Why Do You Think You're Here?

The art of listening keeps resurfacing in my career as I transition from hospital, home health to clinic nursing.

28 years ago I was a staff nurse in a hospital on a medical/surgical unit. I liked to talk to my patients in the evening as I passed their bedtime meds and they lingered on the edge of sleep. Initially, lingering with them seemed almost selfish since my focus was on being an accurate and diligent nurse. Back then, I assumed the most important role of nursing was to interpret lab values correctly, always being observant for signs and symptoms of infection, complications, diligent in gathering data and vital signs, and getting everything charted.

The diligent part of nursing was more than a full time job by itself. Often my patients were angry at the inconvenience of being laid up. They were trying to manage their lives from their hospital beds, shouting orders and trying to carry on their tasks by phone from the hospital bed.  I found it interesting that as evening wore on and business hours ended, these business people would often become reflective and say that maybe they needed this stop in their lives to reflect on who they were and where they were going. They were so busy managing the tasks of their daily lives and keeping all the balls in action that they had totally forgotten about any relationships with their families and friends. They were running in the fast lane, high on adrenaline, and they thought they would catch up with relationships later. But now they had the time to take stock of where they were, and analyze who cared whether they lived or died. Often they didn’t like what they saw.

After 10 years I went into Home Health, and my focus switched from analyzing everything about Jane Doe’s pneumonia to looking at the big picture of everything she is and everything around her.  For about 2 years I alternated daily between hospital and home health nursing. I felt like I was asking my brain to swell and shrink every other day. I literally had headaches, with switching back and forth. The phrase “you can’t see the forest for the trees” had new meaning. It took me about 12 months to really learn how to see the forest. I had to learn the importance of the world as Jane perceived it, her overall health, her physical environment, and the relationships within her environment. I had more flexibility and focus in home health, and was able to look more deeply for the reason for her individual health problems. I enjoyed the luxury of fully reading her history and physicals, and reviewing her chart as far back as available. I was still under the impression that my most important function was connecting the lab and diagnostic tests to her health problems, assessing the medications she was taking and her response to them. Teaching her about her medications and how to take them correctly and filling out medication administration and teaching sheets. Assessing her diet, teaching her ways to improve her health and prevent re-hospitalizations. I case managed her care and added PT, OT, Social work, and community services as needed to improve our ability to fully achieve her optimal health.  Then I met Viola.

Viola had chronic pain due to Cauda Equina syndrome and should not have been able to walk.  She couldn’t feel her feet on the floor, and her legs were purple from her toes to half way up her thighs.  She was able to walk with a walker or by holding onto the walls. She walked stiffly, using her legs like boards. It was my job to evaluate her pain, instruct in medications and teach pain management, and case manage other services. Viola didn’t like talking about her pain, and had a rule that the only way she would talk to me was if I sat down and had a cup of coffee and a donut with her first.  After our coffee and donut, she was very cooperative in discussing pain level, reviewing medications and diet, assessing what she had tried before and working at adjusting pain meds based on the type of pain she was having. After about 6 weeks and several medication dose adjustments and different drugs, I finally admitted to Viola that I didn’t have any more ideas, and I was going to recommend that she be transferred to a different case manager. She was livid, I had never seen her angry before but she yelled at me and said, “How dare you think you’re God!”  I was totally confused. She said I had done more for her by talking to her, caring about her and sharing ideas with her,  than any other health care provider she had ever known. She said, “This is my pain, between me and God, and it isn’t yours to take away!” She had been told several years previously that she would not be able to walk, the pain would be unbearable. She had managed to mentally block the pain. She transferred her pain to thinking about other people’s families and lives, which gave her images and ideas to fill her mind. She would suck up the intricacies of our lives like a sponge. She didn’t like talking about her pain, because it caused her to have to let it in and think about it.

From that time forward, I decided to alter my practice and ask, “What do you want from Home Health? What are your goals, what would you like to work on? Why do you think you are sick?” I focused on communicating to my patients that they are my primary focus, we are going to work toward meeting  their needs and wants, and achieving their goals. My popularity rating grew, I received many thank You notes from my patients, and if my patients had another exacerbation they frequently asked for me by name. I was able to convince many of my Medicare patients that they were too young to be old, and needed to get back to their hobbies or reason for living. Our outcomes improved, they had hope, felt  valued, and had renewed purpose. 

I’ve been a clinic nurse for almost 2 years now and I’m doing care coordination and phone triage. I was curious what health concerns cause people to call in for advice or appointments. I discovered: the most important reason seems to be the need to be heard, know that someone cares, and know that someone  will follow through with your request.

 Sometimes they are chronically ill. I spoke with a gentleman with arm numbness.  He walked in to report that he was still having arm numbness that went from one arm to the other, never both and only at night when he is laying down.  I asked, “What do you think is wrong?”  He said, “Hmm, no one has asked me that before.  But, I have been thinking about that. When I forget my water pill and my legs hurt, my arms don’t hurt. When I take my water pill, my legs feel fine and then one of my arms will hurt.” We found out he always sleeps on his side, and he turns from side to side.  I asked if it was the arm up in the air or the arm that he is laying on that hurts? He didn’t know, he would investigate and let me know.  I would guess that he might lack blood pressure in the arm that is higher than his heart. It’s possible that our questions could save this gentleman from having an ultrasound to check for an obstruction, or CT or MRI to look for other points of pressure or constriction.

My patients need to know that they are my main focus. They have my undivided attention.  I really want to hear and understand what they have to say. They often have spent a lot of time analyzing what is happening to them and often have valuable insight. Listening can’t be rushed, and pain and frustration is often born of unrealistic fear.  I’m encouraged that the Art of Nursing, and listening, seem to be gaining ground in the role and focus of Case Management.     

Nurse training encompasses the whole of a person, who better to focus on all that a patient brings to the table than a nurse?