I have just passed the one-year anniversary of a life-threatening, out-of-the blue health event. On February 17, 2011, I became acutely ill while in Washington, D.C., for a one-day meeting of the Board of Directors of the Nursing Alliance for Quality Care. After one night in the emergency department (ED), I was discharged “home,” that is the hotel, only to return to spend another night in the ED when I was diagnosed with bacteremia and an ileospoas muscle abscess. The abscess was located in my right pelvis next to my artificial hip that had been replaced 5 years previously. Due to insurance coverage, I was transferred across town to another hospital for a 2-week stay before I was stable enough to fly home to Denver with a drain in the abscess and a peripherally inserted central catheter (PICC) line for another 8 weeks of oxacillin every 4 hours. My editorial is not about the details of my illness but rather my observations about nurses and nursing care during my illness. My intent is that excerpts of my “story” will help you understand the importance of what you do each and every day, and why only your best care is good enough.
Nurses are the watchdogs that keep patients safe in a complex health care system and the advocates for patients who are too ill to problem solve for themselves. Unfortunately, sometimes those watchdogs and advocates are not on duty! After my arrival by ambulance and first night in the ED, I was discharged with an incorrect diagnosis partially due to the fact that no one saw my significantly elevated white blood count (WBC) recorded by the laboratory 3 hours prior to my discharge. Multiple people should have seen that report, including the physicians, but more importantly, the nurse. I know they were busy in the ED that night with many seriously ill and injured patients, but my elevated WBC with its left shift was missed.
When a resident physician discharged me the next morning, I had been hydrated intravenously (IV) and had received dilaudid, diazepam, and odanestron. I felt better, however, I was drugged, alone (my husband was on an airplane from Denver to D.C.), and unable to effectively process information or to problem solve. I simply was given two written prescriptions, told I could leave, and advised to see my primary health care provider when I returned to Denver if the “muscle spasms” continued. A nurse was not with the resident while he gave me these discharge instructions. Left alone, I remember lying on the gurney trying to figure out how I could get dressed by myself. My hip still hurt badly if I moved it at all, and I was totally wiped out. About 30 minutes later, a nurse came through the door and was startled to find me still in the bed believing that I had left after being discharged. She helped me dress, but she did not ask me where I was going, how I was getting there, or if anyone was available to assist me. I was too impaired to ask for help or even to remember that I knew people a few floors above the emergency room, including the Dean of the School of Nursing, whom I could have called for help. After all, I had been medically evaluated, deemed to have nothing seriously wrong, and discharged. I could certainly get out of there by myself.
I somehow made it through a long hallway moving haltingly from chair to chair, until I reached the front of the hospital and was able to get a cab to take me back to the hotel. There, a very kind bellman took one look at me and said, “Ma'am, you sit still until I get a wheelchair to help you.” How observant he was, and it was he, not a nurse, who watched over me until my husband arrived a few hours later. My experience that first night in the ED left me asking, “Where was the nurse?” My care in the same ED the second night was much better when my leukocytosis and bacteremia were recognized shortly after my readmission.
Nurses who are highly competent stand out in a patient's experience and help alleviate the anxiety that is normal as a patient is prepared for an invasive procedure, the success of which is doubtful. On my first trip to interventional radiology (IR) to attempt a drain placement into my abscess (an attempt that my physicians thought did not have a high probability of success), the nurse who cared for me was amazing. She was relaxed yet vigilant, informative yet reassuring, by my side seemingly constantly yet competently monitoring the scene of her physician colleague and the others in the procedure room. She was my nurse, and she was in charge of my care. I was comforted, and my anxiety dissipated.
Nurses are the bedside guardians against illness-related and hospital-acquired complications. I experienced skin breakdown on my sacrum and pneumonia for the first time in my life while I was hospitalized. I tried to move because I knew I should (after all, I'm a nurse), but my hip was so painful that I could not do so alone, and I do not remember that the nurses regularly helped me reposition myself to get off my back or assessed my skin for signs of pressure. By Day 4 of my illness it is not surprising that skin breakdown was apparent. I also am concerned about the bedside observation of patient status that nurses have relinquished to auxiliary staff during rather mundane activities such as checking vital signs. The day before my pneumonia developed, I remember that when my vitals were taken, the nursing assistant repeatedly asked me to breathe deeply to get my pulse oximeter reading above 90%. I wonder if my nurse ever was told that my pulse ox was persistently in the 80% range or only that my vitals were “normal” after they succeeded in getting my reading above 90% by coaching me to breathe very deeply?
In retrospect, I should have told the nurse … or should I have needed to? Approximately 36 hours after I remember this occurring for the first time, I spiked a fever and began experiencing significant shortness of breath. A chest X-ray confirmed the pneumonia. Then I received an incentive spirometer that the nurses pushed me to use and another antibiotic. I can't help but think that the pneumonia could have been avoided with more proactive nursing care.
Nurses (or at least this one) are not good reporters of the seriousness of their own symptoms. When I arrived at the emergency room, I felt lousy in a profound “in-my-core” way that I had never experienced. I knew there was something very wrong with me, and I have developed a whole new appreciation for the term general malaise. I was cold to the core but not running a fever; hypotensive, but my blood pressure runs low as a matter of course; nauseated, but not vomiting; and in pain, but it wasn't a 10 on the sacred 1–10 scale of pain assessment except for when I or someone else moved my leg. Since then, I have been reminded that these are the nonspecific signs of sepsis, but I was unable to communicate how sick I felt or that I had never before felt so sick. As my hospitalization continued, I found being asked to rate my pain on a 1–10 scale every time I needed pain medication rather meaningless. It was not helpful to me, and a simple mild, moderate, or severe would have worked quite well. I found myself just picking a number out of the blue most of the time because I was too sick to seriously evaluate the severity of my pain quantitatively. I just knew that I needed relief so that I could rest.
Nurses can be “victims” of technology, and patients suffer as a result. Let me give you an example. About the third day, my serum potassium was low, so an order was placed for oral potassium replacement—those huge pills! I was still nauseated much of the time, was on several big-gun antibiotics, and when my nurse for the day arrived to give me the potassium pills, I was dry heaving into an emesis basin. The nurses carried a handheld scanner that they used to scan my name band each time they gave me any medication or treatment. A very nice safety feature that I am sure many of us use. However, in this circumstance, the nurse was “controlled” by her scanner. She returned to my bedside about every 15 minutes for the next hour, during which I continued to be profoundly nauseated and insisted that I must take the pills because she had already scanned them! Of course, I refused and offered that an IV version of potassium could work quiet well. She seemed quite frustrated with me. She and I were victims of the technology; and most likely, she simply did not know how to delete the prior scan indicating the medication had been administered. Was this patient-centered nursing care?
Lest you think that I had inferior nursing care throughout my hospital stay and home recovery, there were many high points in my care. Many of the nurses who cared for me were excellent, and a number of them were quite young. These nurses allowed me to relax knowing that my nurse was competently watching over me. However, overall my nursing care was somewhat like being on a roller coaster with high points during which I was reassured and low points during which my own nursing vigilance was activated because I felt insecure in the nurse's abilities. I also can tell you that having a float nurse for 4 hours of a 12-hour shift because my nurse only worked 8 hours was not in my best interest. Patients need continuity in their care, and a 4-hour fill-in nurse is not the answer.
There are three other nursing encounters that I must share, one a negative and the other two highly positive. The negative was an experienced nurse who did not know how to irrigate my drain into the abscess. She believed that you only irrigated the tubing into the bag, and I knew it was the drain into the abscess that needed to be irrigated to keep it patent. My husband had become quite skilled at “milking” the tubing to help keep the drain flowing. The nurse was kind and caring, and with my questioning and encouragement did agree to check with her colleagues and later returned to irrigate the drain appropriately. But what about the patient who does not know to question the nurse's action as I did? My drain could have become clogged requiring more aggressive intervention to open it or even replace it. I recounted this experience to the highly competent IR nurse practitioner that saw me each day and she promised to do some corrective teaching with the nurse.
A very wonderful experience was with the nurse who inserted my PICC line on my final day in the hospital. She was amazing in the full sense of the word and has been an IV therapy nurse for 27 years. She was wonderfully in tune with my anxiety about having the PICC line inserted, quietly calmed my fears, explained each step in the process, and expertly got the job done. It was such a relief to get the PICC inserted because, by then, I had no peripheral veins left on either arm. Another high point in my nursing care was my home health nurse from the Visiting Nurses’ Association. A former neonatal intensive care nurse, she spent 2 hours at our home late on the evening we flew back to Denver explaining everything to my husband and me about the intravenous pump, my drugs, and the care of the PICC line and my abscess drain. She was available whenever we needed her, providing that professional guidance and safety net for in-home care that even those patients who are “in the know” need. I keep looking for her at the grocery store in hopes of seeing her again.
There are many other “learning experiences” that I had as a patient about nurses and nursing that I could share with you, but I think these are enough. I want you to hear that, as a nurse, I was sometimes very confident in the nursing care I received but at other times very disappointed. Nurses are truly the ones who keep patients safe in a system that is prone to error; the patient is only as safe as the next nurse who assumes her care. Here are some thoughts about being a nurse that my encounter into serious illness taught me:
- Nurses at the bedside must be the best among us; there is no room for mediocrity.
- Nurses must leave their troubles at the door and vigilantly guard their patients.
- Nurses must hold themselves and each other accountable for the highest quality care.
- Nurses must be willing to admit when they do not know what to do and seek the help of their colleagues.
- Nurses must be aware of the extreme vulnerability that even knowledgeable people experience as patients, particularly when they are acutely ill.
- Nurses must remember that even if their patients are nurses or other health care providers, they cannot always accurately evaluate their own status and describe their needs. You, their nurse, must be present and actively caring for your nurse or other professional colleague.
- Nurses must understand that they are their patients’ and their patients’ families’ first and most important advocates.
- Nurses at the bedside are the constant in the patient's care. Physicians and technicians come and go, but it is the nurse who is the “glue.”
- A competent, caring nurse at the bedside protects and promotes health, well-being, and healing. Positive patient outcomes are highly dependent on nurses providing excellent care.
My message is actually quite simple. You, a nurse, are absolutely essential to quality health care for every patient. Your patients are dependent on you to be knowledgeable about their situations, confident in the care you provide, caring in every patient encounter, committed to patient-centered care, and willing to accept no less than excellence from all others who are involved in your patients’ care. It is the nurse who is the patient's primary advocate and provides the big picture view that helps prevent error in health care and the avoidable complications of illness and hospitalization. I am deeply grateful to all the nurses who were with me and expertly cared for me during my illness and recovery.