The art of nursing is a familiar term, but one which lacks clarity.
Here is a story that shows one aspect of a nurse practicing the art of nursing-intuition.
I was racing in to work one Monday morning on our busy Tele unit, fast walking down the hall, purse still in hand, when I saw her.
Her name was Lynda. She was a young woman in a semi-private room, in the bed nearest the door. At the same time, I caught sight of her heart rhythm on the monitor and saw a tachycardia of around 110-115.
Something within me alarmed. I stopped short and went into her room. Why would a young woman still in bed at six forty five in the morning have a resting heart rate of 110? Her left arm was swathed in a bulky gauze dressing, and elevated from an IV pole.
Her face was ever so slightly flushed, hardly noticeable to the untrained eye. I greeted her in order to closely observe her response. She opened her eyes, and she had those rare kind of startingly blue eyes that take you by surprise. Blue eyes against an attractively tanned face. She was awake, she was oriented.. nothing to put my finger on… but not quite…perky enough to quell my concerns?
All these observations, taken together in the space of about fifteen seconds, sent me into high nurse alert. I tossed my purse on top of the nearest linen hamper (don’t judge) and called her night nurse “I’m in room 4125 B.What’s she here for?” I asked, while assessing her IV site, and glancing at her IV fluids with a plan to increase the rate. Where were her nasal prongs for oxygen? I wondered what her urine output for the night had been.
Her night nurse answered “She was camping over the weekend and stuck her hand in a woodpile to gather wood. She was bitten by a spider.”
Oh. Infection. That explained the elevated arm and dressing. “OK, can we get a set of vitals and a fingerstick”
I can’t tell you now that I remember her blood pressure, so it wasn’t yet alarmingly low. She may have had a low grade temp.
I can tell you what I do remember, and what I will never, ever, forget.
The feeling I had. A sinking, gut feeling. A pit in my stomach feeling.
I was scared. I was scared for Lynda. Something was very wrong.
I called the ICU charge nurse to see if they had a bed- thankfully, they did. Next I called the doctor and told him we needed to transfer his patient downstairs to ICU, and why. She was whisked off the floor before change of shift was over.
In addition to being scared, I was upset. Why had Linda’s change in condition not been caught earlier? As it turns out, the nurse assigned to her had less than six months experience. The same nurse had also been dealing with an SVT of 160 in another patient, a post-op day one open heart. She had actually done an outstanding job in many ways that night.
A heart rate of 110 in and of itself, and when viewed as a discrete piece of information, may not trigger an alarm in a new nurse. It takes time and experience before nurses develop their inner ear and learn to appreciate subtle changes in condition. When the science of nursing rises to the art of nursing.
The art of nursing can’t be taught, but it can be learned.
As for me, I went on with my day, relieved yet vaguely disturbed. I didn’t check up on Lynda. We transfer lots of patients to ICU, and sometimes you just don’t want to know the outcome of every one. Plus, new emergencies and situations present to grab your attention.
Fast forward 20 years. I’m teaching Arrythmia, in a different hospital.
I always try to impress on new nurses the importance of not relying solely on machines and measurements- treat the patient, not the machine. Look for context, trends and baselines.
[Tweet “The grasping of the whole”]
Sometimes what can be measured is only the tip of the iceberg. And sometimes subjective feelings are at odds with the objective signs and symptoms.
And then I tell the story of Lynda with the mild tachycardia and the spider bite.
I’ve told the story many times. What’s funny is that every time I tell that story I re-live the strong feelings I had that Monday morning. The class is usually attentive, but quiet. But this day was different.
A nursing student raised her hand and said, “That was my mother. She died in the ICU.” …..what??……….I was devastated. Somehow I had always assumed that Lynda had survived. I looked at this young woman, and yes, it was like seeing Lynda again. It was her daughter. Same coloring, same sky-blue eyes.
Then it hit me that this young woman, this new nurse, must have been about three or four years old the day I met her mother.
The day I met her mother and we didn’t save her life.
I wish my story about the art of nursing had a better outcome. I wish Lynda had survived, and I wish that her daughter had not lost her mother. I grieve for that four year old toddler.
I wish the art and practice of nursing by seasoned nurses were better appreciated. If they were, more, if not all, nursing units would balance their staffing each shift with an eye towards the experienced nurse to new nurse ratio.
There would be formal oversight of new nurses for a longer period of time, and more resources for them in their first year of nursing. I believe a nurse with six months experience should not be looked at the same as a nurse with six years of experience. But in terms of acuity and workload, they are.
Read Nursing’s Dirty Little Secret .Give nurses the time to begin to develop the art and practice of nursing. Nurses deserve it. Patients benefit from it.
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Until next time, friend