How’s the Weather?

I work as a field nurse supervisor for a home care agency. This means I do a lot of supervising. I don’t provide a lot of “hands on care” to my patients. Don’t get me wrong, I love, LOVE, what I do. But I get really excited when I have a chance to get down and dirty with some bodily fluids.

I have a very special patient who receives visits from a nurse from my agency for a urinary catheterization. This means that there is a small tube inserted into her urethra in order to drain urine from her bladder. If you are interested in a more in depth explanation, feel free to click here or for a ridiculous video demo, click here.

I went to see my patient every month for several years. My function was to “supervise” her care. We would talk about her children and her grandchildren, about her medications and her doctors’ appointment, and about anything else that she wanted to talk about. Sometimes we spoke about her childhood in Europe, how her grandmother was a caterer or how she came to America. I always enjoyed our visits.

One day I went to see her for a regularly scheduled visit and it became apparent that she needed a urinary catheterization. There’s a long back story that I won’t get into, but the bottom line was that my patient was not happy with the new nurse’s technique  so she had cancelled her last visit. Of course, this was not a great idea because the procedure needed to be done, I knew that the best thing for the patient was for me to take care of her at that moment.

Right away I realized a couple of issues:

  1. I hadn’t done a urinary catheterization in quite a while
  2. Well, see #1

I asked her where her supplies where and moved my ID badge into my shirt (yes, that’s a thing we do to prevent gross stuff from getting on our IDs). Then I put a pony tail in my hair, then it broke. I attempted to tie my hair in a knot to keep it out of my face, I was partially successful. I followed procedure beautifully and set up my supplies and began the procedure. It quickly became apparent why the new nurse was having trouble with the procedure. If you have every done this procedure on a woman, you know, some are easy and some are…not. This was one not easy. The patient was patient (lol) with me and we managed just fine. Of course by this time I was sweating and my hair was partially obstructing my view but I was thrilled because the urine was successfully draining.

Quick urine lesson. Healthy pee is light yellow. Dark pee usually indicated dehydration. “Cloudy” pee or sediment (shmutz) often means that there is an infection present.

I was trying to make conversation and appear noncholant while I waiting for the urine to drain.

Me: Are you ok? Are you having any pain?

Patient: Is it cloudy?

Me: No, its nice out today.

 

 

 

 

6 Reasons Why Home Care?

Home care, visiting nursing, community nurse…we are called many things. But that doesn’t change what we do. Nurses who make home visits, regardless of what we call ourselves, are all the same and have the best nursing job on earth.

I became a nurse for many reasons (see my previous post for details). I knew I needed a job right away so I interviewed A LOT. It quickly became apparent that I had some problems. First of all, I couldn’t work nights, this was non-negotiable. I was a single mother, and I had no one to watch my kids. This made me very unattractive to hospitals. I also didn’t want to work on Shabbos (Saturday), also a problem. I needed reasonable hours and/or something close to home (see single mother excuse). I wasn’t discouraged while I was going to all of my interviews and not getting any offers, I knew something was going to come up.

It did.

I got an offer from a staffing company to work per diem at their flu shot clinics. Back in the old days before CVS and Walgreens started giving flu shots, they used to hire companies to staff flu shot clinics at their stores. I went to pharmacies and large businesses and gave many, many flu shots. One woman complained that I didn’t really give her a shot (I did). She said it didn’t hurt at all and therefore I must be lying about giving her the shot. I told her it didn’t hurt because I’m REALLY good at giving flu shots. She didn’t buy it. After that moment I changed my pre-shot speech. Instead of giving the usual list of possible complications and contraindications I added, “the shot may not hurt, but if you want it to, I can arrange that.”

Eventually I was offered a spot in a training program at a home care agency. It was a dream come true (thanks to Sammy and Aviva). The program offered in class training for several months and then orientation in the field and a gradually increasing workload to productivity. It was a challenging time and I made plenty of mistakes but I made it through. I learned quickly that I had the perfect job. I stayed at that job for three years and my next home care position for three years and am at my current position for one year. I NEVER want to leave.

When you see a hospital nurse she is really busy, focused and usually very serious. Home care nurses are always smiling, why is that?

My patients often ask me about my family and how many children I have. Then they all ask exactly the same question, “When do you relax?” “I’m relaxing right now”, I tell them. That is not a joke.

  1. Independence. 

No one was looking over my shoulder. That may sound like a bad thing when you’re a new nurse, but it wasn’t. I may not have done things perfectly right on the first try, but I figured things out. Coming to the solution on my own was very satisfying and exciting as a new nurse. I had a supervisor and case managers in the office who could sometimes answer my questions when I could get them on the phone, but I learned not to bother.

2. Flexibility

I don’t just see patients in their homes. I have done new employee orientation, HHA classes, chart audits, quality control, community lectures, staff education and competencies. Sometimes its nice to spend some times in the office.

I decide when to see each patient. If the patient isn’t available when I want to see them (most were, they were usually homebound) we would chose another option that worked for both of us on a different day/time. This meant that I could go home and eat lunch…or go out for lunch (which nurses get to actually eat?). It also meant that I could schedule doctor appointments for myself or my kids and plan my patients around that appointment…or my kids school play, or a teacher conference, or a trip to the mechanic to get an oil change, or the post office. How do working mothers get things done?

3. The patients

I can sit with my patient for an hour talking about; the photographs on their walls, the numbers on their arm, what they’re cooking on the stove, the work they did “before”, the origin of their last name, their garden, their dog, their paintings, their piano…Of course I discuss their medical history but only after we have made friends. Why would I do it any other way? If I do a good job and I ask the right questions, most of my home and health assessment has been completed before I ask any of the questions on my nursing assessment. My patients are happy to share personal details with me because they trust me. When I teach new nurses I remind them that we are a guest in the patient’s home. We must ask permission before we sit down or place our bag on a chair.

4. The stories

My patients share the stories of their lives with me. Stories of immigration, illness, happiness and sadness. They trust me with the stories that make them who they are. I have met some truly amazing people who have experienced truly wondrous things. I am always humbled by the gifts they give me in the form of memories.

5. The money

The money is comparable to hospital nursing and the opportunity for overtime is usually available depending on the type of agency you work for. Even if your agency does not have overtime availability you can work for other home care agencies per diem while you are working full time for another. I have done this and it has created quite a financial opportunity for me.

6. The nursing

I have treated a wide variety of health issues. No matter what you may hear, home care IS real nursing. Wounds, staples, trachs, PEGs, foleys, sutures, vents, amputations and many more.

I may see a patient two or three times, or I may see them daily for years. Either way I am invited into their life. In this environment I have the ability to help my patients make real changes and I have the honor of watching it happen.

Prostitutes and Italian Restaurant Owners

How do you know if you are having a good day at work? What is the measurement of success or happiness with your work day?

Is it sales? Purchases? The size of a paycheck?

Before I became a nurse I worked as a real estate broker. My productivity was easily determined by the number of houses I sold and the number of apartments I rented. I enjoyed the concrete-ness of my successes. And I had great pride when I was able to relay this information to my co-workers, friends or whomever may have asked me about my work.

I imagine that in every profession the degree of success is measured differently.

Nursing, especially home care can be a very abstract type of nursing. My patients are not acutely ill but usually dealing with some type of chronic disease. My job is to provide care and education that most often does not produce concrete results. So, how do I measure my success? How do I know I am being a good nurse? How do I know if I’m doing it right?

I quickly learned that my productivity as a home care nurse was based on how many patients I saw in one week. It became very important to me to track these numbers. I still have all of the calendars I have used to track my weekly schedule and the patients I have seen each day, each week and how much overtime I got for every day since I started working as a home care nurse. This may seem obsessive but it was all I had. It was the only tangible way I could track my “success”. I didn’t really bother me because it was the norm with the nurses I associated with. They all talked about their “numbers” the same way.

A couple of years ago I had the opportunity to become wound care certified. This was very exciting for all sorts of reasons. First of all, I hardly knew anything about wound care and the thought of becoming certified was a bit of a relief for me. I had felt sorely inadequate because I really had no idea what I was doing when it came to wound care and it seemed that there was no one to help me. My supervisors were somewhat helpful, more helpful than the physicians, but I wanted more. The class was everything I had hoped it would be and more. One unexpected benefit to the class was the ability to literally measure my success as a nurse. I would measure the wounds weekly and track the improvement based on the decreasing size of the wound, resolved infection and decreased depth/tunneling. Until finally the wound was (hopefully) healed…I felt practically godlike.

I realize I am lucky to work at a job where my customers (patients) are always (mostly) happy to see me. I feel bad for people (dentists) whose customers are not quite so happy to see them…or worse, I feel bad for people who work at a desk all day and only see the few people they work with. I have not worked at that type of job in 16 years. At the time I didn’t mind it because I worked with a fun group but I can imagine how different that would have been if I hated my work or my coworkers. And I can imagine exactly what that is like because my dear husband works for the city of New York and not only does he hate his job but deeply dislikes most of his coworkers.

I get a lot of smiles, those are great. I get many thank-yous, those are great too. I recently got a “we so appreciate the work you do, it must take a lot of strength”, that was a particularly special compliment as it was given to me while I was crying in my patient’s home soon after his death. I get few hugs, they do not seem to be a popular form of gratitude. I have received quite a bit of chocolate, some cash, a couple of cards and various gifts including a dress, lipstick, a pin, and once I received a beautiful serving utensil from the adult child of a patient who had recently passed away.

As it turns out I can easily measure how good of a day or week I am having by counting how many kisses I have been offered by my patients and their families. The kiss is truly the treasure. Throughout history, the most valuable currency is that which is the least common, or most precious.

I suspect there are other professions that can also use kissing as their currency of success. My husband and son suggested that these are mostly prostitutes and owners of Italian restaurants. I’m not sure how accurate that is. I don’t know if prostitutes kiss their clients. I know that Julia Roberts had a strict no kissing policy in the movie Pretty Woman. I don’t have any other prostitute experience so I can’t say for sure. I do suspect that owners of Italian Restaurants get kisses a lot although I have never kissed one or seen one receive a kiss. This may be because I only go to Kosher Italian restaurants and they are filled with mostly Jews who don’t typically kiss the owner, maybe because they are Jewish and not usually Italian. I would have to do some research on that.

But the fact remains, when I get that kiss it fuels me and inspires me to do better and to be better. Hopefully tomorrow will be a kiss-worthy day.

Things I have learned:

  1. Gratitude comes in all forms.
  2. Success can be measured in countless ways.
  3. I (possibly) share one of my work goals with that of a prostitute.

Family Ties

Family.

It’s a funny thing when someone in your family is sick.

There are many different types of reactions that the family members typically have.

I had a patient who lived alone in a senior building on the beach. When Hurricane Irene was predicted we called all of our patients and their family members who were being evacuated. My patient’s daughter did not want to talk to me and did not care to discuss her mother’s evacuation. I explained that according to the documents that the daughter signed when care began, she is responsible for her mother if the home health aide cannot make it to her mother’s home due to illness, weather or “acts of G-d”. This patient’s daughter made it very clear that this was my problem, not her problem.

Once I saw a patient for monthly visits who had recently moved in with her son and daughter in law. The patient was near the end of her life and her son felt they should spend this time together. The son spent all day, every day with his mom. He planned activities, took her to get her nails and hair done and to visit her friends. The funny thing was his mother couldn’t really appreciate the outings. She was just too sick and too weak to appreciate or understand what was going on in her surroundings. The nurse I work with joked that the son is busy with his mother’s schedule and his mother is “asleep in her soup”. Maybe this patient’s son was “over doing it”.

One patient I saw was home after a recent hospitalization for a fracture as the result of a fall. She was fine before the fall so she wasn’t receiving any help from family. After she came home she needed some help. I talked to her son about setting up services for his mother. He didn’t know anything about her. He didn’t know where she got her medications or how she usually shopped for food. I was a little surprised that he wasn’t more “on board” and didn’t seem particularly concerned.  Over the next several days and weeks I encouraged the son to be more involved and educated him regarding his mother’s needs. The son “stepped up” and began to worry that his mother was not improving like she should. He took her to see a specialist and she was diagnosed with a terminal illness. The patient died soon after with her son by her side.

I used to see a patient for wound care who had arterial disease (i.e black toes). The patient had a stroke years earlier and her daughter took care of her full time. The patient was bedbound and required complete care, which the daughter lovingly provided. I advised the daughter that her mother’s wounds would not heal and her blackened toes would likely self amputate. The daughter insisted on trying multiple different wound care options and even insisted on a certain type of gauze. I showed the daughter how to wrap the patient’s feet but the daughter insisted on wrapping each individual toe. When I was nine months pregnant this patient’s daughter requested that I be removed from the case. Why? Because she was afraid that it wasn’t safe for me on her stairs. She had four stairs.

I saw a patient recently who had recently had her second stroke. This stroke left her unable to speak and paralyzed on her left side. The patient lived with her daughter and her daughter’s family in a small apartment. The daughter cared for her mother full time including changing her diapers and transferring her with a hoyer lift. This patient required total care and her daughter was happily providing it. I complimented the daughter on what a great job she was doing with her mother, she thanked me with tears in her eyes.

I received a complaint from a home health aide that a patient was developing skin breakdown in her diaper area. I called her husband to ask how often he was changing her diaper. As it turns out, he wasn’t changing her diaper at all. The home health aide was changing it in the morning and the evening and the husband wasn’t changing any diapers in addition to those. I (patiently) explained the importance of keeping the patient’s diaper dry and the husband (claimed) to understand. I followed up with one of their adult children just to be sure that they were aware of the situation.

I want to understand why some families are so attentive to their elderly and sick loved ones and some are so absent. Maybe there’s nothing I can do about it, but I really want to get it. I want to understand so I can help everyone take care of their loved ones so everyone can live (and die) happily ever after. I am aware that this is unrealistic but it is my heartfelt desire. I may have to accept that there is no rhyme or reason to this.

I have worked with a wide spectrum of patients. The majority of my nursing experience is with low income, underserved and poorly educated population. I found that most of my patients felt a strong responsibility to take care of their loved ones. They often didn’t understand their illness or their treatments but they truly seemed to care.  I recently started working with more wealthy and highly educated patients. I was sure I would see a difference, some type of benefit to all of their money and education. It’s been almost a year and I now see there is no difference. The families are the same. Some are hardly involved, some much more so.

I guess its as simple as that. Most people take care of their family because that’s what they are-family.

Lessons I learned:

  1. Always compliment the caregiver
  2. Never assume the family is aware of the client’s needs.
  3. Treat everyone the same regardless of financial and educational status.