I was a better nurse when ...
Jacqueline Vance, RN
It's Nurses Day — a day we celebrate all it means to be a nurse. This day gets me into deep thinking. Particularly about the core of a nurse and how sometimes — even if we don't want it to be — the environment we work in changes us. Let me try and explain.
When I first started out in long-term care, I was a bit ignorant of the “Big Red Book,” better known as The State Operations Manual (SOM), Appendix PP, Guidance to Surveyors for Long-Term Care Facilities. This doesn't mean I wasn't aware of its existence, just that I was not as intimately familiar with it as I am now (as in, I can recite F-tags in my sleep).
I had worked in acute care early in my career where the patient's comfort and needs came first, without bumping into federal regulations. My first jump into long-term care was in opening an extended care facility (ECF) in a hospital. We received a patient on our unit who had advanced metastatic bone cancer. I will never forget her after all these years.
She was a tiny woman, wasting away, lost in her wool socks, nightgown and these colorful cotton head wraps a family member made for her as her bald head — after many rounds of chemo — embarrassed her. I'll call her Mrs. X. One day, one of the nursing assistants came to me. She said that Mrs. X was crying and asked if I would go speak with her.
I went in and sat by her, and after a while I was finally able to get her to explain why she was so distressed. She told me that she just wanted a tub bath and no one would give her one. She spoke of how tub baths were one of her greatest joys and with all of these months in the hospital, she had not had one and was afraid she would never again enjoy one.
Now, of course, the risks were lost on no one. She was not only a fracture risk but even adjusting her position caused her a lot of pain, despite being on some heavy duty IV and breakthrough oral pain meds.
But I, just wanting to meet her needs and wishes, decided to figure out a way.
We had a fabulous tub you could pre-fill in a side tank and lay the patient on a bath bed and then release the water in the bath room. I figured that perhaps with two nursing assistants, if we got a stretcher and transferred her to that, wheeled her into the bath station, laid some towels down to pad the bath-bed, and carefully laid her on it; and if I held her while the two of them washed her, we could do this. We did discuss the risks and she acknowledged and signed off on them. Then, the three of us and the patient set off on the task.
It worked. I'll never forget how she sighed; how she even let us remove her head covering and wash her head. How we kept her in there till the water started to cool.
Ninety minutes later, we had her safely back in bed, powdered, with fresh socks and pajamas and head wrap. She was very content and sleeping almost immediately, the three of us staff soaking wet but very satisfied — and very behind in the rest of our tasks.
It never occurred to me the bazillion F-Tags we violated by what we did. Or how I was more than an hour behind in treatments for the other residents, or how the nursing assistants were behind in getting their assigned residents up and dressed and ready for rehab, etc. We all somehow caught up and I found a neighbor to watch my daughters so I could catch up on my charting before going home.
Before I left that day, I went to see Mrs. X. I let her know that the next day I had off but that when I returned, I would stop in her room early to see if she wanted a bath again. I told her to just let me know so that I could arrange the time better.
Mrs. X passed away that night. That bath was the last act of kindness anyone had the blessing of performing for her. I've spent many moments since then wondering: Now that I am acutely aware of the regulations, would I have made the same decisions? Would I have let my fear of survey penalty rob me of my intrinsic nature of what makes me a nurse? And would that have robbed her of the one thing she wanted before she died?
I'd like to think I would have done the right thing. But would I have put it off? Would I have run this by some ethics committee or a quality committee or something that would have taken too long and missed the limited time window we had (but were not aware of)?
Do we allow the regulations to bump against patient-centered care planning? Sadly, I have no answer. But I do know this: I became a nurse and am a nurse to be a nurse. And that should be what guides us on a daily basis.
I think good care comes first, and that good regulatory outcomes will naturally follow. At least on this day I will make myself believe this.
Just keeping it real,
The Real Nurse Jackie is written by Jacqueline Vance, RNC, CDONA/LTC, a 2012 APEX Award of Excellence winner for Blog Writing. Vance is a real life long-term care nurse who also is the director of clinical affairs for AMDA – The Society for Post-Acute and Long-Term Care Medicine. A nationally respected nurse educator and past national LTC Nurse Administrator of the Year, she also is an accomplished stand-up comedienne. She has not starred in her own national television series — yet. The opinions supplied here are her own and do not necessarily reflect those of her employer or her professional affiliates.