Ladies and gentleman, I need a vacation. As term two of my NP journey comes to an end, I realize that I have spent way too much time on work and school. While I'm happy with my 4.0, my brain has that fuzzy, fried feeling. The kiddo is showing signs of neglect (or at least his laundry is). Hubby is claiming he doesn't remember what a meal tastes like that didn't come from the crockpot.
I have decided going into term three, my motto is going to be "pick your battles." That pile of laundry is not going to be the start of the zombie apocalypse. If I only spend two hours on that paper, it is okay because time was not a requirement. I can stop to cook a quick meal - one that does not include the words: stew, broth or roast.
I can no longer be the "call" queen at work. I have spent the last two weeks acquiring over 150 hours of call time on top of working the standard six 12-hour shifts. I need to learn to say "no." While I hate to disappoint, one must take their sanity into consideration. I joked at work this week; I needed a badge that said "Zombie Nurse." I had slept a total of two hours in three days - the last week of the term with projects due and getting called into work made for very little sleep.
So while I joke that I need a vacation, by the time you read this I will be off shore in the Bahamas enjoying a cruise with the family. I planned this at the start of the term as a treat for them and to preserve my sliver of sanity. So it's time for you to pick your battles and make strategic choices that can help you cope with this intensely demanding yet exciting moment in life.
In my last blog post I described the tests, StrengthFinder 2.0 and Emotional Intelligence 2.0, and shared my personal results from these tests. Today I would like to introduce you to the book, Leading with Soul: An Uncommon Journey of Spirit by Lee G. Bolman and Terrence E. Deal. This is the resource I chose to take me on a path of self-discovery of my strengths, weaknesses, and aspirations for personal improvement. In their introduction, Bolman and Deal state: "We're working harder than ever, but we're not really sure why. We feel a vague emptiness as we rush madly through life, hoping that we can escape if we keep running...The need to reinfuse life at work with spirit, passion, and zest is greater than ever."
This statement completely resonated with me, not only as a leader, a nurse practitioner, a student and employee, but also as a mother, wife and woman. Life balance is a very popular term right now, but what does it mean? How do we achieve it? It was with these questions in my mind that I chose to set out on this "uncommon journey of spirit."
Bolman and Deal describe soul as what is found when we "plunge into the depths of being, there we find soul, a bedrock sense of identity and meaning- who we are, what we care about, and what we are here to do."
They believe that once you have found your soul, it will lead you through the four gifts of leadership; love, power, authorship, and significance. Love is the demonstration of care for colleagues through honest and genuine actions. The authors postulate that when people feel cared for their actions are much different than those who do not feel cared for. This concept is applicable to every relationship and interaction we have. Showing sincere care for your partner, friends, grocery clerk, (insert anyone whom crosses your path here) allows for honest communication and a successful interaction.
In their book, Bolman and Deal compare organizations and interactions that "hoard power" and those that give it away. Productivity is low and resentment is high when there is a significant power differential. Energy is spent fighting against the power gradient, whereas, when power is released people feel a sense of ownership and ability to influence their world, which enhances productivity. The release of power also promotes authorship. Promoting authorship creates an environment where people feel they have control over their performance, they can be creative, and they are trusted to solve problems. This allows employees to see their work as meaningful and to feel responsible for the outcome of their efforts. Significance is bred from successful use of the gifts of love, power, and authorship. This final gift comes from making a difference in the world, from doing something worth doing. This does not necessarily just pertain to the world in a global sense, but to the individual worlds within which we reside and interact.
I am using the concepts in this book to further my own journey towards finding, believing in and utilizing my soul. As I achieve more in my personal and occupational lives I want to ensure that my spirit stays strong and is reflected in the choices that I make. How do you nurture your soul and spirit? Is this something new to you or something that you have incorporated into your life long ago? Have you found your life balance?
I'm sitting here at work, trying to figure out what to write about today. As I ruminate, I realize what a great team of people I work with every day and this reminds me of an assignment I recently completed for class. The question proposed for class was, "Do physicians work autonomously?"
As I wrote the assignment it made me think about nurse practitioners and our battle for autonomy in healthcare.
Each state has different laws governing the rights and practices of nurse practitioners. Some states have a collaborative agreement with a physician to practice, but there are states that ARNPs can work independently without physician guidance or supervision. This state level jurisdiction and regulation makes changes difficult and time consuming for advocates and collaborative organizations (like the American Association of Nurse Practitioners).
ARNPs are given the knowledge and training to work independently, but are limited by laws created by politicians sitting in an office. Most of these politicians have no medical training or experience. They do not understand all our hard work, education and dedication to both nursing and medicine. Does anyone in healthcare actually work independently? We learn as fledgling nurses how important each member of the interdisciplinary team is and value their input. It would be thought that physicians, at the top of the healthcare hierarchy, work independently. While physicians do make many important decisions on their own, physicians also discuss and collaborate with their peers and nurses.
It is going to take a concerted effort of all ARNPs to help our profession move forward and earn autonomy in practice. Just because we have autonomy does not mean we won't pool resources with physicians, but we can make more patient specific collaborations.
I challenge you as we move forward in this journey to become ARNPs....what are you going to do to help our profession move forward? What is your platform going to be? How are you going to make changes that will benefit the whole? What's your collaboration going to be?
The American Association of Colleges of Nursing published the "The Essentials of Doctoral Education for Advanced Nursing" in 2006. There are eight essentials outlining the required competencies of a Doctor of Nursing Practice (DNP) graduate. The second essential pertains to leadership and emphasizes the DNP's ability to facilitate organization-wide practice changes and provide guidance and oversight of nursing staff. I am currently enrolled in an Organizational Systems and Leadership course in my DNP program. Throughout this class we have been required to complete tests evaluating our leadership styles, strengths and weaknesses. We have explored which leadership approaches best suit our styles, personalities and organizations.
The StrengthFinder 2.0 test identifies the test-taker's strengths in four categories of leadership: executing, relationship building, influencing and strategic planning. These categories are then broken down into specific themes of strength. I showed strength as an achiever in the executive category, skills of empathy and developing in relationship building, and strategic and futuristic thinking in the strategic thinking category. I did not show strength within the influencing category. As an achiever, I excel at developing trust within a team through possession of a strong work ethic and dedication to the project. The ability to make the entire team feel like they belong and willingness to work alongside others strengthens the cohesiveness of the team. Empathy allows me to recognize and positively reinforce team members' achievements, as well as encourage others to recognize and evaluate their feelings. Strength in strategy facilitates visualization of the entire picture-potential problems and probable solutions. As a developer, I fill others with inspiration, acceptance, compassion and support. Futuristic thinking allows me to think beyond the present and strategize for the future. These leadership strengths encourage teamwork, innovation, accomplishment and reflection among the team. These strengths I agree with.
A second leadership evaluation was also completed, the Emotional Intelligence 2.0 appraisal. This test is based upon the belief that an important aspect of leadership is the possession of emotional intelligence: the ability to identify and utilize one's mood and emotions, as well as the moods and emotions of others. Strengths and weaknesses in the classifications of self-awareness, self-management, social awareness and relationship management were identified. My scores indicated that although I need to work on my self-awareness, I am somewhat skilled at self-management. I agree that I am usually able to manage my emotions, especially in a work environment. I also agree that some of this perceived emotional management is due, in part, to my lack of emotional self-awareness, which for me is caused by intolerance of strong personal emotion. I believe that this trait also affects my relationship management abilities. I avoid conflict or emotionally harming others at the expense of my own emotions. While this initially serves to enhance relationships, it often ends up sabotaging them. That being said, I disagree with the low score that I received in the category of social awareness. I believe that I am aware of others' emotions, sometimes to a fault. This has served me very well as a psychiatric nurse practitioner, but it also leaves me vulnerable to burnout and emotional exhaustion rendering me unable to acknowledge my own emotions.
These assignments did not necessarily teach me anything new about myself, but did enlighten me as to how to use these personal characteristics in my leadership endeavors, especially the use of my "emotional intelligence." Although I do not completely agree with my personal results of this appraisal, as a psychiatric nurse practitioner this concept appeals to me. It is a reminder that everyone on the healthcare team is a human with strengths, weakness and emotions. Leadership is not about giving orders and micro-managing, it is about striving for change that benefits the majority of people, executing that change through promotion of teamwork supported by individual strengths, and celebrating the change on an emotional level - not just as a business transaction. Leaders have weakness, individuals have weaknesses, organizations have weaknesses, but more importantly, leaders, individuals, and organizations have strengths. It is these strengths that allow for inspirational change to happen. So just a reminder, don't take the easy route of focusing on weakness - celebrate your strengths and the strengths around you!
What is your leadership style? Do you agree with the concept of "emotional intelligence" in leadership?
(Check in next month to read how I plan to use the concepts in Lee G. Bolman and Terrence E. Deal's, "Leading with Soul: An Uncommon Journey of Spirit" to utilize my strengths and improve my weakness to become a more G. Bolman and Terrence E. Deal effective leader.)
Currently, as I try to write this blog post, I have a Chihuahua under my feet and a 7-year-old leaning against my arm. One term into my journey to become a nurse practitioner and I’ve already had moments thinking, What did I get myself into? and, What was I thinking? Balance is not easy. Coffee has become my best friend. But a balance for dealing with school, family and life is achievable, and I have found the following to be helpful in achieving my symmetry.
When dealing with school, it helps to be organized. I try to have one space designated for studying that is clutter-free. Though not much in my life can be classified this way, it helps to eliminate distractions when studying. I make sure I have a visual of due dates and reading assignments, and I highlight my calendar in different colors. I never leave the house without a book in my hand. Even at work or a soccer game, there is always down time to read a few pages.
It may sound odd, but I try to keep my family involved with my school work. I set goals and post them where everyone can see them. If I hit those goals, I reward everyone! Go get that Slurpee or have a movie date at the $1 theatre! Rewards tend to fare well with little kids. When you tell them, “I have to finish this and then...” they tend to give you those few, precious minutes you need. To save time, I pre-make our dinners and freeze them- the crockpot will be your friend. Take a few hours on Sunday and prepare meals for the entire week. Above all… make sure you have healthy snacks on hand to avoid that ‘freshman 15’ again.
Remember you are part of keeping that balance: Make ‘me time.’ Exercise while listening to the lecture recording. Take a bubble bath and brain storm essay ideas. And sometimes I need to step away from it all for a day and just re-collect myself.
You can achieve balance while in school. Take a deep breath. Remember there are lots of us on this fun journey too. A little preparation and organization can go a long way.
After becoming a nurse practitioner and then deciding to obtain my doctor of nursing practice, I have been asked this question many times by patients, friends, family members, and even strangers. My short answer, which truly sums it up, is, "because I like the nursing aspect."
But what is the ‘nursing aspect'? In 1860, Florence Nightingale defined nursing as "the act of utilizing the environment of the patient to assist him in his recovery." 106 years later, Virginia Henderson modernized Nightingale's definition and said, "the unique function of the nurse is to assist the individual, sick or well, in the performance of those activities contributing to health or its recovery (or to peaceful death) that he would perform unaided if he had the necessary strength, will, or knowledge, and to do this in such a way as to help him gain independence as rapidly as possible."
Both women describe a profession skilled in the act of caring, not just treating.
McMillan Dictionary defines doctor as "someone whose job is to treat people who are ill or injured; someone who has the highest degree given by a university." In contrast the term nurse is described as "helping someone to improve or become more successful; to drink slowly over a period of time; the act of feeding a baby."
These definitions illustrate the helping, caring, calm, thorough and nurturing nature of nursing... of a nurse. These are the reasons I don't just become a doctor. As a clinician, I do treat illness, but as a nurse I treat the whole person. I want to improve their health condition. I want to prevent future health conditions. I want to educate, empower, and encourage them. I want to know what health means to them, what they value, what they need in order to achieve their optimum physical, mental, social, and spiritual health.
So tell me, why didn't you just become a doctor?
Having the right mentor can be a valuable asset for healthcare
students. But selecting the right mentor takes skill and time. Mentors are
never more important to an aspiring professional than today in the healthcare
field where the playing field is shifting. A senior advisor at your side can be
an invaluable asset, so here's how to go about finding the right mentor.
When to find a
The best time to search for a mentor is when you
don't need one. That means ahead of time. There's no time like the present. So
just like studying for exams, procrastination is not the way to go here.
Always have your eye out for that unique mentor
that meshes with your personality and needs. Conversation, experience and
dialogue are the keys to determining if a person is the right fit for you.
It is never too early to start connecting with
your peers and cohorts at professional meetings and continuing education
Establishing an easy rapport with a mentor before you find yourself needing
questions answered and opinions verified is the best time to do so.
This leads us to where
to find a mentor:
You may be lucky enough to find a mentor at your
school or workplace. But often we find them where we find everything nowadays -
the internet. I'm not necessarily suggesting an online mentoring network. But
reaching out to build networks beyond your geographical scope can be a big part
of successfully using the web to build your professional presence. So why not
find a mentor this way? You can start by building your presence with a profile
on LinkedIn. Once you have established your profile here start looking around
and connecting with your peers.
Reading and commenting on online journal articles
is a great way to find someone with a common background or interest who may be
willing to take you under their wing. Read everything you can find about those
around you who are seeking a common goal. Then reach out to them through email
or phone calls. Don't be afraid to put yourself out there and ask someone to be
How to know if a
mentor is right for you:
The right fit will be evident when you share an
easy rapport with a more senior person who you respect. Being able to listen
respectfully and converse comfortably are key to a good mentee/mentor
You may read your new mentor's writing and be
impressed by their knowledge and articulate way of approaching a subject. Or
you may work with them and admire their skill set and their easy dialogue with
patients and coworkers and decide that you would like to ask them to mentor
Be sure to tell them where you are in your
educational process and what exactly you are looking for in a mentor. In other
words, what are your expectations? Then they can tell you if they feel
that they can comfortably meet these or not.
Do not be dissuaded from your search if the
first mentor you approach does not prove to be the right fit for you. Remember,
we may all use more than one mentor. One person may help you with the interview
or application process and another may come to your side when you are starting
out in that new position and just finding your place.
So get out there and look for your mentor. And someday soon
you may find yourself mentoring others.
As the holiday season approaches it has become clear to me that
"Yes, Linda, there is a Santa Claus." Registering for the winter
semester it was mentioned by my advisor that in May my clinical time begins.
This day has seemed to be off in a distance for so long. Honestly speaking, at
one point it was looking to be out of my reach and now only one semester
separates my journey into the next place.
Being a student over the past 1.5 years has challenged so many
areas of my life. It has seemed the entire summer went by with my head in a
book or behind a computer screen. Knowing that the end is in sight gives hope.
Each class has also been unique in its own manner and has pushed
me to apply every ounce of energy available. It would be so much simpler if school was the only task in my
life. I also am a pediatric clinical leader in my hometown hospital and have
been trying hard to get items implemented on our unit that will allow for
better assessment of the children that come in.
I have always felt the need to achieve one more thing in life. I
find not setting goals in your life is an easy way to not apply yourself. If
each day went by and didn't have direction it would be simple to accept the
status quo and go forward.
Becoming a nurse practitioner is the push forward that
drives me. I want to be able to make a difference in a person’s life and know
that all of the struggles and lack of sleep have been worth it.
My mother has always been a great inspiration to me. She
obtained her LPN degree and with children she went back to obtain her ADN
degree. She always was striving to have more knowledge and become a better
caregiver. Knowing her time was coming to an end due to terminal cancer she
continued to brighten our days with stories and desires for our lives. She never
wanted any of her girls to settle for anything less that what they wanted to
My father also passed away a few years ago with terminal cancer
and even today I can still hear him talking to me about where my career will
take me. I shared with him the desire to help others and open a free clinic at
some point. I know in his own fatherly way he would be proud.
This blog was written with inspiration from my Mom and Dad,
Margaret and Harvey Spurlin, may they rest in peace.
In conclusion this month, my thoughts for you are to take some
time to reflect on why you are where you are in this journey. Each person
follows a dream, a course or a bigger aspiration for more and over the holiday
season I hope you will take some time to sit and enjoy the lights, tinsel and
mistletoe ... NO TEXTBOOKS ALLOWED.
Happy holidays to all. See you next year.
I'm down to the wire of finishing my PA degree and
the PANCE is looming with a mere 17 days left for me to cram. How do you study
for the PANCE? Because I haven't yet passed, don't take all this advice too
seriously but I'll elaborate a bit on what I think is helpful:
early. My school has over a month of built-in PANCE prep with lectures and
practice exams so we had an earlier start than many programs.
to the blueprint. The NCCPA will become your best friend and I've been told
that really adhering to blueprint content is your ticket to passing.
try to understand, just memorize. If you start early enough, you may have time
to memorize complex patho concepts but the reality is the PANCE is a lot of pattern recognition so if you learn a
lot of key terms it can be much more efficient than trying to re-learn
everything you missed in your didactic year.
practice exams all the time. The biggest thing that has helped me improve on my
Packrat is practice questions because you start seeing the same questions over
and over. I never sit down to study without doing at least 50 practice
questions. I use PAEasy and Kaplan which I bought with 5 other classmates.
Kaplan is really tough and I highly recommend it if you can get some folks to
split the hefty $200 cost. Another good option is the Lange practice questions
either as an iPad app or in book/CD-ROM form. Our school has a Packrat built in
every week and I've improved each time.
to podcasts when you work out or drive.
your practice book everywhere. My favorite is A Comprehensive Review for the Certification
and Recertification Examinations by
O'Connell. I also use First Aid for the Family Medicine boards. I have a couple
others but you really just need a few. If you memorize everything in these you
would totally pass.
stuff down. This helps me because it makes me slow down and realize what I'm
reading. I have a notebook I have taken all my PANCE notes in from said review
books. I overdosed on flashcards in
didactic so I gave up on that medium.
a life and don't freak out. I'm a super busy person and the looming PANCE
hasn't stopped me from going to see Hunger Games, spending time with friends,
enjoying the holidays or cooking comfort foods. It's just a test and the worst that can happen is I fail and lose $400
and have to wait 90 days. That's really NOT
the end of the world.
One of the first things to know here is that it is all about
priorities. And we know schoolwork comes first.
So here is a step-by-step guide to getting through the last
couple weeks of classes, final exams, Thanksgiving and the pre-holiday season.
Step 1: Sign up early
for those holiday pot-luck parties.
Always volunteer to bring the cups and plates! This is why
it is essential to sign up early. You don't need to be stuck cooking mac and
cheese or brownies when you have an exam in the morning. So sign up to bring
the disposable cutlery, plates and cups NOW! You will be thankful later when
you make the quick dash to the dollar store and to run right over to the party.
school holiday get-togethers will provide you with a welcome lunch or dinner
when you most need it - right in the middle of studying.
Step 2: Save time - study now, do laundry later.
Stay focused on your work by cutting back on doing laundry. This
will yield countless found hours to devote to your studies. No need to do
laundry now - it's cold outside and everyone dresses in layers anyway. Remember
it's ponytail and sweatpants season for all students right now. Just bag it all
up in a black trash bag and bring it home for the holidays!
Step 3: Make gift
giving a snap when you procrastinate.
There are two alternate strategies here. You can either shop
early and online or you can procrastinate to the very last moment. I recommend
the latter. If you shop online you may be tempted to be distracted from your studying
while at the computer. And there are actually advantages to procrastinating
with holiday shopping! Markdowns will have already begun and the crowds at the
stores will probably be thinned out - especially if you wait until Christmas
Eve. There is a real art to this. So don't procrastinate on studying,
procrastinate on shopping and be sure to reap the benefits.
Step 4: Smile extra
You will need to perfect this step. Remember, you are
wearing dirty clothes, bringing plastic cups to a party and you have no gifts
to give (yet)! So smile big, keep your chin up, your nose in your books and
pass the cranberry sauce! There will be plenty of time for cleaning up and
P.S. Tell Santa Claus that you want new highlighters for
Christmas! It's never too early to stock up for the spring semester, it's right
around the corner.
As the holidays fast approach and the year is quickly coming
to a close, it seems natural to look back at times. Although looking back at
times can help you see how far you came over the past year, it can distract you
at times from where you are headed.
Often we become overwhelmed at what we have not gotten
completed. As 2013 comes to an end, I am able to see so many milestones
covered. The biggest accomplishment to see is how very close my clinical time
is from here. With each class I find myself becoming more excited about the
time when I can become the provider.
been asked many times what I have planned after graduation and the ability to
see that far ahead still escapes me. I realize each class that is behind me
will only build on the base that I have and provide me with a better
Online classes can be a challenge at times, especially becoming
disciplined to meet all the deadlines. I feel pressured to turn in assignments
and also may have pressure from work or family. The ability to clone myself
would come in handy at this point in my career.
hope each of you take the time to enjoy the holidays as much as you can. November
10 was my birthday and the agenda of the day was working, then homework. I know
this will pay off in the long run.
a brilliant patient. She was exactly who I want to be when I'm 91. I met G.F.
while on pulmonology consults last month. She was sitting up in bed with a CPAP
machine on. Her daughter was sitting in the room, so kind and matter-of-fact,
explaining how her mom was suddenly short of breath yesterday and was brought
came off her CPAP long enough to explain that on Sunday she was at the church
potluck, and the day before that she took the city bus to go shopping because
she, "hates waiting for rides." And then she just felt so bad all Monday and
called her daughter to come to the hospital.
G.F. had pneumonia and by the time
I saw her, she was being treated but just couldn't seem to keep her O2 sats up.
We, as the consult team, decided that perhaps if we cleared out the pneumonia
we could take her off the CPAP and her breathing would resume to normal.
G.F. the next couple days, always so pleasant in the morning, and her lung sounds
improved each time. She just still couldn't wean off the CPAP. And she was
having a hard time eating in between breaks from the machine.
primary team had established G.F.'s code status. G.F. had decided that she did
not want to be intubated or get chest compressions, only the defibrillator.
Then on Thursday rounds, my attending had a frank conversation with G.F. and
her daughter: "She's 91. When we get pneumonia things are different. When
someone like your mom gets pneumonia, we worry. We will do the best we can, but
she can't seem to tolerate room air and these are bad signs."
surprised at his tone. She seemed so well, relatively. Last week she was just
living her life. People get over pneumonia all the time.
her on rounds the next day. She was chugging Ensure like a champ -- still on
CPAP. I went home for the weekend. I make it a habit to check on my patients
Sunday night before I go back to see the events of last week. I pull up EPIC,
click on G.F.'s chart and this message pops up, "The patient whose chart you
are accessing is deceased."
Where you study can be as important as when you study and
who you study with. I never realized this until recently when I attended a
study skills workshop led by a behavioral psychologist who enlightened me to
the importance of the actual location of study time.
Apparently, our bodies take subconscious cues from our
environment that can affect focus, attention and even hormone secretion. These
are factors that we can get working for us with little effort if we know how to
harness them. And I'm all about little things that mean a lot. Little effort,
By going to a designated study area that is a "sacred grove"
of studying, you can condition yourself to maximize your time and focus and retain
material more efficiently. Naturally, you will need to personalize and perhaps
alter some of the following steps to make this happen for you.
STEP 1: Find a
location where you will only study and not perform any other activities. So
it's best if it's not your bedroom or your kitchen table. You want a special
place that the only task you participate in there is schoolwork. You may have a
favorite study carrel or corner table in the library - make this your study
home. You can branch out to secondary
locations later, if desired, once you have mastered "getting in the zone."
STEP 2: This is
an important step! Get down to work in your designated study spot. Do not
"pollute" your study place by checking Facebook, email, texting or chatting
with friends. Make your study grove a place that you focus and stay on task. Schedule
your study time here. Designate 45 minutes to pharmacology, then take a 10
minute break and then do 45 minutes of say, pathophysiology. Your time will be
used effectively when you stay on task.
STEP 3: This is
the rinse and repeat step. Return repeatedly to your study spot or spots.
Though it is best to have one or two places to study, sometimes circumstances
dictate that we have three or more. But go to this place each time and get to
work. (Though if your favorite library table is taken, you will have to select
another place or risk an unpleasant confrontation!) Soon, your brain will be
conditioned by the sights, sounds and smells of your chosen location and be
ready to focus on learning as soon as you sit down.
Once you have mastered the above steps, you can train yourself
to put your mind into study mode in other locations as needed. So you can train yourself to do flashcards on
the bus effectively once you have conditioned yourself.
I have found that I do not study well at the library at the
college where I attend PA school, though we have a beautiful library that is
airy and inviting. I discovered through trial and error that seeing my fellow
classmates working on other material around me makes me anxious. And anxiety
hinders learning. So I have a favorite table at a small public library down the
block and a favored weekend study place at another nearby small local college.
This also eliminates the possibility of too much chatting with fellow students
taking up valuable study time.
So go find your own unique study area, make it specific for
studying and maximize your brainpower!
A new semester so soon. October 5 marked
the beginning of the fall semester. The classes to be covered are care of
children and care of the childbearing woman. Pediatrics shouldn't be such a
challenge, as this is what I do each day. Several of my fellow classmates have
already crossed the finish line which serves to show that the end is in sight.
Looking ahead at the calendar, my clinical
rotation begins in only 7 months. One of the biggest challenges that I have
encountered is being able to step across the line between the nurse and the
healthcare provider. Having been a nurse for the last 27 years, it is hard to
separate the two roles. Each day that goes by I see more clearly the pieces of
the information coming together.
My advice so far is to stay very, very
organized with your class work. Until next time, I will continue to study hard
and keep everyone informed of life as a student.
I just returned from Uganda 5 days
ago -- a harrowing 43 hour journey with a more than a few moments of thinking
we might not ever get home, but I did. And I wanted to recount a day with a
problem we as NP/PA students don't face much in the U.S.: malnutrition.
Bugabero is in the Manafwa
District, a sort of rural suburb of the city we are staying in, Mbale. It is
about one hour on rough roads from where we stay and not far from most of the
villages we visited. Kissito, the organization sponsoring our time in
Uganda in concert with the government, has developed a malnutrition clinic
which runs every two weeks.
Parents of malnourished children
come to get their child assessed, get them medications, vitamins/minerals and
food supplements. A lot of times, the malnutrition in kids is not necessarily
due to poverty, but it is due to lack of education. Mothers feed their
children posha (cornmeal) too early, do not provide milk or eggs, and when
their child loses their appetite or gets sick with malaria, Kwashiorkor or
Marasmus quickly follows.
It is a heart-breaking
problem. Many of the times, fathers abandon their malnourished kids as they
become sicker and weaker. Moms give up on feeding. Children die.
We arrived at the clinic at 9:30
and it was already very hot. Bugabero is always very crowded because it has the
reputation of having the supplies it needs. There are families camped out
on the grass around the compound, laundry drying on the grass, kids playing,
cows and goats and chickens make their home anywhere they please in Uganda.
A Ugandan health educator came up
to us as we were milling around the mothers sitting on the grass waiting for
things to get started. She asked us in Ugandan English if there was anything we
PA students wanted to educate the mothers about. I jumped in, "We will listen
to what you say first and then we can add information after? So we don't repeat
what you say?" I don't think she understood. Fortunately, Matt jumped in and
said he would educate on breast feeding. Uthman translated.
Then the "health educator" spoke
to the 50 or more families squished together on the grass. Her lecture was
tragically unhelpful. Most of these children have protein malnourishment. She
did not speak about protein. What I do remember her saying was, "When your
child gets sick and is unhealthy from malnourishment, fathers leave child
because he is sick. Feed your children so the father doesn't leave."
After the "health education," the
chaos ensued. Dana, my classmate, and I were paired off with the clinical officer
(like a PA) named Ephraim. We went into the hospital building and there was a
table and a bench for the patients.
A mother came in with her child
who had a fever, diarrhea, and was malnourished. Ephraim was going to
send the child for a "BS" (blood smear) for malaria but apparently the lab was
locked that day so we wouldn't be doing any blood tests. He seemed to take too
long with all the patients without finding out much about them or even doing
much of a physical exam. If you only have 3 ways to treat a patient, there
can only be 3 problems. Is it malaria, HIV, or pneumonia? If it isn't one of
those, then there's no point in finding problems you can't fix. It's reasonable
in this setting, but not the way I was trained to think.
In this small room, there were
three mothers with babies on their laps. All the children we saw Monday were
sad. So weak, so skinny. They looked like stick figures with their big
round heads, poky arms and legs and large bellies -- a picture of a person a
kindergartener would draw with unrealistic proportions.
The saddest case was a child who
initially I thought was convulsing from cerebral malaria -- malaria gone so far
it causes swelling in the brain and neurologic deficits. The child's jaw was
open and its head would nod back and forth, and it was having decorticate
convulsions with its arms curling up into its chest. The child was very hot to
the touch, clearly febrile.
Lindsey, a Kissito worker, kept
asking Ephraim why he wasn't attending to this child. Ephraim then explained
the child had cerebral palsy since the age of 3 months and was now 2 and a
half. He would refer her to Mbale (the hospital from my last post). It's
scary seeing a kid that skinny and convulsing and no one seems to mind. I
wonder who gave the diagnosis of CP. Perhaps the 3-month-old little girls
did have malaria then and had deficits that never remised. There's no way
I wrote the history of present
illness in her "chart" (a flimsy notebook the mother carries around) and the
physical exam. Ephraim commented, "Wow, wow, this is nice." I would've
gotten an F on that note in the U.S. I left out so much. All I could think
was, "Any pediatrician would've spent 1 hour assessing this child and it
would've had 10 referrals."
Later in the morning, I saw the
mother pouring orange coke into her open mouth. She apparently can't
swallow well. I suppose any of us would look completely wasted if our
primary nutrition was liquid sugar.
Dana and I next rotated and helped
weigh the kids. Imagine two trees close together with a strong stick nailed between
them creating a bar. Then there's a grocery-store like scale and a harness. You
put the child in the harness and hang it on the scale to get their weight in
kilograms. We helped weigh and document the weight on the patient's log
for 30 minutes. Ugandans are nothing if not resourceful.
We briefly tried to help assess
the arm circumference. It was very confusing to understand which patient was
next in line. Basically, we would just wait for the health worker to tell us
and then tried our hand at checking for edema and arm circumference.
If a child has edema, you tell
them to go straight to weighing because the swelling from protein imbalance
will ruin your arm circumference measurement. There were many kids with edema.
Also, if the child's arm was "too fat" they didn't qualify for the program. I'm
ninety-nine percent sure they were all malnourished. Resources are slim however
and you have to turn some people away.
By this point, about three hours
into the morning, most of the patients had been weighed; they were just waiting
to get their medicines and nutrition. The scariest part of the day was
when I was assessing patients with Uthman translating. I saw three
babies. The mothers would hand me their books and I'd try to see if the
patient was gaining weight, was their symptoms were. As Dana clearly put
it, "These mothers all say the same thing: my child has been coughing for 1
month, has diarrhea, and has been vomiting."
It might be true but it
becomes difficult when literally all the stories are identical. I would
listen and poke the kids. All of them seemed like they had malaria and
anemia secondary to that. To play it safe I wrote "anti-malarials" on
most of the plans. It's horrifying to "prescribe" when you have no true
clinical picture of your patient. I didn't want them to leave
Uganda is nothing if
not confusing. There is so much lost in translation and lost in not
understanding how people work here. But after a day like this you do know
one thing: kids need food. And maybe
that will change something.