A lost cause, if ever there was a cause

To bring about closer collaboration between the medical and social sectors, the Hospital Authority (HA) of Hong Kong, which manages all public hospitals in Hong Kong, has announced, after a three-year pilot project, that it is ready to implement an integrative care model for helping at-risk elderly people who are discharged from hospitals meet their immediate transitional needs. Under the guidance of the HA, non-governmental organizations (NGOs) will have a social worker from the collaborating NGO stationed in the hospital to assess patient needs.

When I learnt about the initiative, I realized it was already a lost cause for community nurses to be champions of community support and care. I worked as a community nurse for a year in the mid-1980s. Back then, there was not much emphasis on community services and care, but now it is entirely different, with governments and health authorities all over the world realizing the importance of keeping patients in the community.

To me, nurses can also be brokers of community services as long as they have knowledge of the service agencies and support services available in the community. It intrigues me as to why we need another professional—a social worker—to come and be stationed in a hospital. Many community nursing centers are an integral part of hospital services. Community nurses go to the wards to assess patients prior to discharge when they receive a referral from the attending doctor. Now, a social worker will be stationed in the hospital and visit the unit to conduct patient assessments. It is a duplication of health resources.

Given the nursing shortage, nurses are ever so cautious when it comes to taking up new roles and responsibilities. Yet, when we focus only on what we cannot do because we believe we are overloaded, we do not see the possibility of what we can do. We need to show stakeholders that we are willing to take on new responsibilities for the purpose of providing holistic care to our patients.

At one time, nurses could have been the champions of community care. We could have done so much more for our patients. But we stayed in our comfort zone of defined practices. We would only see patients who had a referral—to dress a wound, give an injection or teach self-administration of injections, supervise walking exercises or change a catheter. Anything that was to be done had to come with a physician’s order.

Why would health education or patient counseling need a doctor’s referral? Charging for services is, of course, an issue. That is understandable. However, what is stopping nurses from going the extra mile to do the liaison work, to find out the needs of patients and families, and refer patients to the community support services they need, instead of asking them to seek a referral at their next doctor visit?

We need to wake up to the call of our nursing vocation and make ourselves visible and accessible.

For Reflections on Nursing Leadership (RNL), published by the Honor Society of Nursing, Sigma Theta Tau International.

“A nurse must be caring. If you are not ..."

In June and July 2011, I did my clinical update in the medical and geriatric units of two different local hospitals. This is an unofficial requirement of all faculties in our school.

The visiting hour arrived. As an observer, I had a lot of time and freedom to do what I considered useful for my own learning. I went around talking to patients’ relatives. I saw this older woman feeding an even older woman and took an interest in them. It was a daughter visiting her mother in the hospital. As the daughter was giving sips of water to her mother, I asked for permission to take a picture of them. The daughter happily agreed. She started telling me that she had been on television and had been interviewed for radio programs before. She told me her mother was 101 and asked me to guess how old she was. She said she was 76. (She looks younger than her age.)

The lunch hour arrived, and I went to the canteen (café). There I met the daughter again, and we started chatting. Taking care of her mother had become her career now. She would leave home each day around 10 a.m. and arrive at the hospital well before 11:30, the first visiting time slot. Then, at 12:30 p.m., she would leave the ward and go to the café. She would sit in a distant corner until the lunchtime rush hour was through and then order her lunch. She would wait in the café until 5 p.m., the second visiting period, then stay with her mother until 8 p.m., when she would go home. She said it was her daily routine and that it was OK for her, because it was her mother.

She went on to tell me that she had studied geology in college in Beijing, that she used to work for the government of the People’s Republic of China and that her work was well appreciated by her supervisors. She took pride in the many projects she participated in, which were mainly related to irrigation and flood control.

And then we talked about care. We talked about nursing. I invited her to come and speak to my students in the coming semester. Without any prompting, she emphasized that there are a few things that are required of a nurse. “First, you must have a caring heart. You must love your job. If you don’t, you may as well not be a nurse. Second, as a nurse, you must treat the seniors you care for as your own relatives. Don’t choose this job only for the money.”

Nicely put.

I am humbled by her insights, her openness and her dedication to her mother. Yes, you need to be caring as a nurse. If you are not, you may as well not be a nurse.

For Reflections on Nursing Leadership (RNL), published by the Honor Society of Nursing, Sigma Theta Tau International.

When I was young, I was naive.

I believed it was enough to teach nurses to meet basic requirements in providing care. I believed it was unreasonable for us to ask our students to love everyone. (That is still not a realistic expectation.) I used to believe in standards, quality audits and core competencies. (I still believe in some of these things, but in a different frame of reference.) To my mind, as long as everybody did his or her job properly, that would do.

I was wrong. It is not enough to teach our students to meet standards, have their competencies verified by tests or check, through peer- or self-appraisals, whether they have mastered the required skills.

There are so many different systems of accreditation being developed nowadays. Under modern accreditation systems, piles of documents explain protocols, guidelines and procedures about how things are done in a particular context or setting. They have a limited connection with the quality of care. Having documents in place doesn’t mean that the things said in the documents are or will be observed. It only means that specific instructions exist about how something should be done (and is believed to be done), and when and why it is done in certain ways.

As I grow older and, I hope, slightly wiser, I have come to realize that standards and competencies are not enough on their own. As I lecture, work with students on projects and supervise them in field practice, I am gradually coming to see how flawed my thinking was.

The most important thing about nursing is caring—caring about, not just for. It is only when we care about something that we strive to do well, to do better. When we care enough, we show it in our work and how we carry ourselves in practice. It is only when we care about those we serve and our profession that we strive to become better nurses and people.

But the global trend embraces the science of nursing more than the art of it. Something is amiss, but are we aware of what we are missing?

For Reflections on Nursing Leadership (RNL), published by the Honor Society of Nursing, Sigma Theta Tau International.

Illness experience IX: Voices from my body—anybody listening?

Chronicles of my radiotherapy (RT) treatment:
Day 1: Right breast, particularly proximal to operation site, swollen since evening. Swelling disappeared next morning.
Day 2: Again, local swelling and hardening of tissue.
Day 3: Feeling some muscle/chest wall tightness, like I was unable to stretch my arm or something.
Day 4: Chest wall feels tight whenever I try to move my arm in extension. Really uncomfortable. Shape of right breast changed; grooves over the skin.
Day 5: Same, increasing tightness of chest wall associated with arm movement. I almost need to stretch myself every now and then, or whenever I remember it. Some tingling sensation, like fine needle pricks, under armpit. Darkened nipple and areolar.
Day 6: Reported to therapist and saw the radio-oncologist. Nothing can be done, except to put up with it.
Day 7: Some upper-arm edema. Not sure if it was related to posture while sleeping. Started to feel some very occasional pain under breast, maybe several times today. Pain is only momentary. It goes away quickly.
Day 8: Right breast size has shrunk, also grooves on skin are firmer. Consistency of right breast is hard.
Day 9: Felt sticky beneath the right nipple area. Had sensation of being unable to “free” tissue from sticky tissue beneath nipple, even with stretching exercises. This is annoying.
Day 10: I am documenting this for my own interest. As a nurse, I have studied about RT treatment, but I have never learnt in detail about reactions to RT. I didn’t know what to expect.

Although each person’s reaction to RT or any kind of treatment can vary, I would still have appreciated it if someone had informed me of the possible reactions. Now that I am a patient, I realize that health professionals know very little about how patients feel physically.

I think of how I could learn to be a nurse if I were to learn about nursing again. I would treat my patients as teachers; ask them to tell me how they feel all the time. Only through firsthand experience or good secondhand experience (such as learning from patients), and not through broad-brush approaches like the big category “side effects” that we swallowed in school, can we become better nurses.

I also realize that patients usually only need listening ears instead of “fixes.” I have had doctors and health professionals who halfheartedly listened to my “complaints.” I was only reporting my discomfort and worry (for example, being concerned that my chest would easily become fibrotic). There was no consolation; I was simply asked to put up with it. If only I could find out whether my situation was unique and deserved attention, or commonplace and amounting to nothing. But I couldn’t find out what I needed to know. That is why I say that I would love to learn from my patients, so that I will have answers to address those concerns if I am asked in the future.

I am also aware that, as health professionals, we can’t take every patient’s complaint to heart. Compassion is a highly taxing emotion. It drains our energy. We can’t take all the problems of our patients to heart. We would be so burdened that we could not function. But it is our task to find the balance.

For Reflections on Nursing Leadership (RNL), published by the Honor Society of Nursing, Sigma Theta Tau International.

Illness experience III: What a patient needs is compassion

Being on the receiving end of health services, delivered by a long succession of health professionals, parahealth professionals and other unregulated staff, reinforces my belief that, among the many attributes of a nurse, caring is most important. Of course, knowledge, skills and techniques are important, but caring comes first. If we care enough, we will find the right thing to do. For example, Ben did all the searches for me, saving me tremendous time worrying about whether I had searched enough. Screening out all the useless information and pointing out the relevant to me was an enormous help. Thanks ever so much, Ben.

Coming back to compassion. If we care enough, we will be more thoughtful, will adopt the sick person’s perspective and relieve the burden on both the patient and his/her family. I travelled back and forth between the HK SH (another hospital) and my doctor’s offices just because the staff didn’t think of mentioning something to me. So I had to make that extra trip. As time-conscious as I am, I am surprised that I didn’t throw any temper tantrums at having my time wasted on avoidable activities. I think of caregivers who may be old and patients who may be too sick to travel back and forth. I also think of people who are not as mentally stable as I am. Imagine the pain and frustration they have to go through.

I used to think I was a very good nurse. Now I know I can be a better one. Adversities in life can be blessings in disguise. They make me more humane and accepting of other people’s weaknesses. I can now boldly state that “life is precious” and mean it.

Good health to all.

For Reflections on Nursing Leadership (RNL), published by the Honor Society of Nursing, Sigma Theta Tau International.