Outcomes

I was asked to write a few paragraphs on the subject of nursing sensitive patient outcomes. In other words, I am to demonstrate that what I do makes a difference to the patient, affecting in some way the outcome of their treatment. So this may seem a bit pedantic, expecially as related to what you usually get here, but here I go.

Nursing sensitive patient outcomes are different from medically clinical outcomes. The amount of radiation someone gets or the number of years they take Tamoxifen may make a difference to how long the patient remains free of disease, but those outcomes are measured and celebrated by medicine much more so than nursing. Nursing outcomes tend to be more a result of the marriage of art and science that is the substance of nursing interventions at their most basic level. And while they may indeed make a difference to how long a patient remains free of disease, the measurements of the success of nursing interventions tend to be more anecdotal and less statistical.

A nursing intervention typical of our practice is providing information. Nurses do this each day, as they book consults, do chemo education, teach people how to self-inject; nearly everything and anything that a nurse does provides information in some form. As a simple and specific example, I remember the time I was giving a person first-time chemo for newly diagnosed lung cancer.

I called the patient in, got her comfortable in a chair, and gathered the supplies for starting her IV. I checked her bloodwork and called pharmacy for her chemo. I sat down and started her IV, chatting with her as I worked. When I had the IV established, I looked up and tears were streaming down her face. "Oh," I said, "you should have told me you didn't like needles."

"It isn't the needle," she said. "It's everything."

I pulled the curtain and sat down with her. I talked her through everything that would happen that day. I gave her teaching sheets on the drugs she was about to receive and went through them, so she would know what to look for in terms of side effects. I started from the bare basics, like how long it would take that day, that her husband could stay as long as he liked, where he could park the car, and that they could bring their own sandwiches in to the treatment room if they wanted. I told her the next cycle would be exactly the same, and not as scary, because she would know exactly what to expect, where the treatment room was, what the nurses' names were, how long it would take, and what the drugs would do to her. By the time I left to get her chemo and hook it up, she was much calmer. Another patient, a second-timer, sort of took her under his wing and reassured her that the first time was the worst, just because of the not knowing. It seemed to help that there was someone there to corroborate my story.

The next time I saw her for a treatment, she looked like a different person. She was relaxed and smiling. She said to me, "You know, you were right. It was so much easier coming this time. I knew exactly what to expect and it made all the difference." It felt good to know that my intervention contributed to someone's positive experience, just by telling them what to expect.

This experience taught me that the amount of information a patient has is related very closely to their comfort level (and it can be a bit of a balancing act between too much and too little, depending on what the patient needs). Now, whenever I book consults, I make sure I tell the patient exactly where to come, where to park, how long it will take, and what the doctors will do. When they have seen the doctor, I recap what was said and what they can expect next. I always give them my contact information, and encourage them to call with any little question. It is important for them to know they have access to information.

Nursing interventions, like providing information, compliment and support medical interventions. By telling patients what they need to know, they can focus less on things like how to get to their appointment, and more on what the treatment recommendations are. If a patient is more relaxed and less anxious, they will understand more, and their energy can be spent on healing, rather than worrying. While nurses don't prescribe chemo or radiation doses, they have as much power to affect outcomes, and in different but equally important ways.

Updates

Wow, it's been weeks since I wrote anything. I guess I've been busier than I thought.

A bunch of updates:

Aimee has the loosest tooth in the world. You can see the other one coming in under it but she refuses to pull it out. I remember being so afraid to pull out a tooth that I swallowed it in my sleep, it was so loose. I'm sure it'll pop out eventually... She won't be a college student with a bunch of baby teeth flapping in the breeze, in front of her big teeth. Grade 2 this year, holy cow. And she's so smart... reading just about anything, which is scary. She won't always volunteer to sit and read, but she likes playing with books, and she is capable of figuring out words. She actually put a set of books in alphabetical order by title the other day. She's a really nice kid now. I had my concerns for a while, but she really has settled into a smart, thoughtful, pretty little girl.

Jack is becoming such a little character. He's been playing in a rock band at daycare this summer, requesting things like coloured hair gel. He still refuses to agree to piano lessons, but he does watch Canadian Idol religiously (along with the rest of us) and wants to be just like Rex (who wouldn't?). One cool development, though, is that he learned to swim last week. All year he has refused to put his face in the water. Last year, he absolutely would not agree to swimming lessons, thinking that they would make him put his face in the water. Up to last Tuesday, he would not even blow bubbles. For a while, Trevor started to dunk him if he wouldn't at least practice putting his face in, until it got to the point where Jack refused to go swimming. He would turn Pappa down when he came to pick them up early from daycare to go home for a swim, because he was worried Daddy would dunk him. Suddenly, one day, he started going under, on purpose, voluntarily. In the space of one day, he went from water-phobic to fish. Almost literally. He spends more time under than breathing. I think he's developing gills. Now, he swims under water, jumps in (after a running start, no less), and would prefer swimming to watching tv. Amazing. And overnight. Complete 180. He's inexplicable, that kid.

Jack starts kindergarten in 2 weeks. He's making some reluctant noises every time we mention it, but boy oh boy does he need it. He's bored stiff. I think he'll do very well... he'll be about the oldest in his class. He's slowly starting to get control of his behaviour. There are, arguably, fewer major tantrums. Still lots of rotten behaviour, but I am now becoming convinced he will end up a civilized and likeable adult, eventually.

This means that in the very near future, I will be the mother of two school-aged kids. Man, how did that happed? There is no more baby fat in this house... they are long and lean and too smart for me. In fact, I will be the sugar mama soon... Trevor is also going back to school. Full time university. He is less excited about it than the kids are (which is to say, not excited at all). In fact, I'm more excited than all of them put together. I wish it was me. Maybe next year it will be my turn. I just need to figure out what I want to be when I grow up. In the meantime, I am the Major Breadwinner in our family. We'll see how that goes.

Work lately is busy... some days not as rewarding as others. Both my docs are around now, no more summer vacation, so I am doing my original clinic assignment plus the admin-type stuff. I'm really tired tonight. I thought about Gramma a lot this week. Last week was unpleasantly stressful (the opposite of challenging... one of those weeks where there was so much going on, I was overwhelmed and my brain shut down, and I lost 50% of my capacity for work). It was miserable and frustrating and I didn't want to be a nurse anymore. It was also the weekend they were burying Gramma's ashes (Betty's final parking spot, as the irreverents among us called it), which got me to thinking... how would she look at this stuff? I revisited my new year's resolution, which had, as all resolutions do, fallen by the wayside somewhere, buried in the depths of my discontent, and realized that I could look at things as obstacles or as opportunities. My job has me figuring out and assigning a nurse to cover when another nurse is sick. No one likes to cover. No one likes to do 2 jobs, even for a day. Some whine long and loud about it. I had started dreading telling people when they needed to take their turn covering, because of the whining. When I thought of it as an opportunity, I realized that getting good at breaking bad news could be character building. Maybe it will help me develop a thicker skin. I also started thinking of coverage as an opportunity for a nurse to get some experience she may not ordinarily have the chance for. Somehow, even though this week was the worst yet for sick calls and the resulting staffing crisis (which I was responsible for fixing), I found that my minor attitude adjustment made the week feel less horrible. I'm exhausted now, but the week was bearable. I think Betty was guiding me through it. I'm not talking ghosts or anything supernatural, but if you think of it as a sense of spirituality, I think knowing how she would have looked at things gave me the chance to see them in a different light. I was able to use my energy more productively and more effectively. Thanks, Betty. Your legacy.

Hmmm... maybe I'd better drink to her. I think her spirit is guiding me to pour a stiff one.

Baby

My friend TG, to whom I have referred in the past, usually with reference to running and testosterone, and his wife of 7 years, have recently announced her pregnancy. You'll note I specify it's her pregnancy, although he did, presumably, make an appearance at the outset. And he does get credit for that, but as far as the pregnancy itself is concerned, since she is the one puking, swelling, stretching, and, eventually, birthing the baby, it is her pregnancy. I hope she doesn't find this assignation problematic; I am trying to give credit where it is richly deserved.

In any case, the news of this pregnancy is welcome and wonderful, to all in their circle of friends, and I think they will make a wonderful family.

What I wish to record here for posterity is the kind of dad I think my friend will be. I don't get the impression he feels the least bit ready for fatherhood. In fact, I get the impression he did everything he could to stave off its arrival, for many years, by spending hours in the sauna at the gym. I do not claim to know any other lengths to which he may have gone, but suffice it to say that they have waited a while for this baby.

TG tells stories of his childhood that would grey the hair of any mother. He claims to have been a wild kid. He, in retrospect, may well have been the kind of child offered Ritalin by the pediatrician, just to talk him down from the curtains during a check-up. Beyond mischevious. He even has the scars to prove it. And I get the impression that he's a little worried about the "what goes around comes around" theory of fate. He figures he's in for a kid like he was. I wonder how many times his mother wished that very thing on him? Come to think of it, I wonder how many Emergency Department waiting rooms have heard that kind of vow?

In any case, let me describe my friend. He was my first friend when I moved here in Grade 8. He and his wife are bookish. They have more books than, well, me. They also have a lot of cats. They live in a funky neighbourhood in a house that was a boozecan in its former incarnation, which they have fixed up beautifully. They are both professionals, working at the University. He is a self-proclaimed geek, much like my Trevor. In fact, they boys have a silly amount in common. We wives rarely get a word in edgewise.

He is, self-admittedly, terrified of fatherhood. He never seemed particularly comfortable around our children, certainly never offered to change diapers. He always looked vaguely terrified when they were around, like he was afraid they were going to break spontaneously or poop or ask him where babies come from. He never claimed to have any particular affection for babies, at least human ones (feline ones were always welcome). In short, he is a person whom I could easily imagine remaining happily childless for life. But then true love took over, and now he is on his way to becoming a dad.

I want to put down in writing, for posterity, the kind of dad I think TG will be. Here is my prediction.

I think they will have a girl and give her an interesting, different and not trendy name. I think she will be a little princess (I mean that in the nice way, not the snotty way) who loves frilly dresses and wants to be a ballerina. I predict she will love the colour pink and pine for a canopy bed. I think she will have a fluffy white cat and will cry for weeks when it dies during her teenage years. I think TG will be the ultimate princess dad. I picture him building her castles in her bedroom and playing the dragon. I picture him changing the diaper in the middle of the night before bringing her to bed to nurse, so mom doesn't have to get up. I can see him memorizing the ages and weight limits for each kind of child restraint and I can even see him driving a mini-van. He will read to her the day she is born (immediately after he shows her the computer and teaches her the joy of Google, or, terrifyingly, World of Warcraft). I think he will be a patient and attentive, if realistic parent. His child, like every child, will be the Cutest. Thing. Ever. I see him passing along his dry and sometimes obscure sense of humour to his child. I expect this will be the most literate child in the history of the world. And will prbably have really good eye-hand coordination.

From her mother, she will get a sense of adventure, and will probably see the world, with (or from) a backpack. She will also have a spectacular wardrobe, and not a thing in it will have been bought for full price. She will attend every folk festival from conception to retirement and beyond. She will be born at home, and have a gentle, comfortable start in life.

I am so excited for this family. I can't wait to see if I'm right. Regardless of whether I have the baby's character right, I think these two will be fabulous parents.

I find it interesting to note that this baby was conceived about the time dad-to-be was shoring up his stores of testosterone for a 5 km road race in which he was running against our oldest (female) friend, whom he beat by mere seconds. I wonder if there's a connection between hormones and, well, you know.

Another race in a week or two... it might either means twins, or a thrashing that will wither the 'nads of our prolific friend?