Relief

I'd been at my new job as Clinical Program Coordinator for a hospital system's stroke program for nearly three months before I recognized a feeling that had been building for some time now.


Relief.


For the longest time I couldn't imagine doing anything but bedside care. Now, I can't imagine going back. After all, there is nothing I can do as a function of my current job that will endanger a patient's health, a patient's life, or my nursing license. I never really grasped what a burden that was and how tired of it I was becoming.

It wasn't something that was at the forefront of my mind whenever I clocked in to do bedside care. Well, not unless I was being floated to someplace like Orthopaedics or Spine: someplace I felt like I was practicing outside my competency. It's not a whole lot different when trying to run a floor short handed, or there are other confounding circumstances that kept me from giving my patients the best care I could.

When I was younger, I either wasn't fully aware of that burden or I was just better able to bear it. But years pass, times change, I've changed. I don't know how some of my colleagues continue on doing 12 hour nights in bedside critical care, for years longer that my 23 years. Perhaps it's a sense of duty, or feeling they have no other choice, or that is what they love about nursing. I already knew my care was degrading, and I had to get out of bedside care before I seriously hurt someone.

And it wasn't just my patients I was worried about injuring. In order to sleep during the day and function at night, I was resorting to unwise courses of action which I will not detail here. I can, however emphasis with Michael Jackson's desperation for sleep, and the lengths one can be driven to to get it.
But it was more than that. In the autumn of 2009, I was off for 3 weeks with the swine flu, and another three with plantar fasciitus. Fortunately, I had more than enough sick time built up. But it reminded me how vulnerable I'd be if I suffered, say, a broken leg (or worse, a broken back). How would I take care of patients? That's about the worse way to have to embark on a career transition, with the question of "transition to what?" not even yet asked.
I can do my job with a broken limb, even if wheelchair-bound. Not having to depend on my body in the same way is an immense relief. Of course, that doesn't mean I feel no obligation to lose the 10 pounds I gained since changing jobs, and then some. I want to enjoy this relief for as long as I can.

I don't regret the burden I carried as a bedside nurse, it was part-and-parcel of a career I continue to find rewarding on myriad levels, and helped me remember that what I was doing was important: "just a staff nurse" is a semantically null term. But it also became a burden that I knew I could not bear for much longer. It was time to pass it to younger and stronger backs.

Sometimes, you don't realize how heavy a burden was until you at last set it down.

The Face of the Vorlon

"When you have doubt of your course in life, you need only look in the face of a Vorlon, and all doubt will be erased forever."

- Dukat, Babylon 5: In the Beginning

While it would be overstating that all doubt has been erased forever, a great deal of it has been relieved recently.

I knew it was time to leave bedside care, but I had lingering doubts as to whether taking the role of Clinical Program Coordinator for a Pacific Northwest hospital system's stroke program was the right move. What is my role? What to I bring to the table? What is my, for lack of a better word, mission?
Just a couple days ago, I "saw the face of the Vorlon." There's an initiative to get all the system's policies, procedures, and protocols "reformatted" into a consistent form. I figured this would be a good task for me to start with: it would allow me to become familiar with the policies and protocols, and it was work I could do without having to hit the ground as a "stroke expert."

Right.

The stroke program was originally the fiefdom of the program medical director and one nurse. The programs policies and protocols had to make sense to them and they were the only ones who needed to be able to explain it. Well, the one nurse retired, and her replacement has been trying to pick up the pieces. As we've been examining the various protocols, we've discovered a lot of vague wording, inconsistency, and formatting that is more complex than necessary.
The nurse education materials aren't much better. The stroke program's clinical nurse specialist and I have discovered that part of the reason neurological checks aren't being documented correctly on many stroke patients is because of conflicting education materials.

Aye-yi-yi...

I know my strengths: analysis, systems thinking, tenacity, and a touch of OCD. The policies and protocols have to be, in themselves, a cohesive system in support of the larger system of the stroke program. Same goes for the nurse education information and materials. They aren't.

It looks like my role will be to make them such. I can't help but think that improving the policy and education infrastructure of the program will lead to better compliance and therefore, better patient outcomes. That may well be the OCD talking, but I believe it anyway.

The uncertainty of what I should be doing each day when I go in to work has vanished. I know what I need to do, and what I most quickly need to know. The doubt is gone.

Besides, I now have a purpose for which I can leverage my OCD. Since I'm no longer doing bedside critical care, I needed something!

Transitioning

After 23 years night shift bedside-care ICU, it was time for a change. I wasn't sleeping well enough during the day, and staying adequately alert through my 12 hour shift was becoming a dicier proposition. Worse, direct patient care was becoming less fun, less interesting, and less personally fulfilling. I didn't like how jaded I was becoming, the person I was becoming, and the nurse I was becoming.
This discontent was augmented by my fifth, and most miserable, Minneapolis winter. I've heard Garrison Keillor wax lyrical about Winter in Minnesota: its austere beauty, its realism...it reminds me of C.S. Lewis's Screwtape describing Hell. I don't think it's a coincidence.
So after much searching, several applications, and a handful of interviews, I'm now in Portland, OR, helping a multi-hospital system run its comprehenisve stroke program. It's a substantial transition. one that, on many levels, is still underway. On others, it has yet to begin.
Patricia Benner's seminal From Novice to Expert is very much my lived experience, except right now, it's going the other direction. I went from being an expert bedside critical-care nurse to being a novice clinical program coordinator. It's much like wandering around a blacked-out sports arena with just a flashlight to light my way. I have no idea what the entire interior looks like or how to make a contribution in its operation.
My role is very different from direct patient care. Instead of working in a system, I'm working with a system and on a system. A daunting challenge, especially in that I only marginally understand the system. So my "sports arena" isn't laid out like any sports arena I've been in, and with my "flashlight," I can barely guess how it's laid out.
This is on top of re-learning how to live in an apartment and find my way around Portland (a really cool city, by the way). My wife and I are building new relationships and learning how to live with each other with this different schedule. It's a little more difficult for her to "nest" in bed with her knitting until the wee hours if I'm there having to sleep.
But it will all work out. We both want this change, and we tried to "be careful what we wished for." We have confidence in ourselves and each other that we will meet the challenge of this transition, and prevail against it.
That doesn't necessarily make it any easier or any more fun.

WWDD?

WWJD poses a worthy question. “What would Jesus do?” effectively gets to the heart of “the big issues”: poverty, justice, conflict, and other major social and moral questions that face us individually and collectively. The answer we come to when we ask “What would Jesus do?” may not be a comfortable one, but it is likely to be morally sound, wise, and kind.

However, not all the questions we face in life are carry moral weight or social importance. They are not questions of “What is right?” but rather “What is effective?” How do I get the fine cat hair out of my rug? How can I be sure everyone is doing this calculation the correct way? Where in cyberspace should this document “live.” To answer such questions, a better acronym might be WWDD: “What would Dyson do?”

Our cat, Caesar, has a very fine undercoat which he is constantly shedding. These fine fibers interweave and trap themselves in our rugs, are difficult to dislodge by ordinary means. That all changed when we got this Dyson vacuum cleaner. It pulled the white cat hair out of the black rug so thoroughly, the rug changed color. My wife and I were sold.

What would Dyson do? In the commercials, James Dyson speaks of “solving the obvious problems.” But there’s more to it than that. You also look at all the “moving parts” involved in the solution, and carefully reason through how to make them work best. But how does this work in everyday problem solving?

One feature of Dyson vacuums is that they are bagless. After all, you never knew quite a bag got full, changing the bag was always a hassle, and you had to keep a supply on hand. A clear, bagless container solved these problems. Where I work, we occasionally have to use a complex formula to measure how well someone’s heart is pumping. It was all written out in standard mathematical format, and people would have to sit down with calculators to come up with a value that provided critical clinical information. What could possibly go wrong?

The obvious solution? All the computer workstations had Microsoft Excel installed. I created a spreadsheet that allowed the nurse to plug in the appropriate values, and presto, the cardiac output would be calculated, consistently and error-free. It is now available on all the cardiac ICU workstations.

The choice of a clear, bagless collection chamber creates its own issues. How do you empty it, as easily and comfortably as possible? The solution involves two buttons. The first releases the chamber from the vacuum. The second, accessible only after the chamber is released, opens the trap-door bottom to empty the chamber. No contact required. I do this directly in the garbage can outside.

Recently, I got to sit in on a meeting concerning paperwork flow. A hospital's (not where I currently work) Ethics Committee is occasionally consulted about "therapeutic interruption of pregnancy" (aborting a non-viable fetus) and must approve the procedure before before the patient is actually even a patient. While this avoids the regulatory hoops and political stigma of becoming an abortion clinic, it created other problems. How do we track the information in the hospital's electronic medical record system? After all, the patient might have the procedure done elsewhere, or not do it at all.

There was talk of creating a “ghost chart” to contain information, to be "resurrected" when the patient was admitted. But in that the patient wasn't even a patient of the hospital, and might never be, they could end up with a number of these "ghosts" haunting them. These situations were also relatively rare: maybe a dozen a year. Creating a "ghost chart" seemed a cumbersome way to address the issue.

Then, they remembered the patient already has a chart, back at the referring doctor’s office. The Ethics Committee’s decision would be sent back to the referring doctor, and “live” in that chart. If the patient is admitted, the chart from the doctor’s office, including the Ethics Committee decision, would follow the patient over. No virtual chart needed. All the moving parts fit together, and do the job elegantly and effectively. It’s what Dyson would do.

Patient care has a lot of "moving parts," and not all of them (and sometime frustratingly few of them) mesh well. What would Jesus do in approaching these challenges? Aside from approaching the challenge with humility and faith, I find it difficult to come up with a useful answer. What would Dyson do? Identify the problems and solve them. Look critically at the moving parts, and thoughtfully arrange them to best effect.

When trying to do what’s right, it would be difficult to better than ask, “What would Jesus do?” Not all questions are about what’s right, some are about what works. In such cases, the more salient question may be, “What would Dyson do?”