation I've had recently: in the midst of all our class, lab practicums, and clinic work, we have 3 seminars this quarter for which we don't have to do any prep work. We just get to go, listen, think, absorb, and ask questions. Our first one was a 2.5 hour presentation on pain and pain management. Fascinating stuff. And a big part of it is realizing where our own biases as healthcare providers are, and being suspicious of them, because someone's 10/10 pain might be provoked because of having a sheet dragged over their toes because they have a nerve problem, and it is NOT my job to think or act as if they aren't experiencing that much pain, or they're a wimp, or that "can't happen," etc. One person's 10/10 pain might look and sound, in terms of their expression of it, like another person's 4/10 pain. Some cultures disapprove of outward acknowledgment of pain.

Pain is now widely being called & considered the 5th vital sign (temperature, blood pressure, pulse/heart rate, and respiration rate are the main 4), and it's not a sign, because I cannot objectively assess it. It is the patient's subjective experience, but HCPs need to pay as much attention to it as a sign, because of all the ways it affects the patient and their future healing/functioning/mental and emotional health, etc. Anyway, it wasn't much of a stretch for me to say to myself, "yes, someone's pain is their own, and I CANNOT tell them they don't actually feel that bad, or shouldn't, because it's not my body and it's not what I'm feeling." This is a full admission on my part of others' right to their subjective experience. So the neat part is that I finally have the analog I needed to think about other people's subjective experiences of the world in general, and their emotional reactions to it. It doesn't even make sense for me to think, or tell someone, that they should or shouldn't be angry, sad, happy, resentful, etc. I don't know what it feels like to be them, and cannot. Neat! I have applied logic to my own attempts to apply logic where it doesn't belong.

physical exams

2010-10-27T09:15:00.001-07:00

they're hard. and useful. and infinitely complicated. the NYT summarized it better than I in the story they tell of Dr. Abraham Verghese:

http://www.nytimes.com/2010/10/12/health/12profile.html

The nurse's role

2010-06-28T21:19:00.001-07:00

One of the most interesting things about my program is learning that nurses understand themselves and their role, and position themselves professionally in a way very different than, I think, most non-nurses, or at least non-medical professionals, understand. There's a whole lot more to it than "patient care." Or maybe I mean that "patient care" is a phrase that should be understood very broadly. I'd had no idea. I'd had vague notions that nursing was more about process and prevention, and possibly education, than medicine. But there's a lot more to it.

The absolute hierarchy we'd had given to us as NACs involved us being at the bottom of the totem pole (of course), and the stipulation that under no circumstances were we to ever take direction from a physician. We are nursing assistants, after all. But there is more to it than that. Especially in a hospital, nurses just don't work for doctors. Nurses work for the hospital, and doctors are independently contracted, which is why hospital visits that include doctors always involve at least two sets of bills: facility and equipment and possibly procedures (depending on who did them), and the doctor's charges. Nurses don't really take orders from doctors. They are _not_ assistants to doctors. They work with physicians in different settings and are often below them in a hierarchy in particular situations, but this is not on-going. They also carry out physician-prescribed patient care, but there's often a lot of leeway in how and when it happens.

One of the most important ways in which nurses and physicians interact, and which I didn't really get at all before school, is around medications. Nurses are the patient's last line of defense against medication errors. One of our instructors, Evelyn, told us never to "administer a drug if you don't understand the reason for its use." Nurses are responsible for knowing what any medication they are administering to a patient does and how, knowing why it's being administered to _this_ patient, who it shouldn't be given to and for what reasons, knowing whether and how it might interact with the other drugs the patient is taking, knowing correct dosages, dosage schedules, and all the various methods of administering drugs, and knowing what side effects are possible and monitoring for them and dealing with them when/if they appear. Evelyn has said, "if you don't defend your license, no one else will."

One of our [many] textbooks says that "nurses play a major role in promoting and maintainng client health by encouraging clients who need medications to be proactive consumers" (_Fundamentals of Nursing_, Craven & Hirnle, p. 495). We teach patients about how the meds they are taking might affect their lives, tell them what side effects to watch for, In fact, a lot of what nurses [should] do is patient education (which often includes educating their families) and advocacy (which often involves educating clients and helping them make decisions around the benefits and risks of different treatment options). We also engage in assessment and management.

So this brings me to a weird thing I have encountered, and did not expect to find, in nursing: the Nursing Diagnosis. Notes I've taken from my various textbooks lead me to explain a nursing diagnosis thus: a clinical judgment about individual, family or community responses to actual or potential health problems or life processes, which provides a basis for selection of nursing interventions to achieve outcomes for which nurse is accountable. Ideally the cause of the ND is something that can be treated by a nurse. This is weird, subtle animal, and clearly I'm not yet "thinking like a nurse"*, because I don't come up with the same diagnoses when given the same set of objective and subjective assessment data as others do.

*(This is a phrase often bandied about, occasionally, and frustratingly, in lieu of an actual explanation as to why a given test answer is not as good as the "right" answer.)

Among the unexpected aspects of nursing diagnoses is that they cannot share language with medical diagnoses, even though they are occasionally discussing exactly the same issue. For example, a nurse cannot diagnose a patient with dehydration, but can diagnose that patient with "fluid volume deficit." This is odd to me. There are lots of diagnoses that are "at risk" diagnoses: "at risk for falls" is a big one. I'm wondering how, when, and where nurses in hospitals, say, have time to come up with diagnoses and apply them--are they paid for that? is it part of their job description? The professionalization of nursing requires standardization, so there is a governing body, NANDA (formerly the North American Nursing Diagnosis Association), which "defines the knowledge of nursing" by publishing journals and references with standardized diagnoses, their typical signs, symptoms, and concomitant care plans and outcomes. I have a NANDA guide, and currently find the language somewhat mystifying, and occasionally impenetrable. There is definitely a nursespeak, and I'm frequently reminded of how far from fluent I am.

Finally, another cool thing about nurses is that, at least with all the instructors I've encountered so far, there's a lot of respect afforded, and credit given to, people just starting nursing school. Our instructors, while individually teaching a group of us, will say "we" in reference to nurses. We are encouraged to identify with being nurses already, even though we're far from done with our training. This is motivating, and actually has some parallels to letting beginning language-learners attempt to communicate with more adept speakers and each other: mistakes are okay, it's assumed you'll get there eventually, and you can only get there if you're working hard and trying stuff way outside your skill level. But you're not motivated to put in the time if the "experts" don't welcome you to join them and learn from them.

Throughout my time in academia, I never felt included by my instructors. It was always made clear to me that I was below them on some hierarchy that mattered to them, and that obviously they thought should matter to me, as well. I like this a whole lot better.

Nursing school is fun

2010-06-23T17:39:00.001-07:00

It's been a week and a day, and I'm really enjoying myself. Just sayin'. This despite the fact that I have to get up early (I know, woe is me) and be at class early.

I'm taking 3 courses this quarter: pharmacology, pathophysiology, and "fundamentals of nursing." The first two are straight-up lecture-and-exam format (with lectures on one topic or the other for about 5.5 of our 8 hours in class on Mondays and Fridays), the third occurs in lecture, lab, and after the end of week two (this week), clinic. I'll devote a separate post to the awesomeness of my pharmacology textbook. There are information, concepts, and skills we're trying to learn and absorb coming at us from many directions, so there's a lot of straight-up homework as well as studying.

I've been mildly surprised and totally pleased that my textbooks from my prerequisite courses (Anatomy and Physiology and Microbiology), as well as my books from taking my nursing assistant certification (NAC) courses, have been helpful; I've referred to them lots while completing assignments and going over stuff that doesn't make sense from class notes. All of this stuff actually connects! :)

Last week we had our first 3 lab sessions, 4 hours each, 3-4 "classes" per session. We worked on blood pressure, temperature, bed baths, bed-making (for unoccupied and occupied beds), oral care ... really, mostly on things that NACs, not nurses, do in normal settings. I found my NAC training super useful for this, and realized the nurses instructing us haven't had to perform several of these skills in a long time, and as a result, hadn't thought through the chain of transmission (of pathogens)--at what point in these processes do you have to wash your hands and doff and don gloves again? It was, however, a much less scarily exact set of procedures than it was for my NAC training (aspiring NACs can fail their exam if they do crucial or trivial things in the wrong order), and I guess this is because nurses are allowed to think, and NACs aren't supposed to. Nonetheless, reading through the same procedures in my NAC books after re-learning this stuff was great, because I had a better idea of the do-what-when rationale underlying them. Better still, an actual order that someone thought through at some point, thoroughly enough to be worth including in a book for NACs, includes necessary materials and lots of picky details...since NACs should memorize, not think. :/ This isn't quite fair of me to say, however; at least one of my instructors said multiple times that in such-and-such a situation, she would ask her "nurses' aides," because they have a better idea about whatever it is.

We currently have many nursing instructors for lab because we're divided into our 6 clinical site groups (about 8 people per group), and for each lab, an instructor will teach one set of skills repeatedly, so we rotate through. I've noticed some funny linguistic usages and habits that most of our nursing instructors have. I'm no better at not asking questions in lab or lecture than I've ever been at any point in my life. In response, a few of the instructors will give a hand-wavey answer whether or not they have a real one, and follow that up with, "Does that make sense?" It's like they all learned that they're supposed to verbally check comprehension, but the question comes across more as a termination of inquiry than a genuine solicitation of admissions of confusion. They say "Does that make sense?" I hear, "It should make sense. If it doesn't add up to you, that's your problem, not a conflict in the various sources of information you've been given."

This is especially odd given that we're supposed to be developing "critical thinking skills." This is another buzzword we've heard several times. Rather than, "think about it," or explaining that critical thinking actually means analyzing new information in light of what you've previously understood, attempting to reconcile the two, and questioning discrepancies, we're told, "use your critical thinking skills." But in actuality, if our "critical thinking skills" lead us to ask questions at an inconvenient time, the response isn't ideal. (I am grateful that this seems to be more of a lab than a lecture issue.)

For example, one of the instructors was leading a practice on temperature taken at several different locations with several different instruments (did you know that a temporal temperature takes an average of temperatures across your forehead!?) and height and weight, and the metric to standard conversions that go along with those. I had to weigh my partner, so before I did so, I attempted to zero the scale. The weight that I would think should slide back and forth so the scale _would_ zero just didn't move. I looked all around the scale, was still at a loss, and finally asked the instructor. She tried to do the same thing I had, and when she got the same non-results, she said, "Weight is something you want to know as a baseline, so you can compare gains and losses over time, or know if there's sudden gain, which would be indicative of edema. In infants, small differences in weight matter, especially if you're administering meds, but in adults, a pound or two doesn't matter. Use your critical thinking skills! [Repeats all of the foregoing in a different order, then half of it again.] Does that make sense?"

While all of this did make sense, she had effectively denied that it was problematic that this scale seemingly could not be zeroed. She tried it, gave up, moved on, then gave me a spiel that indicated I shouldn't have tried to zero it (I guess). I'm hoping I'll get better at predicting which questions will stump/irritate the instructors, who will be our clinical supervisors, and just avoid those. Maybe at clinic there will be other people I can ask things of without causing frustration?

During our third lab session, after learning about "SBAR" (Situation-Background-Assessment-Recommendation), a communication protocol in medicine aimed at preventing medication errors through general improvement of communication, we did a simulation on one of these:

https://my.smccme.edu/ics/Institute_for_MFTE/Simulation_Lab/Meet_the_mannequins.jnz

(that's a random google hit)

Our Vital Sims mannequin is named Stu-the-Dude, and his compatriot Alex is currently across the country getting repaired, so we have a stand-in (lie-in?) named Miguel. In our lab, there's a "hospital room" with two beds, one for Stu, one for Miguel. They are hooked up to computers so that a person behind the 1-way glass wall of the lab can control their blood pressure, pulse and respiration rates, thus allowing students to be tested on taking the correct measurements of all these vital signs. The person at the controls can even talk into a microphone the speaker of which is in the Sims's mouth. After our introduction to Stu and Miguel, we were given 10 minutes or so to practice taking vitals on them, then our instructor Joanne (primary instructor of Fundamentals of Nursing, and head of the entire summer program, which is an absurd amount of coordination to do, bless her) told us we were going to do a simulation.

"As y'all are walking to clinic in the morning you see Stu riding his skateboard down the hill, lose control, and run into a stop sign. He's bleeding profusely from his femoral artery. You 4, leave the room. You 4 are on the scene. What do you do?"

Ack!

Four of us went into the lab to stand behind Julianne, our other F.O.N. instructor, as she tried to talk into the microphone like a skateboarder between moans in her unusually high-pitched, girly voice, while changing Stu's vitals. We watched through the one-way glass. The first team was given about 10 minutes, instructed to decide whether to tell 911 they needed an ambulance (A-car, I think it's called?) or paramedics. Then it was our turn, and we were supposedly there while the paramedics arrived, and had to make the transition, giving them necessary information.

Turns out Joanne was mostly interested in our ability to work as a team and get a job done, and we briefly discussed how that works. She said normally decisions happen because (1) there's an established hierarchy or (2) someone was first on the scene or (3) the person with the most confidence starts delegating. This was a little weird, though, since we're all new to each other and the program, and no one, I think, wants to be, or be perceived as, bossy or center-of-attention-ish, because one might run the risk of being disliked. Not useful in a program where one's cohort is so essential to one's survival.

After that brief discussion, Joanne had us do it again, reversing roles, and deciding ahead of time who would be in charge. Both groups performed better--of course, we knew what the situation would be ahead of time and had practice, as well.

This whole exercise was stressful and really, really fun. It reminded me of competing theories of language learning. Some instructors only want to give you problems that you have every tool to solve. Others want you to put things together, and attempt to reach beyond your level, and learn that way. I was in the latter camp, and I am excited that my instructors, and this program's philosophy, seem to (mostly) be in that camp, too.

Nutrition and Willpower

2010-05-12T11:55:00.000-07:00

Have been taking a nutrition course this quarter, with the instructor I had from my first quarter of Anatomy & Physiology. He's excellent. The class isn't actually a prerequisite for my program, but I thought it necessary before beginning my RN/MSN program in Community and Public Health nursing, since there's not nutrition course per se as part of my program.

The course is great, and everything I've been seeing in the news lately has made me think this was a wise decision, especially this article from the May Atlantic, which I've posted in several places:

http://www.theatlantic.com/magazine/archive/2010/04/beating-obesity/8017/

Most important in this article, I think, is the way it reframes obesity from being an issue of lack of willpower, to being one of a cultural ill, yet another result of capitalism's excesses.

Important to note, from another useful article on the topic

http://www.huffingtonpost.com/lisa-bennett/should-anti-obesity-campa_b_569921.html

[...]we also recognize that the influence of the media, advertising in particular, is daunting--and cannot be ignored. In 2004, the Kaiser Foundation reported that the majority of research shows that children who spend the most time with media are most likely to be overweight. Contrary to popular opinion, this is not because they are not getting out and exercising. The more likely factor, the study concluded, was the influence of billions of dollars spent on advertising and marketing of unhealthy foods.

Ugh.

I was speaking recently with a friend of mine who's battling an alcohol problem, and we were discussing one of the [many] pernicious cycles in substance abuse: each time a person trying to cease a bad habit 'fails,' he or she feels bad about him or herself for what was clearly caused by a lack of willpower, and therefore commonly viewed as a character failing. This self-loathing leads to more abuse as an escape.

The other problem is that we misconstrue how powerful willpower actually can be. Some people have the idea that they should be able to work themselves into a state in which they are devoid of desire, and in which being surrounded by temptations of whatever sort would simply not affect them. This is silly. Willpower is, on some level, finite, and except for in the case of the most unnaturally austere people, if one is surrounded continually by temptation, physiology and biology will win out. I know that in certain contexts, when I am around cigarettes, I still want to smoke. So I avoid being around them, and it's not a problem. This is a self-hack, and it's necessary to keep me from smoking. Many, many former smokers I've spoken with have said that the most helpful factor in their attempt to quit smoking was the indoor smoking bans that have passed in various states of the U.S. only relatively recently.

In a way, this conceit of equating infinite willpower with good character supports the crappy-food industry. Of course three Oreos are not a problem if I'm a good person, so I can buy them, have them in my home, and if I eat the whole package, that's not the advertiser's and manufacturer's fault, that's my own moral failing.

In the Atlantic article I linked to above, Marc Ambinder states this in a different way:

The only way to cure obesity is to radically rewire the relationship between the stomach and the brain. Diet and exercise can’t do that as quickly or as well.

That is, deciding not to eat a sugary, fatty food is doing something my body and brain did not evolve to have me do; it is the imposition of culture on top of somewhat of a physiological imperative. So my hack is to not watch TV, not see these ads, not bring this crap into my house, because I know that if it is there, I will consume it.

I think having this different perspective on weight problems is good for me, because if I am doing community health nursing with marginalized or underprivileged populations, I will encounter many many obese people, and I need to get over the idea that their obesity represents a moral failing. Taken to its logical extreme, that is a racist idea. Since I would see more black and Hispanic people with these weight problems, I would have to conclude these are peoples more prone to moral failings. Awesome.

Opportunity costs

2010-03-12T14:13:00.001-08:00

Home sick today. I feel nauseated, have felt this way all day. Tried to nap, but there was nothing to distract me from how my stomach felt. Mental activity has proved most helpful, as it helps me escape my body, which is not a very pleasant place to be right now. There are people who live with pain on a permanent basis; they must crave distraction more than anything. Nausea doesn't seem to be a longterm problem in general; a quick Google search yielded little other than random personal blog hits of people undergoing cancer treatments. I've read about burn patients playing virtual-reality video games set on ice planets while undergoing their extremely painful therapies, and that they report experiencing less pain.

It's been an illness-filled week. Lots of our friends' children have fallen ill, our daughter did, too, and I stayed home with her all day a few days ago. Today I have whatever-it-is.

I made the decision a while ago to cut my working hours back from 5 days a week to only 4. I had found myself resenting the last hour or so I spent at work every day, thinking of the things I wanted to accomplish outside of work that I wasn't able to do. A friend pointed out that the fact that my hours have a dollar amount attached to them now (a meagre $11) means that I am able to concretely weigh how much different opportunities are worth to me. Would I rather forego the $11 and spend that time going to the grocery store, running other errands, doing schoolwork and housework? Often, the answer was yes.

It doesn't help that my position at work is weird. I'm working at a position for which I am only required to be a highschool graduate certified in CPR. Everyone I work with outranks me, and so can tell me where I should be and what I should be doing at any given time. Right before I started work there, I got my food handler's permit, which, coupled with the fact that I'm currently taking microbiology, meant that I have been hyper-aware of contamination, cleanliness, etc., and especially concerned with the kitchen. The program I work with is headquartered in public housing, so rodents are, and should be, a concern. There was a long time that whenever I went to work in the kitchen--to do all the dishes, at the beginning of our move back, before we had someone come to do dishes; to get it organized, get things labeled, get systems in place; one of my many bosses would shoo me back to spend time with the clients. I'm happy to work with the clients when I can tell my presence is needed and not redundant, but that wasn't always the case. At some point, I snapped at my coworker, Joey, when he came to shoo me out of the kitchen, then finally talked to my principle supervisor, Jody, about it.

I brought up the fact that I am paid so very little. I know it's a nonprofit, I know what's in my job description, and... I have been trained to do most of the things that my two coworker/bosses do, and I also take initiative, improve systems, and use my time efficiently. I told her it also distressed me that the one work-study student there, Jeremy, does none of those things. He congenially does whatever is explicitly asked of him, but he doesn't look for work to do, and isn't really qualified to substitute Jody and Joey in leading group activities. This distresses me because I know he is paid $1/hour less than I. This is government-subsidized, of course, so Geriabulous isn't shelling out nearly as much for him as they are for me. The money isn't why I'm there, obviously, although it's nice to have any sort of income after 6 months of none. The difference bothers me because it feels like I am not valued. So Jody wisely listened to me rant and seems to have mostly changed the things she could: I'm still paid my crap wages, but when I asked my uber-supervisor if I could work one day fewer per week, Jody chimed in her support and suggested a day that would work for all of us. She & Joey have also gotten off my back about going in the kitchen whenever I find spare moments.

And it's actually better for me to not be working the 5 days, because that would've averaged out to over 22 hours/week, which would make me fulltime and eligible for benefits. I am much better off with my husband's and the extra fees we have to pay for me to be covered by them. This is a Bummer: my joblet in healthcare, which for many people in the organization is their primary soure of income, comes with not very fabulous healthcare benefits.

The fact that I don't have benefits means that I don't have paid sick leave, and I therefore don't feel guilty about not going in for work when I don't feel well. Of course, I shouldn't feel that way at all, even if I had paid sick leave, because everyone is better off if a sick person stays away. I do hate leaving Jody & Joey in the lurch, though; I know how busy Fridays are. :(

Like Flynn!

2010-03-12T14:11:00.000-08:00

Or something. I got the letter in the actual snail-mail two weeks ago indicating that my crush is reciprocated: my dream program wants me. This makes me very relieved and happy, and means I've been able to start planning my life somewhat around the program's timeline. I'll start classes the fourth week of June.

Incontinence

2010-02-21T18:37:00.000-08:00

is no fun. And I'm coming to see my own ability to "toilet" myself as a rather long blip on the screen. I've changed many an infant diaper by now, and have worked hard at potty-training my toddler. Now at work I help adults in various stages of losing, or, in the best case, attempting to regain, their abilities to (1) recognize when they need to use the bathroom, (2) get themselves there, (3) get themselves safely onto and off of the toilet, (4) get themselves cleaned and dressed afterward, and (5) wash their hands. Some just need supervision and reminding because they have epically short memories. Some, since they're hemiplegic, need help getting onto the toilet, or maybe just pulling their pants up. You try getting re-dressed sometime with just one arm. :/

It's a weird position to be in with adults, with whom I have normal conversations about normal things when we're not in the bathroom. It's infantilizing, and how I do my job can mitigate or exacerbate this dignity-robbing effect. The advice I was given back in NAC training was to be professional and matter-of-fact, and non-judgmental. This I have done, and it was good advice.

One hemiplegic client last week was on his way to the toilet, but the process of getting out of his too-big-to-fit-in-the-bathroom wheelchair and getting set up to use his cane to walk in took longer than it usually does, so he didn't make it. I spent a good 30 minutes getting him cleaned up and changed. He was mortified and apologized profusely. I was totally okay with it, in part because of the number of infant diapers I've changed, but that's not a comparison that would have made him felt better. Another client, who takes himself to the toilet without reminding or assistance, has now twice pooped--once on the floor, once on a chair--in the middle of group activities. He is the absolute _last_ client I would have predicted such of--no one else has done anything like this. It seems a little crazy. The second time he left the room without mentioning that it had happened, and someone had to point it out to me. I cannot imagine how incredibly embarrassing this must be for him.

A lot of our clients wear Attends or whatever other brand of disposable adult undergarment. This was the case in the nursing home where I did clinic. Unlike that home, however, we do not merely rely on changing these undergarments, bypassing the bathroom altogether. They still use the restroom. This seems so very important to me. Babies and toddlers don't go to the toilet by themselves, and to not encourage and assist adults' bathroom use communicates to them that they are children.

Personality is sorta chimerical

2010-01-24T15:23:00.000-08:00

A few days ago, our planned physical activity of the day was indoor basketball with a 5' tall plastic basket. Steve, my co-worker, who's a case manager with several of the TBI clients I work with, ran the show. He decided that to even things out, he'd split our group such that the two clients with motorized wheelchairs were on opposite teams, another usually wheelchair-bound client was on one of their teams with her non-motorized chair, then he pulled 3 extra chairs out of the equipment closet. Two clients who normally walk on their own took the first 2, and I evened out the teams by taking the 3rd chair.* I don't think I'd ever sat in a wheelchair. It was fun, and I'm glad I don't have to ride in a wheelchair normally.

I've still not read any clients' files, so I'm still creating my own ideas about what they're "like," what's illness, what's part of their former personality. I'm sure it's a relief for them to be somewhere that people _don't_ continually compare their pre- and post-incident selves. There are some general characteristics one finds such as speech problems (softer than normal and/or inarticulate and/or disconnected and/or nonsensical speech) or loss of certain inhibitions (quicker to anger, tendency to make inappropriate remarks of a sexual or non-tactful nature). But then I think that if I'd had an accident that robbed me of, say, the use of a side of my body, and made me talk funny, and meant I wasn't as smart anymore so my spouse no longer found me attractive enough to be intimate with me, I'd probably be grumpy and quicker to anger than normal, too. And maybe have lowered inhibitions because I quit caring about social consequences because my deference to them didn't seem to help me be accepted by the world at large, anyway, now that I was disabled and looked down on or pitied or ignored.

One client seems to have vocabulary straight out of a John Hughes script. Her response to most things said to her is to grin widely, wave her hand, and say "I'm so sure! I'm so sure!" Did she talk like this before whatever-it-was injured part of her brain? Was she always such a cheerful person? Did her grumpy wires get disconnected altogether? Or the client who makes continual inappropriate flirtatious comments to me--maybe he's always objectified women in this way? Is that just his injury talking? My boss leads group discussions about once a month on communication skills and uses that phrase with the clients, telling them that what they said wasn't their best self, it was their injury talking. It's great they're learning explicitly to use other parts of their brain to inhibit certain behaviors. And this reminds me what a fragile construct self and personality are.

What if I had to ride around in a wheelchair as my only means of locomotion, and couldn't think or talk as fast? That would sort of be someone else, except they would have my not-as-functional body and some percentage of my memories.

*If you did the math, you realized that's not many clients. On any given day we have between 14 & 21 clients present. After the lunch that takes up the first hour, they're split into two groups, red & blue. One does the cognitive game/activity while the other does the physical, then they switch, then everyone goes through free-weights/sitting/arm/leg/standing exercises at the same time in the two groups in two different rooms. That day, the client who should've been in the wheelchair I took was still eating her lunch. She typically takes about an hour to eat the meal that most people consume in 10 to 15 minutes.

Getting Paid

2010-01-03T06:52:00.000-08:00

My volunteer gig has turned into a paid job. The whole thing feels quite serendipitous. The TBI (traumatic brain injury) group had its program moved back to a former location, and its director asked that I move with them, and talked to the right people so that I got hired. The new/former location is quite close to my house, only a 12-minute bike ride or so, as opposed to the original volunteer location which entailed a 30-to-45-minute bike ride south. The move also meant they could switch back to their former hours, as well, which means that my workday fits very neatly into the time between when the Microbiology class I'm taking this quarter ends and when the kids' daycare ends. I can easily pick them up on my way home, in fact. I am still a little shocked that I found a job in my field that fits inside daycare hours and allows me to take the last prerequisite required for my dream program. (I submitted that application on 12/1, won't hear whether I got in until 3/1.)

The first few days of my job I spent washing dishes and barely talking to clients. We aren't running our own kitchen fully. Instead, we're having food brought up daily from the south branch, and having to do our own dishes. I got my food handler's permit the first week, and other than that spent that week getting the kitchen back in order, which felt somewhat like moving into a vacation cabin. The stuff was unused for so long, it all got dusty, it's all needed cleaning, reorganizing. I've thrown away a bunch of random stuff that was either in terrible shape, unidentifiable, or a crappy duplicate. As for the rest of the tasks I was ostensibly hired for, I'm slowly being trained in the why's and how's-of-the-why's: bathroom assists, leading exercises, helping certain mostly wheelchair-bound clients do their particular occupational-therapist-devised standing exercise regime. Each day involves lots of different kinds of tasks, and this makes me really happy and makes the time go by quickly.

I've especially enjoyed the one-on-one time I get with clients when I help them with the standing exercises. I've found my experience with Iyengar yoga and its emphasis on alignment and physical adjustments really helpful in this endeavor. We go to a bar facing a window, I fasten what's called a gait belt around their waists, and help them to do things like stand up with both feet facing forward and parallel to each other, or to put weight in their heels (one client would constantly be on his toes otherwise). My help consists of reminding them of the exercise routine and staying by their weak side, holding the gait belt, in case of falls. They're bearing most of their weight themselves. Because of the yoga stuff, I've been able to brace a heel, or support a calf, so that a client can move the other half of their body more freely, or with more control.

TBIs--and maybe their aftermath, like life in a wheelchair for some? I need to research this--lead to common muscular conditions, one of which is called "high tone," which occurs especially in the lower extremities. Their quads are always contracting, meaning it's hard for them to bend their knees much. Many TBIs involve only one side of the brain or the other, so clients have no control over one side of their body. But both sides, the side with and the side without control, have this "high tone" problem. One client always asks us to tuck (force) his left foot back onto the footplate of his wheelchair. If we don't, his whole lower left leg springs into the air and stays there. With his right leg, he can do the forcing himself.

During standing I end up chatting with the clients. I've found out that the Beatles fan in the wheelchair isn't quiet at all, and that when he's standing up he's about 6-foot 1. His TBI was from a car accident when he was 16 years old. He says he was in heaven 2 to 4 years after the accident, that God sent him back, and that he doesn't really remember the time he was in heaven. This does not come across as delusional rambling in the least. He's incredibly polite, and quick-witted, except that his perfectly articulated, soft speech is produced at about 1/6 of the speed of average speech. One day I called him a "rockstar" because of his hard work; I know from what my boss tells me that he's improved his mobility a great deal, and that this is due to his determination. He replied, immediately, carefully, and slowly: "I prefer to call myself a stud. That's what I was called in high school. I was a wrestler and played soccer." He's 29. He managed to finish high school over the course of several years after the accident, and thinks he survived for a reason. This has something to do with the time he spent in heaven. He wasn't driving the car.

Notes from volunteering

2009-11-16T15:03:00.000-08:00

I've been neglecting my blog. I was thinking I could save my writing time and energy for the statement of purpose I've been working on for the nursing program I really really really want to attend. (Remember the person you had an absurd crush on in junior high or highschool? I have that crush on this program. I reeeeaaaaalllly want to get in.)

I'm come to think, however, that they are two very different kinds of writing, and actually, by neglecting to record my thoughts about my volunteering and my [thus far frustratingly fruitless] job search, my head is just full of more noise. So, I'm gonna get some of that noise out.

Volunteering is still great. It's fascinating. I've learned people's crazy stories and life histories. The TBI (traumatic brain injury) folks are the ones with the most to tell. One man, Jonny, who can't talk at all, by pointing the index finger of his one mobile hand at his alphabet board, told me that he's 31, and hasn't been able to talk or mostly move since he had his spinal cord injury at age 19 as a result of attempting suicide by jumping off a bridge. He's developed this obsession with blue M&M's, which he told me he wanted to use to get high. One of the staff members uses blue M&M's to motivate Jonny, giving him the M&M's whenever he does all of his exercises. I think I solved the mystery of Jonny's obsession with them for myself this afternoon. While listening to _On The Media_, I heard, as an example of sensationalist health reporting in general, that there was an irresponsible news report about a study done on a few rats that had some symptoms of paralysis lessened because they had the chemical that's in blue gatorade and m&m's injected. So of course a bunch of people freaked out and thought it was their last hope. Depressing.

[sample of this type of story here:
http://www.cnn.com/2009/HEALTH/07/28/spinal.injury.blue.dye/index.html]

Another man in the TBI crew I'd observed doing passive range of motion for his left side with his right hand. That is, when exercises involve one side of the body then the other, he'll do the exercise on his right side, then move his left hand or leg with his right hand when it's time for the other side. It's a lot more work, and it's impressive. No one else does it. I told him so, and he said, "well, I want to play guitar again." So far, he's regained some control over mobility only in his left shoulder in the 8 years since he had his stroke.

The people here are the absolute antidote to self-pity.

And there are strange things. There's a super-tall man, James, who spends his 4 hours there every Friday solving the same Christmas-themed jigsaw puzzle (maybe 200 pieces?) repeatedly. And I'm sure he does this the days I'm not there, too. He doesn't like to share his table, fastidiously finishes everything on his plate, in his cup, in his dessert bowl, and after wiping his mouth delicately with his napkin, he goes back to the puzzle. He doesn't interact with anyone, and he's silent, except while eating, during which he emits some otherworldly high-pitched noises, the production of which doesn't seem to require him moving his face at all.

There's a small, confused- and fragile-looking old woman, June, who tends to drift away from whatever's going on, except that she is able to concentrate very effectively if she's given paint and a brush. She doesn't require paper--one day, after the [cognitive] art activity had ended and most of the materials had been put away, we realized she'd been carefully painting the table for at least 5 minutes. She is probably the most passive person I've ever encountered. She answers every question, once she understands the words, with something to the effect of, "If you want me to."

There are two men with Down's syndrome in the morning group, one elderly, one middle-aged. They act in every way like petulant 8-year-olds, often exhibiting inappropriate attention-getting behavior. The middle-aged man is thoroughly devoted to a woman who is always there. That pair are inseparable, and squabble like children. I've used my parenting skills to decent effect with them. To the elderly one, who was pouting last week: "Fred, I know it was frustrating you weren't allowed to pass out weights at the beginning of class, but we'd love to have you help us with that in a few minutes when it's time. Do you want to come join us for exercises now?" He did.

A few weeks ago I was given the opportunity to help out downstairs with the highly structured group, which is made up of people with more significant dementia. We were playing a version of seated basketball, with a sad, deflated soccer ball (a staff member told me it's at least 8 years old), and I unthinkingly tossed the ball to the next person in the circle, rather than handing it to him. He caught it easily, and I remembered what we'd talked about in my Anatomy & Physiology class regarding different kinds of memory--declarative, explicit memory we store in the hippocampus, but muscle memory is stored in the cerebellum (and likely elsewhere, too lazy to look that up right now), and much of it can become reflexes. Catching a ball is one that was mentioned in our textbook. So we ended up playing toss, me to a client, back to me, to the next client, etc. It was amazing to watch. One woman repeatedly tossed me the ball off of her slender, long-fingered right hand with impressive grace. I asked her whether she'd played sports back in the day. She simply doesn't remember. But her ability to catch and throw seems unimpaired.

Finally, it's thrilling to be in a facility that uses all of the implements I learned about in my CNA course that can help people to do things more independently. For several of the people who have partial use of one hand only, at mealtimes there are utensils with wider, rubber grips and rubber non-skid mats to go under their plates. No one hurries anyone. This clearly makes people happier than having someone impatiently shovel food in their mouths.

Tango and Noodle Hockey

2009-10-26T15:36:00.000-07:00

Today I spent at least 30 rather goofily ecstatic minutes with the morning crew in the main room at Geriabulous, listening to tango, and playing "hockey" with about 20 elderly folks. They were all gathered in a circle, in their seats or wheelchairs, wielding fun noodles, which are normally used in swimming pools, and have been cut off so they can be used as thwacking implements to send beachballs and balloons careening around the room. Man, physical activity is so good for the soul. I had so much fun, and they were gleeful. I also helped a blind person play Bingo for the second time--my first day I sat in-between two blind people to help with Bingo. It's weird to see people who haven't been blind for their whole lives; it's gotta be an incredibly hard thing to adjust to late in life, when other things related to one's independence from and connections to others are already made more difficult as mobility and cognitive speed decrease, and friends die and children move away and get busy.

Friday was my first day with the crew that I'd mistakenly described in my prior post as developmentally disabled. They're not. They're all people who've suffered some sort of brain injury that's left them at least cognitively impaired, some from strokes, some from accidents. That group was incredibly fun. Many were difficult to understand, but none were surly. They were happy and optimistic, introduced themselves and asked for, and remembered, my name. I spent threee hours participating in various activities with them, including assisting some as we walked laps around the downstairs offices, playing an indoor version of frisbee golf that involved bases, and reading creepy Halloween-ish stories. Towards the end of the day, around 5:30 p.m., as everyone was waiting for their rides and leaving in small groups, those of us left had no stories, so someone asked if I knew any. I sang "The Fox" (a version of the lyrics here: http://www.festivarian.com/index.php?topic=2110.0), then they asked if I knew more songs, so I sang about 4 different camp songs from my days as a Girl Scout camper and later counselor, all of which had repeated parts that others could easily pick up and sing along with. Then it was mentioned that this one quiet guy in a wheelchair who's lost a lot of motor control is a Beatles fan, so we all sang "Help" together, then he sang "Yesterday," and it wasn't poignant and sad, it was impressive and inspiring.

Volunteering

2009-10-21T22:19:00.000-07:00

A few weeks ago, I interviewed for an underpaid job with a nonprofit organization I thought had a super-cool mission: they provide adult daycare. It's called day health for obvious reasons, for the frail elderly and otherwise disabled, to give respite to the caregivers--usually family members--for such folk so that the caregivers don't get burnt out, and the care recipients can stay out of longterm care facilities as long as possible. Before a bunch of statewide budget cuts, this nonprofit also provided counseling and support for the caregivers. Makes so much sense to me. Also makes sense that the state would be short-sighted enough to think it was a good place to save money in the budget, not realizing how much it saves them on Medicaid in the long run to keep people out of longterm care facilities. Huh.

Anyway, this organization, which I'll call Geriabulous, needed more hours from me than I could work, so they didn't give me the job. But I think they're so great that I decided to volunteer with them, which, as of Monday (5 days ago), I'm doing 9 hours/week. I like the work. It moves slowly, since it involves the frail elderly, which forces me to slow down and practice patience. I haven't worked my afternoon shift yet--afternoons are for the developmentally disabled, and I'm interested to see what that will look like.

Mornings go in chunks: 8:45-9:45 arrival, coffee (decaf), social time; 9:45-10:30 exercise; 10:30-11:30 some sort of activity; 11:30-12 get situated for lunch. Transitions are slow.
While people are there they see nurses, get vaccines for things, see OTs and PTs--it's really great, and a huge contrast to what I saw at the longterm care facility where I did my clinicals. At the LTCF, emphasis was on speed and task-completion: get them fed, changed, into bed, stat. That is, everything was about physical health, pretty much completely neglecting mental and emotional health, which was, of course, detrimental to physical health. The only "recreation" I saw was residents pushed in their wheelchairs to a TV room, where they sat for hours on end, listless. I realize the missions of the two institutions are different, but they both purport to provide "care," and I think the LTCF's care was distinctly lacking in a caring attitude towards the "care" it provided.

Back to Geriabulous: my first morning there I helped a blind woman, Judith, and a Spanish-speaking blind man, Jose, to do the exercises. Sylvia, who leads the exercises, asked that I help them figure out what they should be doing since they can't watch her and mimic. Everyone (about 30 folks) are gathered around in a big circle in the main room of the converted church that houses the nonprofit. To get to their spots, the clients inch along in walkers, push themselves in their wheelchairs--they are _not_ impatiently and efficiently guided into place by workers who think they need to get the next thing done. The first 3/4 of the exercises are done while sitting. Sylvia has them shrug their shoulders, move their arms in different directions, tap their feet forward and sideways... then we pass out weights, between 1 and 5 pounds, letting the clients choose how much they want to use. It's pretty neat, and they are engaged and really participate. The employees and volunteers are there to check on folks who aren't participating, ask them if they need help, and if so, what help. We treat them like adults, and they are clearly pleased we do so. I like this a lot.

I am starting to understand what my developmental psych instructor meant this summer when she called the elderly "invisible"--they are ignored, overlooked, treated like children or annoying pets, they are wished away. I think I might end up doing geriatric nursing as a career. This is a fascinating population to me, and working with the elderly serves as a perpetual reminder to be grateful for my senses and my mobility, and to do what I know I can to maintain them. My social circle is filled with energetic, young (in spirit and health, if not in age), optimistic, beautiful people, and this means I have a narrowed perspective on life. Working with the elderly would allow me to expand my horizons a little as I am helping an under-appreciated population.

advice

2009-08-05T17:50:00.000-07:00

Yesterday I finally met with my erstwhile primary care provider, a nurse practitioner who's partly my inspiration for this, and whom I'll call June. She has always seemed to me to be a happy, well-balanced person who enjoys her job, does great work, is responsive, knowledgeable, etc. She's been by far my favorite PCP, and I've changed to a different one only because her clinic about 1/3 as far away from my home as June's is. June was encouraging about nursing in general, and about me being a nurse in particular, but has made me reconsider my original intent of doing an intensive immersive program in which I'd complete my R.N. and M.S.N. within 3 years.

June said that she did this sort of program, worked her tail off, learned tons, but when she finished school felt like she was thrown into work as a practicing clinician with not nearly enough supervised clinical experience behind her. If she had to do it over again, this is definitely not the path she would take. The program I've been looking at requires about 500 clinical hours, and she says this is far too little. She recommends that I become an R.N. and attempt to find work in an E.R. for a year or two to gain experience and exposure, and only later, if I decide it is worthwhile to pursue the M.S.N. and become a nurse practitioner, should I return to school. June said there are definitely E.R. nurses who earn more than she does, but of course as a nurse practitioner, if one is lucky enough to find work, one has far more control over one's hours, interactions with patients, etc. She also said that the intensive programs are _so_ intensive they make it difficult to spend time with family. My daughter is 2. This does not sound so appealing. So, I have some research to do!

I will not take these things for granted

2009-06-19T00:00:00.001-07:00

I have just spend 9 days working with and for people who can often do very little by and for themselves, who sleep in single beds with roommates that they may or may not interact with, and who go to meals at which they might not talk to anyone because their tablemates are mostly deaf, or they themselves don't really speak comprehensibly anymore.

This makes me appreciate so many things in my what-I'm-coming-to-view-as-temporary functionality. I have two functioning eyes, two functioning ears, and four mobile limbs. I can walk when and where I want. I can ride my bicycle or drive a car to go places I want to get to. I can talk to people to let them know what I'm thinking, or to pass the time. I wonder about residents' boredom. Are the residents who spend 7 hours a day parked in a wheelchair in front of the nurses' station bored? Or is the level of what engages their interest lowered such that boredom doesn't really apply? I can read, and acquire things to read that I want to read. I can go to the bathroom when I need to and be clean before and after. I can choose what to wear, and put it on myself, or take it off. I have a high degree of control over what I eat, and when. I can listen to music when I want to. I can dance.

I share a bed that I can make myself with someone I love who knows me well, and with whom I feel safe and understood, and whom I can care for as well, so I know that I am useful. I spend time with friends whose company makes me happy. I laugh a lot.

There is a poster up in the physical therapy room of a 70-year-old-ish woman wearing a swimsuit, with the caption: "Growing old is not for the faint of heart." No kidding.

Vocation

2009-06-17T21:00:00.000-07:00

I spent 10 years in indentured servanthood in academia, moving from one degree to another because they were paid for by my TA-ing, but never really envisioning an actual future along one of these paths. I kind of let it remain blurry, and hoped that by doing my work well and getting good grades, the future would take care of itself. It didn't.

I married the right man, found the right city to live in, the right housing situation, but didn't know what I was doing professionally, despite, or because of, all those years in school.

I knew my current career path wasn't sustainable or viable, but didn't know what to put in its place. I thought through lots of random possibilities, then this whole nursing business kind of dropped into my head one day while I was waiting for the bus. I dismissed it, then several curiously serendipitous things happened, and the people close to me in my life didn't tell me that I was crazy or that I was just doing another degree and why bother.

When I attended an open house at the school where I now hope to study nursing, they suggested we become Certified Nursing Assistants so that we could get our feet wet in the field and make sure this is what we want to do. So that's what I've been doing. Eight days so far of clinic, and all signs still point to yes. I find this stuff compelling.

Then this is what my mom wrote to me in an e-mail, after she read all my blog posts back-to-back yesterday, and which I have her permission to quote:

Today I re-read the chapters of your blog I'd already read and caught up thru the latest entry. [...]. I think you have found the ideal vocation. It challenges your mind and engages your heart, providing the sense of giving back that you require. Good call.

:)

Management

2009-06-12T23:17:00.000-07:00

On Monday and Tuesday, I was on the third floor, shadowing Joe. Wednesday, Thursday, and Friday, I shadowed Jane. Jane works hard and constantly, interacts with the patients like they are human beings--she addresses them by name and jokes with them and is clearly concerned for them. She has been a great example and teacher, although even she and I had a conflict during dinner the first day I shadowed her--she asked me to feed a certain resident, and while I started to do so, I realized that the resident was picking up her own fork and attempting to get food on it, and simply didn't have the coordination to do so. She could guide the empty fork to her mouth without a problem, however. So I started spearing bites and leaving the fork on the side of the plate for her, and she did fine. She'd had 3-4 bites this way when Jane looked up, saw the fork wasn't in my hand, and said, "You have to help her, she can't feed herself." I said, "Yes, she can, she just needs a little help." So Jane got up, and began feeding the resident herself, hurriedly. I have taken very seriously the idea that my job is to help residents and patients achieve their highest level of independence--this is important for their physical health, because they need to move, and for their emotional health, because it makes the difference between helplessness and self-esteem. The NACs, even the fabulous ones like Jane, have such a large workload (10 residents to herself), that they tend to do everything as fast as possible, which tends to be to the detriment of residents' exercise of any sort of autonomy.

Later that day, I began pushing a resident in her wheelchair towards her room, since Jane wanted her to get there faster. Stella, the supervising LPN on Jane's side of the floor, saw me and said "Ms. Smith can push herself. And she needs to! She needs the exercise. It's the same way with feeding residents who can feed themselves." I was very glad to hear her say this.

Stella pays attention to what's going on on her floor, stops NACs in the dining room from talking to each other and has them talk with the residents, helps out NACs by doing any task they need if she's got a spare moment and it makes their job easier... she's a great manager, respectful of the residents, warm with the NACs, manages to keep something like a big picture in her head while performing tasks both detailed and demanding, and man do I wish for the 3rd floor's sake that they'd move her up there for a while.

The first day I shadowed Jane, she introduce me to Kiko, and told me that she and he watch each other's section of the hall when the other is on break. I was pleasantly stunned. No one does this on the 3rd floor, which is why us students had such trouble finding NACs up there--they were on constant breaks, and all together. No LPN on the 3rd floor really directs anyone's behavior or sets any limits. Clearly they wouldn't leave for simultaneous 45-minute breaks if someone noticed and called them on it.

Underdogs

2009-06-12T22:55:00.000-07:00

I've just gotten home from day 5 of my two-week clinic. Students are playing hooky like flies, or something. I've been there all but 3 hours of the 40, and most folks have missed at least one entire day.

I've found this to be challenging and thought-provoking and fulfilling. I realize it might seem premature to say so, but given that I've embarked on a drastic mid-life career change, the fact that I've had no second thoughts--even after spending a week changing "briefs" and wrangling wheelchair footrests (no two are alike, good Lord)--seems significant. I find the ways I'm spending my time and using my brain and hands and health gratifying. I'm finding, so help me, negotiating the often conflicting expectations of different authority figures to constitute an interesting challenge and test of my social skills rather than an infuriating obstacle.

Every population I interact with I recognize to be disadvantaged, which unfortunately seems to be what my exercise of patience is predicated upon. The residents are mentally or physically impaired, dependent on others, aware of this, and are often depressed or peevish or aggressive as a result. The NACs are mostly immigrants, dealing with linguistic and cultural challenges, and thus also to be dealt with patiently. The RNs & LPNs that manage the floors, like the NACs, have over-large workloads, and simply cannot be everywhere and aware of everything at once. And I don't mean in these cases I'm gritting my teeth and exercising great forbearance.

I mean it's as easy for me to slow down and consider circumstances and some greater good and not get my hackles up as it is for me to do with my daughter, the first person with whom I think I have truly been patient in my life. Too bad I haven't figured out how to generalize this situational attribution to everyone, not just the "disadvantaged" according to whatever standard I clearly must be using. Would be nice if I could be patient with my husband, family, students, and friends in the same way. I'd be a lot less grouchy. A friend of mine once told me that relationships are all about managing expectations, and I see the truth of that statement more and more as time passes.

In theory, practice is like theory.

2009-06-09T09:21:00.000-07:00

But in practice, it sure as heck isn't. Yesterday was my first day of clinic, at a real, live, longterm care facility. I am on evening shift, 1-9pm. The nighttime NAC instructor, not Betty, was our supervisor, even though she'd already supervised the day shift from 6:30 am to 2pm, since it should've been a third person entirely, Amita. Amita was stuck with car trouble a 2.5 hour busride away, so she didn't make it.

I'd come to think from Hazel's descriptions of her experience working as a NAC that I'd see a bunch of overworked NACs who couldn't possibly take as much time to practice humane care as is ideal, since they had too much to do, given a too-large resident-to-NAC ratio possibly made worse by the current economic climate and the budget cuts that have happened everywhere as a result. Instead, I saw NACs who should've been overworked, given the too-large resident-to-NAC ratio, but who weren't, because they did the minimum and took frequent and long breaks. It's frustrating for us as students, because we are each paired with a NAC, whom we are supposed to shadow and help, but the NACs keep disappearing--we'll look down the hall and see the other 4 students on our floor, and no NACs are to be found.

This has good and bad aspects. The bad are that care is performed peremptorily, minimally, and with almost no conversation or human interaction. I have seen the NAC I shadow--I'll call him Joe--joke around with a few residents, but mostly he comes in their rooms, quickly changes their briefs, wipes them, changes their clothes, and they are put in bed with no explanation or gentleness. Joe is effective, fast, safe, and self-assured, but he does not talk to or with them.

The good side of this is that, when and if I manage to get a job in a facility like this one, simply by working the hours I'm paid to work, there _is_ room and time for me to care for residents in the ways Betty has taught us. As Joe was putting one resident to bed, he was brusquely moving her limbs about and tucking pillows under here and there (essential to preventing pressure sores), and I reached down to pull the gown he'd put over her front further down her legs, so it would cover more of her and not be wrinkled. She thanked me--and before that she'd only replied in monosyllables to direct questions.

I had conversations with a few residents this afternoon and evening, and they seemed mildly surprised, and appreciative. One resident, who I'd assumed from a series of repetitive sounds she'd made yesterday must be quite absent mentally, told me she was 95, and asked about the bruise on my thumbnail. Another told me he can read again after his Parkinson's medication (L-Dopa) since it has helped him control his fidgetiness, and that he likes good fiction. _The Razor's Edge_ was his favorite novel for years, he said. He's only reading pulp fiction currently, because that's what he finds on the shelves at the facility. He hopes to move from this facility into an assisted-living facility, since his symptoms have abated significantly with his medication and he is again mobile.

Joe has brushed no one's teeth so far that I've seen. If I went two days without brushing my teeth, I'd start to feel not human. Amita, who has rented a car, suggested in our debriefing today that we touch the spot on our neck that makes us stupid, and ask our shadowees, wide-eyed, "So, I know that different places have different ways of doing things, but when do you do P.M. care here? 'Cuz I have to check off tooth-brushing on this list I have from my instructor..."

As for the briefs, all the residents I've seen so far that don't walk to the restroom by themselves wear them, which is distressing. It possibly has more to do with the trouble it is for caregivers to assist with toileting than full incontinence.

I realize I am being harsh on minimum-wage workers, many of whom are immigrants trying to make it here. Maybe they started off kind and gave up. They are kind to each other, and to me. Nonetheless, I find at clinic, as has been the case for me everywhere else, time flies as long as I'm busy, and crawls if I'm not. So today, during a few of the crawling times, I asked residents if they are comfortable and may I adjust their pillows, or if we might make beds while residents are dining... and Joe tells me "Don't worry, it's no problem." He clearly thinks I'm the type that works too hard, in a bad way, since it makes trouble for others, but I'm not there to take 30-minute breaks every two hours (we're in a somewhat far-flung part of the city--I wonder where he and the other NACs go!). Does time not crawl for Joe when he is idle? Hmmm.

A final thought: without giving up a minute of their ample break time, the NACs and LPNs on the floor I've been on could at least use proper terminology for the sake of preserving residents' dignity and self-respect. We are supposed to say briefs or Attends and clothing protectors, NOT diapers and bibs. :/

Power of Attorney

2009-06-06T15:21:00.000-07:00

So I've always heard the personal is political, and that has felt very true in my own life. I'm now learning that the medical is legal.

NACs are certified, not licensed, so there are many limits on what we are allowed to do, that is, our scope of practice. As one become licensed to do more advanced things, one takes on increasing liability. I'm not even licensed. But I am still at risk for tort claims, both intentional and unintentional. Assault or battery would be in the first category, neglect in the latter.

Battery means touching someone without their consent. If a patient or resident is a "no-code," or DNR, that means there is a do-not-resuscitate order in effect for them, and were I to find such a patient in respiratory or cardiac arrest and perform CPR, I would be engaging in battery.

It's all about consent, and that's trickier than I'd even realized it could be. OBRA, the Omnibus Budget Reconciliation Act of 1987, put into place all sorts of regulations regarding quality of life for residents of long-term healthcare facilities. Part of OBRA guarantees the right of such residents to having a fulfilling sex life, should they so choose. Such residents can include the mentally retarded and people with early-to-late-stage dementia. The mentally retarded, it's worth noting, can often be 6-year-old brains functioning inside of healthy adult bodies with all the normal hormones and desires you'd expect to find there. So here's where it gets weird: the mentally retarded, if they're on the same level of retardation, may have a sex life, and even procreate, and no-one can enforce that they be on birth control, unless their parents, say, have their power of attorney and have made such a decision. So Betty knew of two mentally retarded residents who had sexual relations that resulted in pregnancy. The woman had had her baby and her family took it and raised it. I guess the illegality of a healthcare facility interfering with or preventing such an occurence is the result of some combination of ADA (Americans with Disabilities Act) protection of the rights of the mentally retarded as citizens, plus their OBRA protections as residents there. However, mentally retarded patients of differing levels retardation may not engage in sexual relations with each other, because it's considered that the more severely impaired person is unable to give informed consent. But it's ALSO the case that as soon as someone has been diagnosed with dementia, even early-stage dementia, he or she is considered to be unable to give informed consent--so technically an institutionalized husband and wife on the same mental decline schedule couldn't share a bed (although clearly no pregnancy can result from their union). Yet I know this happens. I think there might be difficulties with conjugal visits, however. But Lord, wouldn't you want to just be able to cuddle with the person you'd spent 50 years married to, and to provide them physical contact and comfort? Ugh.

I found some of this pretty confusing. I asked Betty about it, and she said to prevent the situations that might result in non-consensual sex, you get to know the facility, its regulations, and its residents well, and you get to know who wanders. It seems to me that this must be such a different side of healthcare than that doctors experience or are trained for.

On another note, I related to Betty what Hazel had commented regarding what affects quality of care, that is, that the most important factor is the ratio of residents or patients to NACs. She said that is quite true, and that it is sort of regulated by law... OBRA has regulations for this ratio. But then she added something I didn't know: OBRA only applies to facilities that accept patients or residents on Medicare. I need to do a little research on what percentage of longterm healthcare facilities _don't_ accept such residents.

I wonder what unions or professional organizations might exist to help affect this ratio... I'm guessing that overall NACs are not a particularly politically radical or politicized group of workers.

One last note regarding legality: HIPAA, pronounced as though there were a female hippo, refers to the Health Insurance Portability and Accountability Act of 1996. It protects patients' and residents' privacy. Betty says she's heard people violating it constantly, because they'll discuss patients' conditions or situations in public areas such as cafeterias or elevators, where information can be overheard. She said that we should realize that the women two tables over could be the family members of the patient whose diagnosis we're discussing, and that maybe they haven't heard about it from the doctor yet. Ouch.

Dementia

2009-05-31T22:29:00.000-07:00

I'm studying intro to psych on my own as one of the pre-reqs I'll need for nursing school, and read this paragraph today:
"Impaired memory, particularly for very recent events, typically is one of the first symptoms to appear. Poor judgment, language problems, and disorientation may appear [...] and episodes of distress because they feel confused. Their behavior may become uninhibited, they may lose the ability to perform familiar tasks, and they may experience significant physical decline in addition to cognitive impairments. [...] being a caregiver for a spouse or one's elderly parent who has developed dementia often is a stressful and psychologically painful experience. Over half of the people diagnosed with senile dementia show combinations of depression, anxiety, agitation, paranoid reactions, and disordered thinking that may resemble schizophrenia. Ultimately, they may not even be able to walk, talk, or recognize close friends or family members."

Sigh.

Betty has had us think of all the terms we can in class for bowel movement and urination, so that we'll recognize when patients or residents are telling us they need to go. Hospitals and long-term care facilities should actually have a copy, on each floor, of a notebook that catalogs all such terms. This is necessary in part because of the loss of inhibitions that accompanies Alzheimer's, in particular: people who had been gentle and discreet before its onset can become potty-mouths.

She told us about a 3-level Alzheimer's facility nearby, where the least-impaired, sweet, mildly forgetful Mrs. Smiths are on the first floor, and hostile and foul-mouthed residents occupy the second, and the third is for residents who mostly can't do anything for themselves any more. They're all on their way to the 3rd floor eventually--there's no cure, and they all go through the emotional, physical, and mental decline. Our job, she says, is to respond to even unkindness in a therapeutic manner. To figure out how to find connection and fulfillment in meeting the needs of even the most difficult residents. And to know our own limits, and ask our nursing supervisor occasionally to transfer to a less emotionally trying section of a facility if such a spot is available. I wonder, especially in light of Hazel's comments, whether such a transfer is realistically possible in most workplaces. It seems incredibly trying to respond to aggression gently. But I've learned to do it with my daughter, because I have a different set of expectations about what a 2-year-old is capable of and "means" by her actions. She is not yet herself. I suppose I can try to adjust my expectations consciously when I work with people who are no longer themselves.

Betty has occasionally calmed a distraught patient by putting a pile of clean washcloths on her overbed table and asking her to help fold them. I find this poignant; I suppose such a task can ground a woman who has spent a lifetime doing laundry for others, and who is now feeling lost and helpless. Betty says "it'll take her an hour." She is a no-nonsense instructor, but her tone of voice as she relates these things to us, imitating herself in such situations with vulnerable and confused patients or residents, is incredibly kind and non-patronizing.

She emphasizes that in a healthcare situation, as healthcare providers we are _always_ in a position of power, and patients/residents are vulnerable, and often perceive themselves to be, so they can be fearful of us as well, that we might withhold care, and let them suffer. Funny--I'm guessing most NACs don't have good enough health care insurance to afford the kind of care they themselves provide to others, but I suppose it is true that the balance of power between the p/r or the NAC is in the NAC's "favor," for the little that is worth. :/

Healthcare Fails & Jobsite Reconnoitring

2009-05-29T13:53:00.000-07:00

Betty has told us some disturbing war stories, some on specific events, others on things that tend to happen.

In the tends-to category, the day she showed us how to clean and care for dentures, she told us to be really conscientious about them (she actually said to "be ever-so-careful"), because they are expensive, warp easily, and along with hearing aids, are the number one item to fall into the bed and be sent out with the laundry. Eek.

There was a point in her career where she worked for an agency that would farm her out to cover staffing shortages at various facilities for 16-18 hour shifts. She said she saw some really unacceptable, unhealthy, unsafe stuff going on at the different places she'd go to about once a month. During one of her shifts it took her _2 hours_ to wash a female resident's hair because of how gnarled it had become from neglect.

She advocates answering call bells quickly. She says she's seen it happen lots, and there's nothing sadder than getting to a room in a longterm care facility to a resident who's broken down in tears, saying "I put the call light on, but no one came, and the doctor just prescribed me this new laxative, and I tried to hold it and just couldn't"--and the person has messed him/herself. It's a first-order health risk, since urine and feces damage the skin, especially the fragile, non-elastic skin of elderly people, and it's also such a blow to a person's self-esteem. How can you have any dignity or sense of self-worth when you're unable to avoid going on yourself?

Several weeks ago a student ask how we should go about finding a job, or deciding where to work. I must confess I'm not currently looking, even though I intend, rather abstractly, to find a job for this summer after I'm certified. Anyway, Betty said what she's done for hospitals is dress normally, go to the cafe, drink a cup of coffee, and pay attention to how long call lights stay on at the nurses' station and listen to how and if people talk about patients. She also said that if anyone stops to see what you're up to, tell them honestly, and if s/he is a nurse or NAC, take the opportunity to ask them what they think about their job, what they like best about their place of work, etc. Clever, and I wouldn't have thought of it. Isn't it great in life that we can learn from others and don't have to reinvent the wheel? I'm not sure, however, how such recon would play out, if it could, at a long-term care facility.

Clinic

2009-05-21T21:50:00.000-07:00

I have really enjoyed, and felt intimidated by, learning skills that require me to use my hands, not just my head. We've had to make an occupied bed, clean dentures, take blood pressure (that's so hard!), and we're way behind. There are a total of 24 skills we have to know for the practical part of the NAC exam, and they all have lots of steps. The actual book the state publishes that supposedly contains all the information is dreadful. A given skill will contain some number of steps, but their division is arbitrary--some are separated, some chunked, some skipped--and their directives are often unclear. Step 4 says, in useful, clear, commands, "Raise the side rail on the working side and move to the other side of the bed." Step 5 will say, "Patient is covered with clean top sheet, bath sheet and/or soiled top sheet has been removed." When? Before which step? Doing what before or after? The book is full of these. And we've just finished our 3rd week of class, next week has a holiday, so we have only 8 more classes in which to learn to do all these skills. Eep!

Our lab is old, and full of old, no-longer-standard equipment. Betty grumbles about it and it's pretty funny to hear her. We have about 10 beds in the lab, and at least 4 of them have side-rails that extend the length of the bed. Nowadays, no healthcare facilities have these, since leaving them both up is a form of physical restraint, which, like chemical restraint, only occurs under physicians' orders, and only when it is considered a way of protecting a patient (not staff) from harm, if no other methods work. Facilities now have beds with 4 side-rails, two at the top half of the bed, two at the bottom half, and only one half is left up at a time.

We practice skills like feeding or making an occupied bed in 3's: one do-er, one patient/resident, and someone to read the misleading and infuriating steps out of the NAC book. Therefore, the 4 or 5 fragile and expensive mannekins in the lab are in our way, we have to stack them on top of each other, where they lie, foley catheters askew and limbs partially detached, looking ghoulish and abused. The first day Judy saw us do it, she commented that it looked like Auschwitz. Incidentally, for this purpose we use one of the over-long-side-rails beds one of the now-verboten rails of which is permanently and unhelpfully stuck in the up position.

Unlike in the classroom, where there are books and a lecturer involved, I feel hapless in clinic, which is good, because it is humbling and means I'm not a "seminar pariah"--each of us is useless at some things, skilled at others, and all of us, even Betty, don't perform skills in exactly the same order as they're written in the pamphlet. And all of us need extra help figuring out how to measure blood pressure. Betty is taking extra time this week and next to do FORTY-FIVE MINUTE tutorials with every pair of students in our class willing to take the time to do that with her. That is a _lot_ of extra hours for her. She's really, really, dedicated. And often impatient with me, and I don't even mind, which is funny.

They hear you

2009-05-21T21:22:00.000-07:00

Betty says to be aware of what we're saying to and around patients and residents, and to never say anything we wouldn't want re-broadcasted over a loudspeaker. Unconscious, partially conscious, "asleep," heavily drugged, whatever, they might, and often do, hear you. Betty's mom underwent highly invasive back surgery years ago, and the last thing she heard as she went under was the surgeon saying to a resident, "the bigger the cut, the more you can charge." Yikes! Betty went on to say it's not just a matter of avoiding saying the wrong things around patients, but that we should also try to talk to them kindly and conversationally, even the unconscious ones. "Hi, Mr. Smith. It's a beautiful day today. It's around 12 o'clock noon, May 21st, the sun is shining. I went on a vacation last week to the ocean. The water was so lovely... You know, talk to them as if they were your signifant other, or your parent, or child."

At this point a student asked, "How do we avoid getting attached to patients?" "You don't," said Betty. "I have held many people as they've passed on. I've had people cry in my arms when their spouse passed on. You're allowed to have emotional connection with your patients, it's how you display it that determines whether it's appropriate. Are you gonna pass by someone in the hallway who's sobbing against a wall without asking them what's wrong?" She said if you present a robot-like mask to the people you're serving, you're doing that to protect yourself, not for them. And our job isn't about our convenience, it's about our patients' and residents' well-being.

This seems like a job where one has the opportunity to do really good work and make a difference for people who are vulnerable. I hope it will help me to cultivate my better angels, kinda the opposite of how, I think, had I become a lawyer, I would've become successful by strengthening my worse qualities.

Disaster preparedness

2009-05-14T20:22:00.000-07:00

Betty's husband used to be in the military, now he works at the local airport, I'm not sure in which capacity. Yesterday we discussed disasters, since NACs are expected to know the disaster preparedness plan at the facilities where they work and know what is expected of them should one occur. (Maybe a NACs job would to be to get on the phone and call the next shift's RNs and NACs in early.) Betty asked the class for examples of disasters, so people said "earthquakes, volcanoes, terrorist attacks..." Betty said, "and we live close to an airport." I wasn't sure where she was going with this. Like, a plane drops out of the sky onto the city and causes a disaster? She told us that each local hospital has a command center with a red phone manned 24/7. I'm not sure if the phone's color was a figure of speech. One of the hospitals works as an uber-command-center for the rest of them, so that in case of an emergency, it can quickly be determined which hospitals have how many beds, how many can be made available in X amount of time, how many operating rooms can be up and running quickly... I asked if the need to use this system had ever arisen here. "All the time." "Why don't we hear about it on the news?"

So then she told a story. Back in her 20s, she'd run away from home (clearly that was all resolved later--the first day of class she mentioned caring for her Daddy when he was dying). She was living at the YWCA in Memphis and didn't have a car or 2 pennies to rub together, so she walked to the local AT&T office (then Southern Bell) without any identifying papers whatsoever, and got a job as a long-distance operator--headset, cords, plugs, the works. If the person next to her was missing, she'd scoot her chair in-between their two stations and work two switchboards. (At this point in Betty's story, Judy piped up that she'd done the same job back in the day, as well.) Betty worked a split shift: 10am-2pm, 10pm-2am. So she'd walk along Beale Street between work and the YWCA multiple times a day. One day she went into work and after a while, the whole switchboard lit up. She thought it was on fire at first. No one could get through to anyone. She finally found out that Martin Luther King had been assassinated. After working for what felt like days and was likely 18 hours, she walked home in a daze, and said it was like a war zone outside. When she got back to the YWCA she went up onto the roof where the other women were gathered, because from that vantage point, they could see the Lorraine Motel, and the window of what had been MLK's room. Police were milling about. Anyway, Betty's convinced that, as awful as it was that MLK was killed, the panic and chaos that followed his death compounded the tragedy, with people's reactions making things worse.

So, she said, bringing it back to our local airport, stuff happens here all the time, and it's dealt with efficiently and safely, and it never shows up on the news, because that wouldn't be helpful or productive, since people's reactions would make things worse. I find that thought creepy. Like what? Airplane crashes we're not hearing about? I'd love to figure out what's not making it to the news that's of enough concern to make multiple hospitals coordinate bed and operating-room availability.

Privileged

2009-05-14T15:50:00.001-07:00

I am changing careers at age 35 with an almost 2-year-old, having just embarked on what will be, at best, 4 years of training before I'm earning real wages. This would not be possible without my husband's deep pockets and near-infinite patience with me (to be sure, on a global level; on a day-to-day basis he's actually human and snips at me when I'm out of line).

This Nursing Assistant certification program is complicated: it began with First Aid certification (two 5-hour night classes), then we took CPR and HIV/AIDs & Bloodborne Pathogens certification courses, each about 8-hour Saturdays. Then there are twenty 2.5 hour classes, and finally 80 hours of clinic in June. One woman who doesn't look much older than me had to bring her (astoundingly well-behaved ) 4-year-old grandson to one of these classes for 5 hours. My husband watched our daughter during the Saturday classes, and my housemates and he dealt with the other irregular class times. We have (and can afford) good, reliable childcare during the days.

There was another woman, let's call her Nikita, who managed to attend all of those irregular classes. On the first day of normal NAC class, when we were told to leave our cellphones off during class, she protested that she has a two-year old with sickle cell, and that she needs to be reachable by phone were something to happen. Betty and her co-instructor "Judy," (who's there specifically to help all the ESL students), agreed that perhaps she could leave her phone on vibrate, and dash out of class to answer it. Nikita hasn't come back to class since about day three. I assume that childcare issues are the reason.

Our economy sucks and so many people are trapped. I listen to Planet Money (http://www.npr.org/blogs/money/) regularly, and keep hearing about people in Detroit who've worked in the automotive industry their whole lives, are losing their jobs, so have mortgages they can't pay, and houses they can't sell, because property values there have dropped at a more dizzying rate there than elsewhere. Who wants to move to a sinking ship?

I, on the other hand, am changing careers mostly because I want to feel like my life is meaningful. Yeah, the economy's this bad, and I get to play around at the top level of Maslow's hierarchy, right? How fair is that? (There's a little more to my decision, but I'll save that for another post.) I think most of the people in my NAC class are there to bump up the amount they're getting paid to provide home care, or in the hopes of getting a decent wage at all--this for me is just a step to learn a little about the field in which I hope to advance further.

And it's not cheap! The course is a little over $900, scrubs, shoes, stethoscope, other random equipment, books, transportation, add up to another $500 or so. I hope and assume a lot of the other students have financial aid for this, but still. I wonder if Nikita will be able to get any of her money back.

Communication and interaction in caregiving

2009-05-13T16:39:00.001-07:00

Betty talks a lot about communication. There's a specific chapter in our book, _Essentials for Nursing Assistants_, on communication, in which one labels pictures with "message," "receiver," and "sender," accompanied by workbook questions so simple I realized I was overthinking their answers (example: which of the following is an example of communication? (a) giving a gift (b) driving to a friend's house (c) saying something to someone). Betty brings it up all the time, and, I am glad to report, in much more thought-provoking ways.

We talk a lot about Standard Precautions, which are certain procedures you follow in healthcare in which you basically treat every patient/resident (henceforth P/R) as though he or she could be carrying HIV or Hep. That is, gloves if you come in contact with certain bodily fluids, mask + protective eyewear if possibility of splashes, washing hands before and after doing anything with a patient/resident in his/her room... (You do specific precautions if someone has, say, TB, which is airborne, or measles.)

So some student logically asked whether we shouldn't just wear masks all the time. Betty said "No. If you put on gloves to take someone's blood pressure, or come in with a mask on to change sheets they've soiled, what message are you sending?" She went on to explain that it'll freak out a P/R as to how serious their condition is in the first case, and in the second, you humiliate them, because you're sending the message that you don't want to be in that room doing that task. "Learn how to breathe through your mouth or put a little vicks vaporub under your nose." Everything she tells us is centered around the safety and comfort of the care-recipient, and I'm certainly realizing that NACs spend more time with P/Rs than anyone else and likely affect the P/R's quality of life the most. Maybe not in hospitals. But this is certainly the case in longterm care facilities.

Our book mentions Maslow's hierarchy of human needs: a triangle the base of which is physiological needs (food, elimination, sleep), over which is safety, then love, then self-esteem, and finally, self-actualization, and gives examples of what NACs can do to meet each level of need a P/R has. While the ways in which NACs would meet physiological needs are obvious, Betty continually points out ways we're affecting the P/R's self-esteem. We'll likely be caring for the elderly, that is, folks who've spent their lives doing for themselves and others and are now forced to be helped and depend on others.

The main way we can accomplish this, she says, is to give the P/R choices whenever it is possible to do so without jeopardizing their care. "Mrs. Smith, we need to get you a bath so you can be clean and dry, but if that's not convenient right now, would you like me to come back at 9 am, or around 1 after you've had lunch?" She says this works wonders. It is also the main principle behind "Love and Logic," a parenting style my housemate's mother introduced us to, the goal of which is not explicitly to build self-esteem, but rather, to teach children how to make decisions and live with their consequences. The situation in a care facility is obviously different. The trick with L&L with kids is that if kids make a "bad" decision, their parents don't rescue them from the consequences. So it can't work exactly the same with Mrs. Smith--a NAC can't simply not perform care a P/R balks at. The L&L side effect I've enjoyed as a parent is how it calms me down to think through how to present a potential conflict as a choice, and I'm guessing that'll be invaluable on the job, as well.

Most of the things Betty has told us about communication I've "learned" at some point or another, but I hope to internalize it all, because it seems like I'd be a better friend, wife, and family member, as well as employee and co-worker, were I to make a habit of all of this stuff: get down on the person's level--sit, if you can; listen; make actual real eye contact and don't turn away when talking or "listening;" never, ever interrupt (I'm terrible about that); and with the elderly, especially, use a low tone of voice, since this could make the difference for them "between isolation and engagement." We also learned a little bit about resolving conflict in the workplace: ask to speak to the person, in private (eek! scary! but so useful.), be willing to hear stuff you don't want to, talk only about the specific event--don't generalize or psychoanalyze or try to make observations about somebody else's behavior patterns, be willing to agree to disagree, if necessary... I wish I'd learned some of that stuff before going to grad school and stepping on toes and later hiding from those whose toes I'd inadvertently stepped on. Ugh. This stuff is _not_ instinctive for most of us, I think--wish someone had explicitly taught it to me. Never too late, right? :/

Why my teacher is great

2009-05-12T17:29:00.000-07:00

My instructor, let's call her Betty, is southern and in her late 50's or early 60's, I'd wager. I first spoke with her when I took an all-day CPR course as this whole NAC class got into gear. I ran into her in the bathroom as I was leaving, and she told me "you know what, with all this MRSA (Methicillin resistant Staphylococcus aureus) and other stuff around, you should just open the bathroom door with your back." I love her accent--it reminds me of a certain kind of southerner I really miss. She sounds like my maternal grandmother, and she has a fantastic laugh. The first day of our actual class she got kinda defensive about a crappy powerpoint thing going on, but she wisely abandoned it altogether and went back to lecturing, and she's great. She's been a nurse since 1974, when she was thrilled to be getting a little over $5/hour. She's been a hospital nurse and a nurse in longterm care facilities, and prefers hospitals because they're faster-paced.

We've had 6 class meetings (all about 2.5 hours long) so far, and at least three times she's brought up the phenomenon of hospitals being obliged to provide care to people in the E.R., and mentioned a few hospitals who have to subsidize 40% of what they do, because it's free, with the other 60% of what they do, which of course makes the costs of the 60% that much more. She said people get sent home sooner and sicker than they used to because of something called DRGs, diagnostic-related groupings, started by Medicare, that determine how much will be spent on a patient's care based on the original diagnosis that put them in the hospital. Sort of makes sense, seems like it might cut down on abuses of piling up procedures to make money. But instead, it sounds like it just forces MDs to send patients home that shouldn't be. A student asked about that, and Betty said that the doctors "are good people, they don't want to do it, they're just trapped by the system." At this point, I raised my hand and asked whether there are organizations for nurses who have opinions on how the healthcare system should work, and do they practice advocacy... she looked at me and said "I teach." True. But it seems like approaching the problems from the wrong direction, so I said "what about policy"? She didn't really answer me the second time. I'll push harder later. :)

I did find out after class today that she's had cancer 4 times; she said she's living on borrowed time.

Nursing Assistant Certification course

2009-05-07T16:57:00.000-07:00

For years I've been reading about healthcare from a top-down perspective as a pseudo-intellectual devourer of articles in Mother Jones, the Atlantic, Harper's, etc. I've formed many opinions about our country's crappy healthcare system, its failures in getting care to the people who most need it, the pattern of people avoiding seeing a doctor till they have to get to the emergency room since E.R.s are not allowed to turn away patients. I'm a big-pharm hating, single-payer-healthcare-system loving typical liberal you'd meet at a party who's read just enough and has just enough personal and anecdotal experience with the healthcare system to have opinions, but not enough, really, to justify promoting them to others to the degree that I do.

So when I decided to become a nurse and went to an open house at the MSN (Master's of Science in Nursing) program I hope, eventually, to attend, and they advised those of us without HC experience to get our Nursing Assistant Certification (NAC) and get some experience in the field before applying, I didn't realize how strange it would feel for me with my surplus of education and dilettantish knowledge of the field to be put into a place where I was taught how healthcare works from the bottom up. I'm taking the class at a local community college, many of my classmates are young, a lot speak English as a second (or third) language, so a lot of the things I'm learning are introductions to concepts such as how a hospital is set up, or what are pathogens, what is the NAC allowed to do, what can the nurse do, what may doctors do...

Because of the number of non-native speakers of English in my class, some concepts get repeated a lot, because they are expressed in an idiomatic way or they are "hard" words. Chain of Command was one of these. It was said in a way that makes me think of A.A. Milne capitalization, and repeated enough that I kept thinking of The Wire, specifically of Lt. Daniels frowning while upbraiding McNulty. I am concerned that my tendency to speak out about what I think will get me into trouble doing this job. As a case in point, I took an all-day course on HIV/AIDS and bloodborne pathogens last weekend as part of this whole certification, and in order to leave, we had to take a multiple-choice test and score 80% on it. I took the test, a few of the questions were poorly worded, so I circled an answer and wrote a comment as to why I chose the one I did, to make it clear I'd understood the material. The instructor graded my test, then told me, I'm sure to be helpful, that if I wanted to do the nursing program at her community college, I needed to "get out of the habit" of writing comments on tests, since it looks like I'm "arguing" with the questions, and it's just "not good." I've been a teacher for 10 years and have probably written over 100 tests by now--it's hard to do it well, and I appreciate student comments, since the point of tests is to make sure students have learned what you wanted them to. Huh.

Since I've told folks I want to be a nurse, most have been encouraging, and have named character/personality traits I have that will make me a good nurse. I'm looking at this drastic career change as an opportunity to be required to change things about myself I need to change: (1) I need to learn to keep my mouth shut. (2) I need to slow down my speech--I'll likely be caring for elderly patients, especially as a NAC, and if they can't understand me, that'll only increase their sense of isolation. (3) I need to move more slowly and carefully, and not multitask as much. (4) I need to get over my desire to make sure others know that I "already knew that," whatever it may be. Like, decouple the ego from the intellect. And, (5) one thing this will require from me that I'm not willing to admit should change is the oomph in my stomach I feel about waste and non-re-use. Preventing the spread of pathogens requires using all kinds of disposable equipment and double-bagging and not (gasp! ouch! ooomph!) that "perfectly good" whatever. That will be hard for me.