A Nurse Narrative
Nurses are compelling story tellers with compelling stories to tell. Nurses’ most memorable stories include situations where they have made a difference, where breakdown has occurred or where there was important learning. Public story telling among nurses helps make distinctions in clinical practice visible and creates opportunities for ongoing discussion and learning. Even the story teller learns from telling the story.
BWH Nurse periodically features clinical nurse narratives for the purpose of stimulating ongoing discussion and advancing our learning as a professional community. This narrative is told by Kathleen McIntosh, BSN, RN, Tower 14CD, and is followed by comments by Ellen Liston, MS, RN, program director, Nursing Practice Development, and advisor to the BWH Nursing Practice Committee.
By Kathleen McIntosh, BSN, RN, Tower 14CD
Recently I had a challenging patient while working nights. I assumed care of my patient at 7 p.m. after getting the hand off from the day shift nurse. The patient (Ms. G.) had a very difficult day. Around 12:30 p.m., the nurses heard a loud moan and scream from her room. Rushing in, they found the patient flailing in bed with a new right facial droop, right hemi paresis and aphasia. The stroke team was called, and after all her tests were completed, she was diagnosed with multiple embolic strokes.
She had been admitted into the hospital with neurologic deficits and visual changes. She was a long-term breast cancer patient who was nearing the end of her life. An MRI had shown what was thought to have been metastatic disease of the brain; she was then started on decadron and radiation to the brain. On a second read, they decided it was actually emboli. Then this event occurred.
I had just started my two weeks on nights when I met Ms. G. My thoughts were that this was going to be a very challenging patient and, in addition, I was also precepting a senior nursing student. My first night with Ms. G. was very difficult; she was restrained with a Posey vest since she was unaware of her environment and very impulsive. She was agitated, and you could see in her face her frustration over her inability to communicate and express her feelings. I needed to figure out how I was going to make her safe, comfortable and support her husband, who stayed with her every night for the rest of her admission. We alternated from giving pain meds, giving Haldol and repositioning her to calm her down. At some point, when there was nothing I could think of to do, I held Ms. G. and stroked her head until she feel asleep.
By the second day, Ms. G. appeared to be doing better. I stepped off the elevator for my shift, and Ms. G.’s husband was right there to update me on her day. He set up some goals on how he wanted the night to go. One request since she was more awake and aware was to receive fewer sedating medications. I was on board with this plan. Ms. G.’s children had been at the bedside all day, helping to make sure she was safe and comfortable. With their help, Ms. G’.s Posey vest was removed, and she felt less restricted in the bed. Still very weak on her right side, she was still unsafe or unable to walk. The plan was to place the Posey back on the patient when the family left or the husband was asleep, but it remained off all night, and we were able to discontinue it. Unfortunately, on this particular night the patient could not get herself comfortable in the bed. She seemed uncomfortable in her own skin, and you could see when she looked at you she had no clue what to do. She was scared. Even though her husband expressed to me to not give her any sedating meds, I explained that she needed some sleep for her body to recover from this stroke. She needed to calm down and rest. Some Haldol was given and worked great; finally she was able to rest. I was exhausted and ready for my weekend off. But what I realized is that I could not stop thinking about Ms. G. and what else I could do for her.
By my Monday night shift, I was there early to see how the weekend went. I was so happy to see Ms. G. up walking around with her husband and son who had flown out from San Francisco. Ms. G. was feeling so much better, and, even though she was still unable to communicate, she was able to show us what she needed by nodding her head. She even did a little ta-da pose when I walked into her room. This night was still difficult for Ms. G. I walked her around the pod and gave her rides in the wheelchair. Again, she was restless, and for some reason I could tell that she did not want to go to bed. I ended up sitting with her on her husband’s cot, since she refused to go into her own hospital bed. With our arms around each other’s sides, I asked if she was afraid. She nodded her head. I asked if she was afraid to sleep. She nodded her head. I asked if she thought something bad was going to happen again. She nodded her head. This woman was such a tough woman before this stroke and the cancer occurred. You could tell by the pictures, cards and family involvement that she was loved so incredibly much. But she was so scared and vulnerable now. As nurses, we want to be able to do it all; we want to be the ones that know what we can do to save a patient. This was a tough one for me, and I struggled to find something that I could do for her. We talked about how we were all here watching her all night and we would make sure she was safe. Finally lying in bed with her husband, she fell asleep.
The last night of Ms. G.’s admission, I was not her primary nurse, but that didn’t stop me from helping her nurse, who was grateful for my advice on how to calm her down. This night, in true Ms. G. way, she was refusing to go into her own bed, and finally, from sheer exhaustion, she fell asleep on her husband’s cot. I just had to laugh. Saying goodbye to her and her husband that morning was hard. She had been a patient that I was initially afraid to work with, and she ended up being my most rewarding and memorable experience. I was going to miss her and her family, for they had an effect on me too. I was so moved to see how much love and patience they had with her.
Ms. G. recently passed away. I am very saddened for her family’s loss. She will be a patient that I will never forget.
Commentary
Caring practices, including interactions and interventions guided by strong notions of good care, is one of the characteristics of excellent practice that was uncovered in the practice of BWH nurses in Finding and Defining the Good, a qualitative study conducted by the Department of Nursing. This characteristic is evident in Kathleen’s narrative, as is her engagement with Ms. G. and her husband. Kathleen’s emotional connection to Ms. G. and her concern for Ms. G.’s vulnerability compel her to find ways to comfort Ms. G. and seek the least restrictive ways to keep her safe from harm.
As I read this narrative, I was struck with the word “challenging.” Kathleen said Ms. G. was “challenging,” though the word was not meant to label Ms. G. Rather, it was used to describe Kathleen’s own state, for it was she who felt challenged. Throughout her story, Kathleen is challenged to figure out how she was going to keep Ms. G. safe and comfortable. She could not stop thinking about what else she could do for her and searched to find something. I spoke with Kathleen, wanting to learn more about how this patient challenged her and about what guided her judgments and interventions.
I asked Kathleen what it was like caring for Ms. G. that first night. She said, “you want your patient to have a restful, peaceful night and she was restrained; you hate having to restrain a patient. She could not calm down, she was writhing in bed, and she could not focus or communicate.” As I listened to Kathleen describe this, I heard the emotion in her voice, and I asked how she herself was able to stay calm. Kathleen acknowledged that it was very hard. She laughed at herself and said having a student with her was helpful. “You are not always calm and you don’t know what to do. Explaining to my student helped me. Talking helps me.” Kathleen shared Ms. G.’s distress and vulnerability, and that fueled her to keep searching for relief for her patient. Kathleen’s awareness of her own responses helped her organize her thoughts, explain her actions to her student and remain engaged and comforting to Ms. G.
When Kathleen returned the next evening, Ms. G. had improved, though she was still restless. Her husband was reluctant to sedate her. Kathleen said she understood that he wanted to be able to interact with her; that it helped him see she was getting better, and that she was more like herself. Kathleen said she had a good rapport with Mr. G., who was “a very kind and intelligent man.” Because of this rapport, Kathleen was able to make the case that Ms. G. “would have a good tomorrow if she rested today.” Mr G. was on board as long as he was involved. Kathleen demonstrated her skill with Mr. G. by extending her caring practice to him, by being attentive to his needs and by providing him with information and support.
Kathleen returned after a weekend off, and while Ms. G. had continued to improve, she remained restless and sleep remained difficult. She described sitting with Ms. G. on her husband’s cot with their arms around each other and asking if she was afraid to sleep and if she thought something bad was going to happen to her again. I could imagine that moment, with patient and nurse sitting side by side holding each other, and I asked Kathleen about that. She said that because Ms. G. was a nurse, she believed Ms. G. understood that she was trying to help her. Kathleen acknowledged that “it was very hard (to ask those questions) because I didn’t know what I would do with the answers – I did not know how to make her less scared. No one else was asking those questions.” She told Ms. G. that she was watching over her and that she would be safe. Kathleen believed her reassurance relieved Ms. G., and this relief helped her to finally rest. Kathleen made the choice to ask these questions, which took great courage as she was opening the door for Ms. G. to share her fears and anxieties even though she might have no solutions.
Kathleen was not Ms. G.’s nurse on the last night of her admission. I wondered with Kathleen how this happened, and Kathleen recalled that it was the result of the scheduling dilemma of coordinating eight- and twelve-hour shifts. However, Kathleen passed on her wisdom about Ms. G. to her colleague, and, in this way, continuity was maintained. Kathleen was not surprised that Ms. G. would not get into her bed. She said this had happened with her as well, and her concern was that the cot didn’t have a bed alarm so she positioned herself at the door of Ms. G.’s room. I asked her where she sat this last night. She smiled and said, “at her door.” Her sense of responsibility for this patient did not waiver even though she was not her assigned nurse.
Ms. G. transferred to a rehab facility, but she was readmitted the next day to the oncology service. Kathleen was informed by Ms. G’s husband that Ms. G. had died. Kathleen reflected on what she learned and said, “It is a great thing taking care of people who are so vulnerable–holding a hand, consoling the family, asking the right questions–I can do something.”