AndSicker blog

This is a student nursing blog that is more like what I had envisioned for my own blog here. It's much better than mine is, though. The author is probably just a lot smarter than I am.

One thing I'm struck by in perusing this blog is that it doesn't get very absorbed in the theoretical aspects of caring, holism, "health", etc. Although I am resistant and skeptical naturally in those areas, I get dinged so much and so uniquely on my clinical paperwork and care plans on not "knowing" patients better that I have started to wonder if it is really me and not an innate voyeuristic desire to peer into people's lives on the part of the instructors (which is what it seems like to me). Maybe it is because this is a male nuring student, or maybe it's the difference between an ADN and BSN program... although I have to say that we were never even exposed to the term "metrology," which I find embarassing...


  1. The reason my blog might seem a little light on nursing theory is that the clinicals I've attended since I started blogging have all been obvservational experiences at a psych hospital.

    Our nursing school's base Theory is Gordon's Functional Health Patterns. We don't really get to impliment these things as often in observational experiences, since we're not actually doing much compared to our med/surg rotations.

    Our ADN school, in fact, includes more clinical practice than the four-year universities in our state, about twice as much. What we're missing that the BSN students get is additional classes on pathophysiology, statistics, management, and care of families.

    Even after I return to med/surg next week, I doubt I'll mention much in the way of Nursing Theory, mainly because I don't have much use for it when I'm at the bedside. This is one of the major advantages of the ADN schools compared to the BSN schools in my area. It's all well and good to write about how Sr. Roy's caring model differs from Florence Nightingale's (just some of the madness that's being inflicted on us in our last semester), but the theories are things to reflect on, not refer to on the unit. Theories are useful ways to organize your thinking, but you can always organize your -own- thinking.

    Every unit we go to for clinicals, the nurses tell us they prefer it when we're there, because we're actually caring for the patients in the RN role, whereas the state university students are just collecting data for their writeups.

  2. Your last paragraph is particularly interesting because my feeling from the comments on my clinical paperwork is that if I were to do the paperwork correctly, I would only be interacting with the patient to collect data about them and not to help them, or even to learn how to help them at bedside.

    There is a book about men in nursing edited by Chad O'Lynn that includes a chapter about educating male nursing students in which it says that research on male students shows that they feel they are expected to know things intuitively about bedside caring that they don't know. I wonder if it isn't the case that they are identifying a universal problem and just assuming that it is a problem with them as men.

    I've heard nursing instructors criticizing the introduction of computerized charting into the hospital as an extension of "treating the monitor and not the patient," a typical critical care faux pas, but I wonder if they aren't responsible for promoting this way of thinking themselves.

    The worst example I can think of is a patient I picked up who the doctors decided to discharge. S/he made it abundantly clear that s/he did not want to talk to any more nursing staff and just wanted to leave the hospital, but I got criticized on my write-up about this experience for not collecting information about how s/he performs self-care at home. What am I supposed do? tell the patient s/he has to talk to me so I can use the info for a clinical write-up? I would be so flipping mad if I were treated that way as a patient!

  3. Assessing self-care ability is a pretty important part of discharge planning, even though it often gets thrown out the window by busy case managers. Good discharge planning starts at admission, remember. This also won't be the first time you're charged with gaining the compliance of someone who is combative or dysthymic. There really isn't any need to say "hey, I just need this information for my write-up", there are more subtle ways of going about it. Waiting until discharge isn't one of those ways.

    In my opinion, the computerized charting lets us spend -more- time with the patient and -less- time with the documentation. This, of course, assumes familiarity and comfort with using computers. They'll get there, don't worry. Another thing I like about well-executed computer charting systems is the inclusion of checklists, which are extremely useful but time consuming to generate on your own. Whenever I hear someone complaining about treating the monitor and not the patient, I ask if they'd be happier treating a book instead of a patient for twice as long. There's a strong current of luddite sentiment among nurses, of course there's also a strong current of not being familiar or comfortable with comptuers as well, which is well-corelated with inadequate computer training.

    Due to the huge differences in sample size, it's difficult to make the kinds of assertiosn you're making about men in nursing with any confidence. A recent study done by Texas A and M, for example, had a sample size of less than 200. Personally, "knowing what to do" at the bedside seemed to have more to do with prior experience as a CNA or LPN than gender. I actually found a lot of it very intuitive, what I found difficult was organization (i'm not a very organized person by nature) and spatial relationships (which I may or may not have a learning disability with). A combination of direct-care work in group homes and bartending (believe it or not) prepared me adaquately for dealing with the people in the beds, it's just the rest that's taken practice to improve on. ALL of us, male or female, feel like we're expected to know things we don't know during clinical practicum. That's a standard feature of self-directed learning. At some point, we gotta figure things out for ourselves, male or female.

    It may be that your paperwork is very different from ours (maybe we should compare clinical data forms and see! hehe). Most of our data can be pulled from the charts and from our notes on our assessments, the rest comes from memory. At the end of second semester, we've got our head-to-toe 10 minute assessment down pretty well, and by now, our fourth semester, we don't even have forms to fill out, we just hand in a journal entry about that particular 16 hour span at the bedside (two 8-hour shifts). At first we had to fill in all these little spreadsheet cells, but now we're just expected to know what we're doing.

    To loop back to what I began and you ended with, you'd be suprised how readily the most "difficult" patients volunteer information once you've spent some time talking to them about anything -but- their hospitalization.

  4. I think you're misunderstanding the situation with this patient I was assigned. This was not a patient with an attitude problem, but one who was sitting up waiting to sign insurance papers and for a ride to arrive and was just tired of answering questions and getting poked and prodded. Anything I would have done would have been a literally completely academic exercise.

    That said, I also reject some of your perspective in principle. You have done a very good job of adopting the nursing paradigm of total care with its accompanying rhetoric of compliance that you have been taught, but I have done a bad job of it. I reject the notion that the job of floor nursing is inextricably linked to the need to send tentacles of caring out into patients' homes. When people come into the ER, they come in with the idea that they are going to get X subset of their body or mind fixed and then be on their way. They are not expecting a total psychosocial evaluation based on standards they have not assented to. As I am sure you are aware from your interest in technology, data collection is a problematic invasion in a society that prizes privacy. Law enforcement can't do it without probable cause, but we as nurses are encouraged to uncover and expose every aspect of patients' lives?

    This improper aspect of nursing comes from historical accidents, in my opinion: (1) the development of modern nursing theory by women; and (2) the relative inexactitude of past medicine/nursing. As Foucault observes in The Birth of the Clinic, in early medicine, there was an attempt by doctors to see disease in its "natural" surroundings--the home and family. But this was a response to trying to isolate diseases, not create total health promotion. The need to define/control all variables in a patient environment is inversely related to the understanding/manageability of pathology. Complex or multiple overlapping conditions may need a greater understanding of the patient, but there is no need for anything that goes beyond proportionality. If you are driving funny, the police officer can pull over your car, but he can't use it as an excuse to go through your phone records. If a patient comes in with a potassium imbalance, it is relevant to know their dietary and medication profile but not their sexual history. So, you shouldn't ask them about it.

    Anyhow, I basically agree with you about the computers, although part of the point about treating the monitor is that format controls perspective. Check boxes are not just efficient, they also define how the assessment should be done. Of course, this is true for paper forms as well, and there is a generational issue with nurses over the age of about 30 not being used to ubiquitous computing. But I also commiserate with older nurses who just want to talk to patients, form impressions, and write them down. That actually requires more skill to do well.