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the five bravest things our nurses do

We are coming to the end of “the week of the nurse” and I have come to the end of another week on service on the pediatric floor.

It is embarrassing to me that I don’t ALWAYS stop to thank the nurses I work with for their bravery.

What? Bravery? What’s that got to do with nursing?

Nurses give out medicines, tend to patients’ and parents’ needs, and carry out doctors’ “orders” RIGHT? Well, yes, but there is so much more, especially on a pediatric unit (and probably on adult units as well, but I can only write about what I know).

So this post is dedicated to the dedication and bravery of our pediatric nurses and the wonderful things they helped me and the rest of the health care team do this past week.

1. Unknown faces

This week a new TEAM of doctors and students was with me, helping to care for the patients. Either residents who had never worked on our floor before, or were there in a new role. Medical students who had little to no prior experience with children. The nurses have to be BRAVE to be willing to ask these folks questions about the patients they are caring for. Will they get the “right answer? How does the nurse evaluate the level of competence of the physician giving an order, writing a medication dose, or requesting a test, without seeming to be rude, insulting or obstinate? Yet, the nurse will be held accountable by the patient and by their own standards for doing the right thing by the patient. This is hard, requires excellent knowledge, dedication, passion and superb communication skills. If they ask ME every time a new face does something a little unusual, they risk alienating the physician. If they don’t ask at the right time, or in the right way, and a patient is harmed, they have not met their responsibility to the patient. This new face thing happens approximately once a month. How much bravery does it take to face these challenges time and time again?

2. Unknown diseases

This week we had a number of children admitted to our service with symptoms and problems that defied immediate classification as a known disease or process. Some of these children were quite ill. While as physicians we may spend 15-20 minutes with these complex patients and their families, the nurse is there much of the day, many times a day. They are faced with multiple questions that they may not be able to answer. They have to face the out-of-town relative who shows up at 3 am and demands a full and complete explanation of what is going on. Certainly the nurse can call the physician at any time to help with these issues, but they are almost always the first to face those questions, and the anger and anxiety that sometimes gets foisted upon them, due to the worry of the family. Don’t you think it takes bravery to face these situations again and again and still come back to work tomorrow?

3. Unknown outcomes

Every day, every week, nurses work with children who have complex and/or congenital diseases, who are admitted to the hospital because they are sicker than their usual sick. Many families handle the stress of the situation quite well, many others do not: we are all human. Nurses have to be willing and able to meet these families in their own space. They have to be reassuring, yet realistic. Hopeful yet stoic. They have to amend their standard practices to adjust to the family’s practices—for feeding, for administering medications, for sleep time, for play time. They have to accept the parents’ assessment of the child they know so well, and try to interpret that assessment in conjunction with their own knowledge and standards for “normal.” This can be quite stressful when the nurse has to be the intermediary between the parent and the physician. They have to face this problem nearly daily. Parents of children with life-limiting chronic or congenital diseases are always thinking: “Is this going to be my child’s last admission? Will we be able to go home?” At the same time, for children with multiple admissions (such as some patients with cancer) over the course of several years, the nurses get very close to those children and their families. To do an excellent job they have to truly “care.” But to be able; to stay in nursing over decades, they have to not care so much that a child’s death will destroy them. Would you be brave enough to do this every day?

4. Unknown Future

Most weeks we see children on our floor who are there because of suspected child abuse or neglect. This is hard for all the health care providers. It is especially hard for our nurses, who must provide loving care for the child, observe the interactions of the family members with the child, try to facilitate parent-child bonding, even if the parent doesn’t act appropriately. They have to contain themselves and their anger at our “system” that sometimes seems incapable of providing the protection these innocent vulnerable children need and deserve. Every time a child is admitted with signs of physical abuse, I know they are thinking about our most  “famous” local case—Aveion Lewis—and wondering if THIS particular child will be the next to come back with an injury beyond hope, or be found in a dumpster somewhere. How many of us could face this uncertainty, and still do our jobs with a smile on our face, and a supportive attitude?

5. The unknown unknown

Nurses in all walks of our health care system are expected to identify new problems. In a patient admitted with respiratory distress, the focus is on ongoing intermittent assessment of that patient’s breathing and its effects on the rest of his or her systems. But what if that patient develops a new problem during the admission? We, as physicians, depend upon the nursing staff to help us identify new issues, new problems, new diseases, or new aspects of the current disease so we don’t miss anything. That is quite an expectation. I can’t imagine how stressful that would be. I salute the bravery of our nurses to face this challenge with grace, and help reduce OUR stress, and that of every doctor in every hospital every where.

Now, don’t get me wrong, the nurse is not the ONLY health care provider whose bravery needs to be sung. But this is, after all the ‘week of the nurse.” And this is my tribute to the many nurses who make it possible for the Carilion Clinic Children’s Hospital to embrace all children and families who need our care. I need to let them know how much they are appreciated. I need to let YOU know how much they do, and what challenges they face on a daily basis.

I would love to hear from some NURSES about whether they agree (or not) with any of my points, and I would love to hear from some DOCTORS about examples of bravery you have seen that I have not mentioned. I would love to hear from PARENTS and other HEALTH CARE PROVIDERS about your thoughts on this post.

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