In desperate hope I go and search for her in all the
corners of my room; I find her not.
My house is small and what once has gone from it
can never be regained.
But infinite is thy mansion, my lord, and seeking her
I have come to thy door.
I stand under the golden canopy of thine evening sky
and I lift my eager eyes to thy face.
I have come to the brink of eternity from which
nothing can vanish-no hope, no happiness, no vision
of a face seen through tears.
Oh, dip my emptied life into the ocean, plunge it
into the deepest fullness. Let me for once feel that lost
sweet touch in the allness of the universe.
Tagore, from Gitanjali, LXXXVII
I recently took a second job as a Hospice RN. It's a relief to have a proper orientation finally, skills are reviewed, discussions are scheduled with members of the interdisciplinary team. The quote above is from Dr. Elisabeth Kubler-Ross' book "On Death and Dying". An ancient, battered copy was brought to me by one of the administrators after I mentioned trying to borrow a copy from a friend, which then been lost in a move or something.
A lot of my time now is spent following established Hospice nurses on routine and initial visits during the day, while maintaining my Charge Nurse position at the nursing home. I've had many sixteen-hour days in the past week between the two jobs, but the sustained activity is easy to bear when the work is intellectually stimulating and meaningful.
When I tell people in conversation that I've begun working as a Hospice nurse, there have been basically two types of reactions. Often, people immediately begin sharing their own experiences with death and dying. Some people talk about how great the care provided for their loved ones were, or how beautiful the facility was. Some stories relate experiences of caring for a loved one at home. In almost all cases, the story ends with what was most helpful in achieving acceptance or closure.
Alternately, many people react with a darkened expression and something like "I could never do that" or "People must get burned-out fast from that" or "what a depressing job".
Although I'm still getting to know my new colleagues, it already seems as though nothing could be further from the truth. True, it's work that involves a fair bit of crisis, but the same could be said for my nursing home work. The folks I've started to get to know through Hospice are some of the most well-adjusted, philosophical and peer-supportive Nurses I've met in my career so far. This was one of the major factors in deciding to apply where I did, I met some of the Hospice Nurses that would come into our nursing home to consult on some of our residents, many of whom I had developed an appreciation of/closeness to.
The few shadowing experiences I've had so far have bolstered my confidence. Support from social workers, clergy and fellow RNs is never farther than a phone-call away, and the solid skills I've developed in the nursing home give me confidence that I can walk into any situation and provide whatever care is necessary in the moment, be it a foley catheter, incontinence care or a total bed change for a bedridden patient. A quiet presence or a detailed explanation as the needs of patients and families dictate.
Careful management of nursing home residents has taught me to assess people thoroughly and systematically. A lack of pre-established routines or protocols (or orientation or structured training) forced me to develop my own habits and techniques and critically analyze them later. This probably isn't a mode that is well-suited to all new RNs, and it certainly had it's drawbacks, but after two years of developing my Nursing practice and then stepping into a totally different setting, I have the feeling that I'm no longer a Beginner. Perhaps a decade or more away from being able to call myself an "expert", but a Beginner no more.
Knowledge of and comfort with specific procedures is important, of course, a practiced hand can make the difference between incontinence care and a total bed-change being either a great relief or vastly unpleasant. Beyond the simple neuromuscular familiarity with the tasks, however, lies a much deeper and interesting competency to attain. Learning to evaluate situations holistically and coming up with therapeutic responses to suffering or anxiety is a major part of what I see as the real "core" of nursing practice. The "little extra things" aren't little, or extra, or even things, but rather key elements in delivering care therapeutically. It's necessary to be present. It's the simplest thing in the world, and so often absent in the care of the infirm or seriously ill.
When people comment on how depressing they perceive my jobs to be, I often compare End of Life care to Labor and Delivery. I was pleasantly surprised to see this position expounded in great detail in Kubler-Ross' book. It first came to me that folks with dementia seem to step backwards (in order) through previous developmental stages and polarities, until a time is reached where nothing is expected of the person, and everything they need is provided to them (hopefully).
Care for people who are in this condition provides a special challenge to new and experienced Nurses alike. On the most basic level, in the absence of the ability to communicate functionally, competent care for the patient relies heavily on assessment and observation skills as well as a level of critical thinking that may not be routinely employed in the case of someone who can share with you the location and quality of their pain or how their stomach's feeling. The real challenge, however, involves compassion and the preservation of dignity. This is the area in which the Nurse's role of Advocate is all-important, a subtle mode that is usually instantly perceivable to family members but even more important in the care of someone with no family and no visitors.
My only regret, perhaps the last regret I'll ever have, is that I didn't reach this level of awareness three years sooner.