Exemplars
Critical nursing incidents where you made the difference
Susan Tregoning
School of Nursing and Midwifery, University of South Australia, SA
PP: 041 - 043
Article Text
Learning by Experience
Heather Sutton RN, RM, App Sci (Nursing), FRCNA
I have worked for many years in a major metropolitan obstetric hospital. I was the Clinical Nurse Consultant in the Emergency Department. We frequently had to care for women who were either miscarrying the pregnancy or threatening to do so. The emotions that the women and their partners were experiencing at that time ranged from anxious to distraught. The woman was often in quite a lot of pain as well as being distressed and anxious about the thought of losing the baby. It was not uncommon for the woman to actually miscarry whilst she was in the Emergency Room. When this happened the midwives and the medical staff would usually quickly remove the fetus or embryo so that the woman and her family were 'not upset further'.
One evening whilst I was looking after a woman who had just miscarried, the RMO rushed me out of the room with the fetus for just this reason. However, I did have a strong feeling that the woman would have liked to have seen the fetus. In fact I wonder if she may have thought that there was something really awful that she should not see. I think that it was then that I began to question 'why shouldn't these people be able to see the fetus if they wanted to?'
Shortly after this experience another woman and her partner came into the Emergency Room and she miscarried there. I remember that the pregnancy was in the very early stage and the fetus barely developed. It was still too soon to determine the sex of the fetus. The woman and her partner were naturally very upset, and while they were comforting each other, she turned to me and asked if she could see the fetus. I remember she asked tentatively as if she thought that I might disapprove. Having had the previous experience I decided that she most definitely could. However, I must say that I did feel that I was taking a risk - I might get into trouble! The reaction of the woman and her partner was wonderful, it also ensured that I would do the same thing again. When they first saw the fetus they cried quite openly for a few minutes. Then the wonderful thing happened. They suddenly began an exploration of their 'would have been' baby. I mean suddenly, because at one moment they were very upset and the next they were fascinated by the fetus. They were examining its form, identifying different parts such as hands and feet. They spent a long time discovering and then putting their baby to rest. I believe that was what they had been able to do by their detailed and loving examination of their 'would have been' baby. They were able to let it go. The couple seemed so much more at peace, and at that point seemed to be resolving their loss. I do not doubt that they would have grieved some more but I do believe that in being able to discover the fetus as they did they were able to put it to rest. They could come to terms with their grief. I am sure that my action that evening made a critical difference to that woman and her family.
Lifetime Memories
Anne Johnson - RN, RM, B Ed, Grad Dip (Health Couns)
I came onto an early shift in ICU and was told that I was looking after a 14 year old girl who had just arrived. The night duty staff quickly filled me in on what they knew; following a severe asthma attack she had arrested in her parents arms on the front fawn of their home at 2 am. A neighbour who was a St John Ambulance officer had resuscitated her. She was rushed to the local hospital where resuscitation was continued. The hospital staff thought she had suffered severe brain damage as a result of the anoxia and was possibly brain dead. The parents were following in their own car and would be arriving soon.
There was a lot of activity and everything was happening very quickly as we set up the ventilator, IV lines, drug infusions, monitoring lines and transducers, took bloods for analysis and completed initial baseline observations.
There was so much activity I didn't get a chance to clean her as I would have like to have done before her parents arrived. She had lawn cuttings in her hair, between her fingers and toes, and dried blood on her skin. I thought that this might distress the parents. After speaking to the doctor, the parents were brought into the room by one of the senior nurses. Their full concentration was on their daughter. They rushed to her side, they both held her hands. They were visibly distressed. I quietly introduced myself and stated that I would be caring for their daughter for the shift. I told them that when they were ready I would explain everything to them. They said they were ready then, so I gave them an overview of the situation as it was, what drugs she had been given and why. This reinforced what the doctor had told them. I then explained all the tubes and equipment. They asked some questions and I answered them as they arose. I said that I knew there was a lot to take in and as the day went by I would be willing to explain again, and again if they wished, as I could sense that they needed to understand fully to try to gain some control over this tragic situation.
I was very aware of the lawn cuttings on her body as well as the dried blood. I apologised to the parents for not having had time to wash their daughter before they had come in, and if they wanted we could wash her together. The father declined but the mother was very keen. The mother wanted to wash and I helped by drying. It was a special time as we washed her daughter. She told me how difficult her daughter had been in recent times and how her moodiness and disruptive behaviour had caused many family fights. We talked about her school, her friends, her likes and dislikes. She noticed so many things about her daughter's body as we tended to her. Her daughter became more of a real person to me as we spoke, and through talking I could identify areas that I would need to talk about with the parents, as I felt they were issues that could hinder their grief recovery if left unaddressed.
When the father came back in to join us we talked about some of these issues. We talked about adolescent behaviour and how their daughter was so typical of her age and stage of development and how difficult it is to tell someone you love them when they are a problem to live with. It was through this conversation that the parents were able to tell her that they loved her. The scenes were very emotional and I felt very privileged to be part of it.
So much happened that day between the parents and myself: too much to go into. I went home exhausted but happy, feeling that I had made a difference and that somehow they would see the time in ICU as positive, even in such tragic circumstances. I was off duty the next day and found myself wondering what was happening, so I rang up. The girl was found to be brain dead and her parents had agreed for her organs to be donated.
I had a feeling of great sadness for these parents and an incompleteness within because I hadn't been able to express this to them after their daughter's death. A few days later there were some items to be sent to the parents, and after conferring with some of my colleagues, I took the time to write a note to the parents on behalf of the ICU staff. This helped me to feel more complete within.
Two weeks later a letter arrived from the mother of this patient and it really confirmed to me the positive effect, not only of my part in the providing of emotional support to families, but the positive effect of the whole team. I personally treasure feedback from parents as it helps me develop as a professional, and learn more about myself. It also enables me to find out what is important to them. The part of the letter from this patient's mother that I particularly hang onto is her expression of how she treasured the time in intensive care and how she would always remember the gentleness and dignity shown to her daughter. For her personally to have washed her daughter was one of her most treasured memories. She also stated that she felt strongly about being able to help to tend her daughter at the end of her life and how it somehow completed the circle. Her feelings of closeness to her daughter as she looked at her nakedness, washed her body and brushed her hair were in her heart for all time. Even the horror of her death on the front lawn was changing for her. She was with her daughter, she held her, and was able to tell her over and over and over again how she loved her.
This incident reaffirmed to me that one should always let parents make their own informed decisions about their involvement in their child's care and should also be flexible enough to respect and support their decisions. In my attempt to protect the parents by wanting to wash their daughter before they arrived, I would have prevented the mother from having such treasured memories to hang onto forever. We not only provide emotional support for the patient's family members during the period of hospitalisation, but also for how they are going to view the situation for the rest of their lives.
Managing a 'Difficult' Client: An Insight Orientated Approach
Nicholas Procter - RGN, RPN, BA
Mrs A observed me closely whenever I entered the room. I could feel her eyes on me. She always told me what to do for other patients even before I'd a chance to ask them. Mrs A occupied bed two of a four bed bay in a surgical ward at one of South Australia's large metropolitan general teaching hospitals. Recovering from a lower spinal fusion, Mrs A, (an RN)was always giving her expert advice and direction to staff on the management of the remaining patients even if they didn't want it.
The intrusion and interruption caused by her was intolerable. It had become part of her daily routine. My colleagues warned other staff entering the ward to 'watch out for that nuisance RN in bed two, she's always telling us what to do'. As my shift wore on I became increasingly angry and frustrated by her interruptions and involvement in other people's lives. She was stopping me from being the kind of nurse I wanted to be ie autonomous and free from unnecessary intrusion by others to practise. I wanted to be free from her! To complicate matters, the other clients were complaining about her over-involvement in their care.
How could I realistically limit the impact of this person's behaviour on others? Maybe I should listen to her more. After all, sometimes she was actually right about things. But, wait a minute, she can't run my life like that! I too am an RN, a competent practitioner. Or should I ignore her, turn away whenever she speaks. Ignoring Mrs A only made me feel worse. Guilty that I was neglecting her needs and doing little to help ease the frustration felt by the other clients. Such guilt left me feeling tied up in knots - an intolerable state of mind. I never thought that anyone could get under my skin like she did.
Next, I tried to encourage her to mind her own business. Generate a climate where her involvement with others was difficult to come by. I avoided making unnecessary eye contact, conversation, or any encouraging sign which may suggest approval of her behaviour. In addition, I spoke with other clients in the bay in a low voice in an attempt to minimise the changes of her 'tuning in' on the conversation. Again this failed. Perhaps due to her understanding the culture and dynamics of a hospital. She was able to 'read' events as it were. Her continual intrusion upon my work continued. I just wished she'd shut up and mind her own business.
By now I was in desperate need to manage this client and my feelings towards her. I was beginning to lose confidence and patience and I could see myself neglecting her care. So, I decided to ask her what she wanted for her care. I thought that perhaps she was asking me for something through over-involvement with others. At first she was silent - then began to cry. Amongst the anger and tears was some explanation of what was going on inside her head. She shouted and made brisk hand and arm movements as she spoke. She expressed feelings of sadness, isolation and powerlessness. Sadness and anger at not being able to perform nursing care on the other women in her bay. Powerless to influence their recovery in a way she knew best. Moreover, because the nurses did not come to her, she often felt isolated and uncared for.
I responded by acknowledgment of her feelings. Through a process of mutual inquiry we discussed what was important to her 'right now'. This was to not feel lonely and isolated. She realised that by constantly telling nurses what to do she in effect isolated herself from them and them from her. Staff avoided contact with her as much as possible. Set her up as a nuisance because of her intrusions and over-involvements. What emerged between us was a move away from a defensive to reflective position. We formulated short and long term goals, working through feelings of disappointment and frustration.
Reflections:
- I learned the meaning of anger. I believe it is a feeling that comes when we want to change something but for whatever reason - can't. Mrs A wanted to change her rate of recovery and overcome the limitations associated with immobility, powerlessness and loss of control.
- I wanted to 'change' Mrs A by ceasing her involvement with others. I wanted to stop her criticisms and comments about the other clients and my nursing practice. I wanted to fix my pain, solve my problem, find a cure. However, progress was slow and only made possible by taking an insight oriented approach to my own behaviour and practice.
- Finally, involvement with this client highlighted the value of being prepared to listen. Active listening and clarifying information, gave rise to awareness of what was needed to bring about change.
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