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.
Saturday, February 12, 2011
Thursday, January 27, 2011
Soapbox: Permanent Novice
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.
Thursday, January 20, 2011
Nursing Defined (self-plagiarism)
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.
****
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
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.
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.
Wednesday, October 27, 2010
physical exams
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
http://www.nytimes.com/2010/10/12/health/12profile.html
Monday, June 28, 2010
The nurse's role
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.
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.
Wednesday, June 23, 2010
Nursing school is fun
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.
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.
Wednesday, May 12, 2010
Nutrition and Willpower
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
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:
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.
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.
Friday, March 12, 2010
Opportunity costs
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. :(
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!
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.
Sunday, February 21, 2010
Incontinence
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.
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.
Sunday, January 24, 2010
Personality is sorta chimerical
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.
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.
Sunday, January 3, 2010
Getting Paid
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.
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.
Monday, November 16, 2009
Notes from volunteering
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.
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.
Monday, October 26, 2009
Tango and Noodle Hockey
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.
Wednesday, October 21, 2009
Volunteering
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.
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.
Wednesday, August 5, 2009
advice
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!
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!
Friday, June 19, 2009
I will not take these things for granted
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.
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.
Wednesday, June 17, 2009
Vocation
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.
:)
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.
:)
Friday, June 12, 2009
Management
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.
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.
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