Senior Nurse Mentor

The Costs of Controversy

Loyalty to the nurses I worked with, a need to place patients first, messy hospital politics, and the complications of caring for teens despite a hostile head nurse were among the reasons why I didn’t act on the larger issues such as the lack of air embolism training or the growing tension between the administration and nurses. It was all I could do, I told myself, to do my job well. I wasn’t running the hospital. Heck, I was so far down the chain, I didn’t even have a clear idea how the hospital was run. 

There’s another reason I avoided plunging into those larger problems. Controversy creates trouble. Creating it might weaken my credibility, something I valued highly. I depended on that credibility to allow me to have influence decision making despite my lowly position. I deal with that in more detail in My Nights with Leukemia, but I’ll touch on it here.

Medicine attaches great importance to numbers. Working nights on a medical unit, my nurse and I spent much of our time collecting numbers for flow sheets kept in bright yellow notebooks. That included fluid in and out, as well as vital signs such as temperature and blood pressure.

After I’d worked on Hem-Onc for about six months, I realized there was an aspect to patient care that couldn’t be captured by numbers. A child’s brain is sensitive. A change in mental status or personality could signal a problem well before the numbers turned sour. Since I was providing hands-on care while parents slept, I had the best opportunity to sense those changes.

For those intuitions-without-numbers, I needed credibility—lots of it. If I sensed that a patient was in trouble and that his or her chemotherapy needed to be stopped or blood tests run, I had to be taken seriously. Unable to change medical orders or protest them on my own authority, I had to persuade. In My Nights  you can read about the situations that arose and how I handled them.

Credibility meant being as error-free as possible. I could not afford to make mistakes, even small ones. During my 26 months at the hospital, I made tens of thousands of decisions. Not all of were right, but none were bad enough to generate an incident report. Why? Because I learned from everything. If I heard about a mistake, I came up with a way to prevent it. If I almost made a mistake, I learned what not to do. If I made a mistake without bad consequences, I made that a lesson. The result was that I never made a mistake that mattered.

That gave me credibility. In the wee hours of the night, based on nothing but a gut-level hunch, I feared that I might need to raise such a fuss that phone calls would go out and the issue I was raising would be brought to specialists with many years of experience. I didn’t want their decision to be distorted by, “Oh, that troublemaker again.” Unfortunately, given how people generalize, creating political trouble might damage my credibility on medical matters. Since a child’s life might hang in the balance, I could not afford that risk.

No, this wasn’t about courage. I can be stubborn when I want to be. I was willing to risk being fired to get a child’s treatment changed. In my mind there was a scale. One side was labeled “A child dies because of delay,” while the other read “I get fired for raising a false alarm.” Seen that clearly, any risk and any cost I might pay was worth it. I couldn’t give a child back his or her life, but I could always get another job. My real worry wasn’t being fired. It was being ignored.

Keep in mind another factor. That was an easier choice for me than it was for a nurse. I didn’t have four years invested in my education, nor was I planning a career in nursing. Getting fired only meant the loss of perhaps a week or two of income before I found another job. That was an easy choice to make, especially for kids I liked. The downside would be leaving them behind, but I would never betray them.

The difficult came when I needed to put my credibility on the line for something less clear than the little girl who had grown oblivious to her surroundings in the last hours of her chemotherapy much that I describe in My Nights. Looking out for her was my responsibility and one I would defer to no one. Raising the alarm when she was in trouble was precisely what I was supposed to do. It was the reason I was there.

In contrast, pushing the hospital to train for air embolisms might be a good idea and might even prevent something bad from happening. But it wasn’t a part of my job like those children were. I carried weight when my patients where involved, weight I could use to influence decisions. I might end up accomplishing nothing if I took on larger issues and was labeled a troublemaker.

To have that credibility, I must tread carefully in other areas too. I must get along with other staff, even those ill-tempered day nurses. I had to show good judgments in small matters, so if a situation came up where I needed the nurse to back me up in something serious and fraught with risk, she would.

That was the situation on night shift. On my own initiative I could have the operator connect me to the sleepy resident who’d been assigned to Hem-Onc that night. I did that all the time. But I could go no higher without the assistance of others.

On day shift, I faced a different challenge. Since the hospital was fully staffed, expertise was so easily available that even I could simply pick up the phone and call. I did not hesitate to use that new-found power. I knew all too well how little I knew.

On one occasion, at the end of my shift I was sent to day surgery’s post-op area to help a nurse overwhelmed with caring for five small children by herself. One by one, the children awoke and recovered enough to go home with a single exception. One two-year-old boy would not wake up. I knew little about post-op care, and the nurse seemed to know only a little more than I did. At my insistence, a nurse anesthesiologist was called in. On nights, such a person might be a half-hour’s drive away. On days, she was just a minute’s walk down a hall.  She said the boy was fine. I liked having experts on call like that.

Day shift had a problem though. With all the hustle and bustle, patients were sometimes ignored. That’s what happened with Lenny, a seventeen-year-old boy, when an accident, probably involving a motorcycle, sent him to our ICU in a coma. When he came out of that coma, he came to us. He was able to look around and respond to what I said but not to speak.

Soon, he had improved to the point where he needed better care than the mere custodial service we could offer. Since he was silent, he couldn’t complain, so I decided on a bold move. Not certain my nurse would agree, I waited until she went to lunch before walking him to a tub filled with warm water. He took to it with obvious delight, rolling from side to side, but taking care to keep his head above the water. It’d been weeks since he’d been able to bathe. He loved it.

On my part, I was in luck, first because he didn’t drown and second because, while I was with him, his physician came around and was so impressed with his improvement, he promised to transfer the boy to the rehabilitation unit that very afternoon. He was true to his word.

Of course, when my nurse returned, she was surprised to find the boy not in his bed. When she asked where he was, I replied, “Oh, he’s taking a bath.” From how she looked, you’ve have thought that I’d decided to drown him to free up a bed. I had to show him happily splashing in the tub, before she’d believe me. 

Ah, but to get away with antics like that, I had to be credible, meaning that other staff believed I knew what I was doing. I also had to be creative at coming up with solutions in the midst of all confusion of day shift. That wasn’t easy, particularly when I often had no one to turn to for advice.

Think of my plight. When the difficulty with isolation orders arose for the girl who had shingles, I knew the isolation nurse and could call her. But when Lenny was being ignored, I didn’t know anyone in rehab to contact. I had to come up with that stunt. Lenny and I were  fortunate that it worked.

That’s where senior nurse mentors would help. They’d be roving troubleshooters who had what most nurses lack—a knowledge of the hospital structure and personal contacts. The busier the staff are and the more rapidly they turn over, the more needed they are. 

Think of them as like the hospital’s switchboard operator. They have the power to connect anyone to anyone. That can be very important. It might even be life-saving.

Lenny was a minor incident. Next, we look at how useful a senior nurse mentor could be in a major crisis.