Brave Woman

Adventures of a future nurse-midwife

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Acute

Posted by Lucille on March 25, 2016 at 9:40 PM

I meant to write this post around the halfway point of the term, to celebrate being halfway through nursing school, so it should convey something about the nature of this term that instead I'm writing it in the last days of spring break. The cohort ahead of us had warned us pretty unanimously that acute was the hardest term of the program. It was true that this term contained a steep learning curve. A lot of new information was introduced this term, but perhaps more importantly, the different areas of knowledge we'd been building up to this point (pharmacology, pathophysiology, clinical judgment, leadership, emotional support, etc.) developed to the point where they started to brush against each other. As our classes illuminated gaps in our knowledge of topics we had already covered, we invented more time to fill them in and tie different aspects of nursing together. I remember reflecting earlier in the term that without noticing it, I had crossed that invisible line between feeling like a nursing student and feeling like a student nurse.

My first clinical placement was in surgical oncology. I loved this placement. The nurses were leading several programs to strengthen the unit, with goals to eliminate falls and release time to care. On the abdominal floor last term, going back and forth between immunosuppressed patients and patients on contact precautions, I had been told to never sit down in a patient's room if I could help it. Furthermore, every patient was nauseous and the bed controls were finnicky, so I was told to avoid raising the beds. This meant that almost every conversation I had with a patient was brief and involved looking down at them from above (and I often went home with a back ache). On oncology, every nurse I worked with encouraged me to take time to just interact with a patient, with no task-oriented goals other than to get to know them. Pulling up a chair with a patient and getting to hear their story was wonderful. Despite taking hours out of every day to just be with patients, my confidence in my task-based skills still soared as I shifted from assisting with to taking responsibility for tasks like assessments and charting, DVT prevention, intake and output, etc. The funniest part was that in the entire oncology placement, I never had a patient with cancer. The unit had a lot of overflow from other parts of the hospital and I took care of several postoperative patients, patients with different kinds of dementia, and patients with different problems related to substance abuse. On one occasion I got to finish the day by going in with the doctor to tell my patient the mass had been benign, and then join the family in the dance party that followed.

My second clinical placement was on maternity, which actually involved rotating through labor & delivery, mother-baby, lactation, and the NICU. I had expected to feel the most confident in this placement because of my experience as a doula. This turned out to be far from the truth. Rotating through different units made it difficult to develop a sense of the normal routine, and I found that the nursing role on these units differed more from the doula role than I had expected. In three days on L&D, I attended five cesarean births (which included getting to see an intraoperative Mirena placement and an intraoperative tubal ligation), observed one cerclage procedure, and saw one vaginal birth (just for the five minutes in which the baby was born). I also assisted with several patients in labor, though none without epidurals. Partially this was because moms who wanted to have a natural birth were more likely to request not to have students involved in their care, so the births I attended as a student nurse were a skewed sample. I also had to realize that the births I had attended as a doula were a skewed sample, too, for being made entirely of the sort of families who hire a doula, had natural childbirth as Plan A (though were open to other plans if they seemed beneficial), and were all reasonably healthy. It surprised me how many of the patients I worked with or heard about had truly high risk pregnancies.

The nursing culture, too, was different than I expected. My first day on the unit, I saw several awesome advocacy moments and several moments that concerned me. I imagined that the nursing staff was a combination of nurses who had approached birthwork from more of the doula/midwifery side of things and nurses who had approached it from the medical side, and that their attitudes differed accordingly. In later days on the unit, I realized I was wrong. More often than not, the person who advocated beautifully for one patient and the person who casually undermined another were the same nurse. I don't mean that one nurse in particular seemed to flip flop between different attitudes, I mean that I saw this from the majority of nurses I worked with. It confounded me. Tuning in closer to what came up in the clinical judgment process, I noticed that the first question asked when one nurse asked another for advice about a patient was almost always, "Are they midwifery or OB?" And the answer seemed to inform their response. On multiple occasions, I saw nurses try everything they could do avoid an intervention for a midwifery patient, and then start preparing for an intervention before the topic had even come up for an OB patient. I raised my confusion about this in our leadership class and it prompted a discussion on internalized oppression in healthcare. By treating "midwifery or OB?" as a proxy for "how commited is the mom to a natural birth?" it seemed that many of the nurses unconsciously or consciously prioritized the providers' goals over the patients'. Whether despite or because of these challenges, I learned a lot, especially on the postpartum, lactation, and NICU floors where I had less experience, and I got to work with some wonderful preceptors.

Buoyed by the massive ego-boost I got in the middle of this term, I sailed through the normal crunch around finals, and before I knew it, it was spring break. Travis and I normally travel to see his family on school holidays, but because he was studying for an engineering exam, we stayed in town and I even spent a couple of nights at my parents' and brother's place. We had originally talked about going to the coast for a few days, but ended up deciding to do a staycation and explore some events around Portland. We went to a St. Patrick's day party, the zoo, a magic show, and a tulip festival. We also spent a lot of time relaxing at home. My brother and I had made several deals over the course of the term to try a book/show/youtube channel/podcast if the other person would return the favor and we both enjoyed trying out each other's recommendations. I made promises to come back to a few of them when I have more free time. Which, now that I'm in the midwifery program, should only be about three years from now.


Grateful for a quick breath of rest and family time before we dive in again!

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Sometimes I have the privilege of being a part of intimate, powerful moments in other people’s lives. I cannot and would not share these stories, because they are not mine to tell. However, they touch my life and become part of my own story. When I share these moments here, you can trust that I have not broken anyone’s confidentiality. The characters are invented. They are not real, but could be. I take creative license to communicate the essence of my experience while respecting the privacy of others.