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After decades of research and effort, why is there a persistent struggle to truly practice the ABCDEF bundle?
Are antiquated sedation practices because nurses are unwilling to change, or is it because they are unsupported and untrained in the risks and realities of sedation? Even when training is provided in the classroom, what do nurses learn at the bedside? How does poor leadership impact sedation and mobility practices at the bedside? Are nurses safe to question long-held habits and beliefs? “April” joins us now to share her experiences entering the ICU and how the ABCDEF bundle is really being practiced.

I have before shared my experience with meeting with a medical director in 2019. I told him what my Awake and Walking ICU was doing, and he scoffed and said, “yeah, there’s about that in the research, but you’ll get our nurses to do that.”

Those words have burned in my soul ever since. As a nurse have worked with hundreds of nurses, I adamantly reject that sentiment.

One of the root problems that I am passionate about addressing across all disciplines- including physicians- is that clinicians are RARELY EVER really taught what sedation actually does and the high costs of immobility. We can NEVER assume that someone “won’t” do the ABCDEF bundle when they have never had the education, support, and opportunity to do it.

This episode, I want to dive deep into the perspective of nurses, especially as they enter the ICU. How are they taught to not only care for patients, but approach learning and the heirchy of power within the ICU.  What kind of sedation, delirium, and mobility education do they receive in orientation, and then what are they pushed into at the bedside? How can we dare expect them to understand the ABCDEF bundle when they are immediately immersed into a world of antiquated practices and culture?

This episode we’re going to hear from a brave nurse that is in the thick of this conflict between what is best practices and what is normal. What she knows from the research and what she is seeing at the bedside. She is an experienced nurse newly entering the ICU and will share with us the process of “iniation” that many nurses receive. What she shares with us is not to unjustly zoom on one nurse or one unit. This reveals a system problem that helps understand that nurses are usually willing to do what is best for patients, but are unable to do so when immediately sucked into this environment and given inadequate and improper training.

To protect her from more retribution than she already has received, her voice and name have been changed this episode.

Episode Transcription

Kali Dayton 0:00
Thank you so much for coming on the podcast for being willing to share your experiences and your insight. Can you give us some context into as safely as you can? A little bit of your background and what your experience has been coming into the ICU? Yeah,

“April” – Anonymous Nurse 0:16
Kali, thank you so much for having me here. I’m a few weeks in, I’d say three to four weeks into a program that is transitioning me from kind of a med surg tele background to the ICU to critical care. I come with eight years of experience in med surg tele, and step down intermediate care, or however you want to say that progressive care, and also just a little hint of emergency, and there as well. So eight years in and now making the transition to the ICU?

Kali Dayton 0:51
What made you want to go into critical care medicine?

“April” – Anonymous Nurse 0:55
That’s a good question. I, I was never one of those ICU or bus nurses. But as I was progressing in my care, and just found this love of absolute, like nerdery of you know, geeking out on pathophysiology and pharmacology, I just love the intellectual aspect of ICU.

And that was hard, it has been hard to reconcile the fact that I worry about, you know, the moral distress of what we’re doing in the ICU with patients who are so so sick and sedated and not able to advocate for themselves. But I kind of let the intellectual part of me went out. And I’ve decided to go ahead and make this leap into the ICU.

Kali Dayton 1:44
I mean, you have a lot of experience, a lot of knowledge and nursing medicine in general. But you also had done a lot of research, you would listen to this podcast, you knew a lot about delirium, mobility, the ABCDEF bundle, you came in with a really unique perspective.

You were also kind of bracing for it, you knew that patients were going to be sedated and immobilized. And we talked before you entered, just knowing that this is going to be conflicting. How has that been for you knowing a bit of what should be and then seeing what is?

“April” – Anonymous Nurse 2:19
Honestly, Kali, it’s been really hard, because as a brand new ICU nurse with no authority, I can’t see anything. I can’t question what’s going on with the sedation practices, or the lack of mobility that I’ve been seeing in the ICU.

And I just kind of have to sit with it and in witness it and kind of biding my time until I get the respect and authority as an ICU nurse to say something to just start questioning to start pushing back. But right now, I don’t. So all I have is observations, and I’m definite misgivings for, for what I’m seeing and being told to do with my patients.

Kali Dayton 3:10
And I’ve heard this from podcast listeners when you hear this information, especially for our seasoned clinicians that had accepted this environment in this care as the norm. When they find this information out. And they realize what’s actually happening to patients what the alternative should be. It’s really hard to go to work after that. Because you look around and you see the harm that we’re talking about here. You can’t unsee it. Yes.

“April” – Anonymous Nurse 3:38
Exactly. Exactly. And I I am definitely in that phase right now. You know, there was the initial excitement of like, wow, my eyes have been open to delirium prevention and the ABCDEF bundle and early mobilization. Now, I’m in the hard part of what do I do about it? This is morally distressing. How can I make an effect on this? And I think I’m at the lowest point I’ll probably be in my career in terms of this. And I hope that I can help shed some light on some of your other listeners who are going through what I’m going through.

Kali Dayton 4:24
This is why I’m having you on the podcast because I think this is a shared experience. Whether for new grads newly into the ICU, or people that have been in the ICU for decades, how to bring this change, but your experience right now reveals a lot about why we’re here. Why the ABCDEF bundle has had such a struggle and rolling out.

We’ve talked a little about this will be for the recording and I want to dive deep into what are you being taught you’re in an orientation program. You’re being taught the basis of Critical Care Medicine. We would hope that some of the basics include how to help patients survive and thrive. What are you being taught about the ABCDEF? Bundle? How was it presented to you?

“April” – Anonymous Nurse 5:11
So, the ABCDEF bundle was actually a pretty significant part of my orientation, kind of the didactic portion of orientation. And the educator, who presented it seemed very passionate about it. And I think she truly is. But that has not translated into what I’ve seen in practice.

And what I’ve seen in practice is that travel nurses have not really bought in to the ABCDEF bundle. And so it’s hard to have that consistency and culture, when you have over 50% of your nurses are travelers, how can you get on the same page when there’s such a turnover every three or four months.

So what I see from the travelers, and this is no way, I’m speaking poorly of travelers, because I think there are amazing travelers out there who have just come with huge amounts of wisdom, but what I’m seeing is that we have, the travelers I have worked with have not bought in to early mobilization, they have not bought into, you know, have, they haven’t been educated to, you know, all the harms of sedation.

And so while I believe the management, and the course staff do have, at least you know, an awareness of the ABCDEF bundle in bringing that into the ICU isn’t being practiced because of the high volume of travel nurses.

Kali Dayton 6:55
And that is a very relatable problem right now in a lot of ICUs. We require so much consistency, education, especially when this is a change from the norm. When you train a team, you’ve got to keep your core team together. And their bundle requires the entire team a lot of relationships, you need to know their names of your colleagues, in order to call on them, to rely on them, to utilize them to work together with them.

So when you have so much transit unemployment happening, it’s really hard to change the culture and preserve that culture. So when you you’re being you’re being trained by a travel nurse, which is really difficult, I think, I think anyone can agree that when you bring in new people into the ICU, part of that mentorship is developing that relationship of having someone that you’re going to work with in the future, and someone that you can go to with questions in the future. That’s not what you’re being provided. Right?

“April” – Anonymous Nurse 7:56
No. And there’s a general, you know, awareness that this is not an ideal situation, by any means. But just it’s kind of the reality of the situation that they don’t have enough core staff, to train, you know, all of us who are coming through this this program. Also the core staff. Actually, I don’t really want to bring up that part. But yeah, it’s absolutely not ideal. And I’m missing that cultural socialization aspect that should be part of a training program.

Kali Dayton 8:32
So you’re learning things in orientation from an educator, you’re hearing, good truth, great perspective. Then you get to the bedside, and you’re working on application. And what are you seeing at the bedside as far as let’s just talk about awakening trials? How are you taught to do awakening trials at the bedside.

“April” – Anonymous Nurse 8:52
So what I was taught in the classroom, was that you do an awakening trial at 8am every day. And sometimes there can be two awakening trials, but generally one at 8am every day. And what we are taught is that you shut off sedation, at this point, you bring it to a halt. See how the patient does. And if they don’t tolerate it, if they don’t pass the awakening trial, then you put the sedation back on at half of what it was before, and then you go from there.

What I’ve seen in practice, is that the nurse will bring down for example, the purple fall by like five, five mics. Sorry, is it makes your milligrams Okay, so, the nurse will bring the propofol down by five mcgs, or so maybe even 10 and see how the patient does. And then she’ll see that the patient is overriding the ventilator like his respiration was are higher than what the vent set respirations are interesting. “He’s not tolerating it.” Or she’ll see his heart rate go up or his blood pressure go up and she’ll say, “He’s not tolerating it. We need to go back. He doesn’t pass for it today.”

Kali Dayton 10:17
And that’s it. That’s it.

“April” – Anonymous Nurse 10:21
It was so it was such a small change that she made that I even asked her afterwards. I was like, What are we going to do the SAT? And I didn’t even register that that was what she was trying to do. She says, “What are you talking about? We did it!”

I said, “THAT was an SAT? That’s not awakening, awakening.” There was that much of a contrast as compared to what we were taught in the classroom.

Kali Dayton 10:54
So that was on day shift. So then when you then report you doing the rounds on that patient? How was that discussed?

“April” – Anonymous Nurse 11:06
The nurse just said exactly what we did. “We tried to go down the propofol, he was overriding the ventilator. He didn’t tolerate it. And so he did not pass.”

Kali Dayton 11:19
And did you see how far he was overriding the ventilator? Like what were the actual respiration?

“April” – Anonymous Nurse 11:23
Yeah, so his set respirations were 18. And he was going to 26 or so hovering around 26.

Kali Dayton 11:33
And no investigation as to why the respiratory distress- is their anxiety is there fear? Is there pain?

“April” – Anonymous Nurse 11:39
Is her interpretation is he’s having anxiety, is he he was able to communicate enough. He’s like, Are you in pain? “No.”

Kali Dayton 11:49
During the trial?

“April” – Anonymous Nurse 11:53
You know what? Not during the trial, it was just in general, what do you like with the data? Right, right. And “Are you having trouble? Like, with your breathing? Are you finding it difficult to breathe?” And you would say “Yes.”

And then that was enough for her to decide, “We’re not changing any of the settings there if anything going on.” And sorry, I also want to say like, so he’s on propofol. Also, he was on 200 of fentanyl. And 1.4 of dexmedetomidine.

Kali Dayton 12:31
So significant, but he was still responding to questions, which is great. That’s that’s a lot of fentanyl. And ventilator settings were lower.

“April” – Anonymous Nurse 12:43
We’ve been here. She was on a PEEP of 7 and fi02 of 40%.

Kali Dayton 12:56
So in some ICUs, he would have hopefully been extubated, or really close to being extubated.

“April” – Anonymous Nurse 13:02
Yeah, sorry. So yeah, so I mean, there was discussion, like “he’s getting close. He’s getting close here.” So I was I was hoping for more, more enthusiasm about it. And then I felt that, you know, and I’m interested to hear what your perspective of this, but to me, it seemed like kind of a very half hearted attempt.

Kali Dayton 13:30
Right there when I would love to see more discussion, saying, “Well, why? Why was he overbreathing the vent? And is a respiratory rate of 26 really that dangerous? Can we help him calm down or to anxiety? Those kinds of things to decrease his respiratory rate? And ultimately get him extubated? Are we costing him another day or more on the ventilator because of this approach to an awakening trial?”

So as if I was there, as a nurse practitioner, I’d be digging in deeper, I would be saying, well, “Let’s do it together. I’ll go in the room with you. Let’s take the sedation out together. Let’s work this through and see if we can get him extubated.” That’s what I would do. Or, “let’s sit him up. If he’s not ready to be extubated. If he fails, his breathing trial. Well, let’s, let’s get him ready for a successful breathing trial later, or even tomorrow by mobilizing him. Let’s get PT and OT in there to help with the awakening trial.”

Like that’s what we need to be doing with that kind of information. So that’s what I would love to see more collaboration, how to bring everyone together to achieve the goal of getting the patient awake, mobile off the ventilator. When we just say okay, it’s a field trial. Without further investigation.

We missed so many opportunities to fix the problem, to learn to collaborate, we just missed out and it’s our patients that suffer but for you coming into this environment, that’s got to be so confusing.

“April” – Anonymous Nurse 14:56
It’s very confusing. Because like so many Do things in nursing, we’re kind of taught one thing, and then we practice another. And I was like, Well, is this really our goals with SATs and SBTs? Like, is it really how it’s done?

But, you know, I really like to think that it’s, it’s not that, that this was just someone who, you know, my preceptor comes in with 30 years of experience, who staunchly feels like she’s, she’s doing right by the patient, because “It’s not nice to have a tube down your throat.”

And she really feels like, you know, she keeps saying, “Oh, he needs to sleep, she needs to sleep, that’s good for him. He’s done a lot of work, he needs to sleep.” And it really is coming out of a good place. Right? Like she’s, she’s, you know, really identifies as an advocate for a patient.

So, you’re right, it’s hard for me to reconcile that. That practice that she’s, you know, that she’s practicing versus what I think is kind of really known to be wrong.

Kali Dayton 16:43
And, again, you’re seasoned, you’re educated, you know, that sedation is not sleep, you know about delirium. And yet, it’s still hard to question these things. Because when everyone around you treats it as so normal, and you’re new to that environment. It’s it’s so intimidating. It’s so hard.

I fall for this as well. I mean, I had worked in in Awake and Walking ICU for two years, then I think was probably my third facility. It was in 2016, that they were finally doing awakening trials. And this that it was taught to me very much thing, “wait, you turn down sedation enough to see them start to move, turn it back on.”

And so even though I had worked in this Awake and Walking ICU, in this environment, where I, almost all my patients were awake. I was like, “Oh, is that what we do?” I had questions. “Why are we doing this?” How do we…. and they said, “That’s how you know that they can’t tolerate the ventilator.”

Well, I was wondering, “Why aren’t they tolerating the ventilator? Because I’ve seen so many patients tolerate the ventilator. So why not? I don’t think it’s just the ventilator. And I don’t think that’s a real neuro exam. I still don’t know what’s going on with the brain. I don’t know why they’re acting this way.”

I had all these questions, but you kind of succumb to the environment. It’s a “shut up and do it.”

“April” – Anonymous Nurse 17:55
Yes!

Kali Dayton 17:56
environment, which is scary. And I was, you know, two years into my career. And even though I had experience, I had knowledge, I didn’t have the right knowledge to advocate and push back. But there’s this, you’re not psychologically safe in those environments. You’re the newbie.

For me. I’m like, I’m the newbie and the visitor. So I just shut up and did it the way that everyone else is doing it, you fall into this, what Dr. Ely calls is a “malignant normality”. And that’s what’s expected of you right now. Right?

“April” – Anonymous Nurse 18:25
It is. And it’s even worse than that, in my case, at least that if I question, then I’m being labeled, as, you know, difficult or uneducated, you know, like, why would I push back on a nurse have 30 years experience? Or that I’m resistant to feedback? That’s when I hear sometimes.

So it’s really it’s really difficult and detrimental for me to voice, anything that goes against, you know, this practice of over sedation.

Kali Dayton 19:09
And you feel like your employment is at risk?

“April” – Anonymous Nurse 19:11
Yes, I do.

Kali Dayton 19:16
It’s just so unsafe for everybody. To have this kind of environment where clinicians are not safe to ask questions, bring evidence to the table, bring their past experience. I mean, in my perspective, as a nurse manager, I’d say, “Wow, a med surg nurse with eight years of experience, who you do a lot of extracurricular things. I mean, who brings on so much rich insight to the ICU? Awesome. Let’s do everything to make sure that we give you a chance to succeed in ICU, that we keep you you’re going to be a great asset to the team. You’ve already shown leadership in your career.”

You would want to foster that kind of environment where you can keep gems like you, but that’s not what you’re feeling. That’s how You’re experiencing, you’re worried about losing your employment because you’re trying to advocate for patients.

“April” – Anonymous Nurse 20:06
Right. That’s obviously how I look at it. I think as an employer, they probably they want me to be teachable. And the questioning the nurse of 30 years, is, you know, maybe in their eyes, not not trainable.

Kali, I wanted to bring up the point that, you know, during rounds, when we brought up, you know, what happened during the awakening trial in the morning, the physician could have spoken up to, and I, you know, when I talk to physicians about delirium, and early mobilization, they seem really on board.

And they’ve, they’ve made that switch in their mind from, you know, target RASS of minus four or minus five, to being awake. And you know, that RASS of minus one minus two. But sometimes I think that physicians kind of let nurses for the show of some things because it’s just easier for them.

And you get these, I don’t want to say this in a negative way. But you get these ICU nurses who are so set in their ways, and they’re so proud of how good they are, and their practice that they would just be uphill battles and go against them.

So it’s, it’s a multidisciplinary, right, like, you need. It sounds to me that the doctor didn’t say something back when, when, you know, my preceptor gave this summary of what happened during the waiting trial, like he should have felt like he had the authority to come back and say, you know, “That’s not a true awakening trial, or what else can we do to get this patient more awake?”

Kali Dayton 21:59
And I think there’s a lot behind that. My first thoughts are one, I don’t think physicians are as trained and prepared to practice the bundle as we assume that they are. I don’t know that. They really know how, for the most part, I’m generalizing, right. But most do not necessarily know how to do waking trials, how to help patients with agitation, how to work through delirium, how to mobilize them.

So they can say, “Wow, the evidence is really compelling. I understand the science and the statistics from these studies.” But at the bedside, do they know how to bring you that human approach, and even just the logistics of how to work a patient through coming out of sedation? My experience is that they don’t, they also need that training that support that experience, to develop that expertise.

So we sometimes rely on them, we want them to take that leadership. I don’t think they’re prepared to second, even if they do understand and they do have the skills for this. It is really scary to challenge a nurse. So I have experienced that as a nurse practitioner. I remember when COVID hit, we had a patient that was not even agitated, he was restless on the ventilator. He was coming out of sedation and one of the float nurses who was probably 30 years, my senior very experienced I had a lot of respect for her came and asked for an Ativan drip. And I was shocked, right?

And I and I, it was hard for me to tell her no. What I wasn’t used to nurses asking for sedation period, because I was used to my nurses nurse the head trained me right that were so expert in this. But this is a new environment. She couldn’t understand why he was awakened. She wanted an Ativan drip because he was anxious, she said. And so I just remember being like, How do I tell her? No, because the reality is, I’m doing notes and transfers and discharges on 13 patients right now. 14, maybe 16 at the time.

I’m not the one at the bedside having to help this patient work through, I can go and I can assess and I’m gonna give like recommendations and try to help her. But I’m not the one having to be in that room all the time, like a nurses. So there’s this really the sense of guilt of saying no, just don’t say it, then you deal with it. But most clinicians don’t know how to help them deal with it. So it’s really conflicting.

So you, you just don’t want to be that provider that says no. Also, it’s a seasoned nurse. So you trust that they know what they’re talking about. So in that moment, I had to say, I had to take it as a teaching opportunity. And I know my initial response probably could have been better, but I said, “Well, who’s going to clean up that mess?” I was still kind of in shock, right? But and that could have took her back? And I said, “Well, just think about it, right? We start that drip now. It’s gonna be like a grenade that you’re passing on shift to shift. It’s going to cause a lot more delirium, a lot more agitation, and someone’s going to have to take that off. And if we can’t mobilize them….”

I just try to explain that big picture. So I tried to take that moment to educate, and I wasn’t used to necessarily having to educate the nurses because they were the ones educating me most of the time. But that’s what leadership leaders should do providers and others, PA, nurse practitioner MD, when those, they’re coming to you with a request for a reason, because something’s happening with a patient.

But if we give recommendations that are not in line with the A to F bundle, or we accept their ideas that are not part of that bundle, without investigating the root cause, providing actual support education tools, to really fix the problem, then we’re never going to master the bundle.

So you’re right, the physician missed an opportunity in that moment, to guide to do best practices, and to educate and help bring that culture change. This is what we need I what teams that I trained. Sometimes the physicians will say, we support you, we’re all about it, but they don’t participate in the trainings. So then later on, they become the barrier. Not all physicians are bought on board.

And so one team said, “Yeah, obviously this one physician didn’t catch the memo, what we were working on. And I was trying to get my patient awake, and they didn’t want the patient to be awake. But I couldn’t didn’t understand why they needed to be sedated. But the physician was stuck on that with no explanation other than ‘they’re intubated.’ ”

So here, we made all this progress with the other members of the team. And ended up being the physician that was the barrier because they figured that “this is a nursing thing”. “Mobility is a PT or OT thing.”, “Thumbs up from a distance.” That’s not what makes a change. It’s actually been involved as physicians, actually knowing it for yourself and knowing how to teach it, how to guide it, how to troubleshoot it for each patient with all your clinicians.

So that’s my that’s my tangent about the physician provider role. Your observation was correct. They needed to have jumped in and said, Look, they’re so close to being intubated. What if we stopped them up? Could their peep dropped down? Could we get them extubated today? Instead of saying, oh, yeah, they took what, eight extra breaths a minute, on the ventilator when sedation was turned off? Well, yeah, let’s keep them intubated. for another day. At least. That doesn’t make sense.

“April” – Anonymous Nurse 27:08
I wanted to bring up the point here that, you know, my preceptor kept saying, you know, it’s not nice to have a tube down your throat. You know, it’s not nice to let him be awake through that. And I, I was hoping you could kind of walk me through that sentiment that you hear. And because in my mind, he’s so sedated that you can’t explain to him why he is tube down your throat, but and this is just my my, you know, early ICU thinking here by early, early.

This is my newbie ICU thought here was can you awake? Can you get them awake enough to explain to him, you have a tube down your throat, you have COVID pneumonia, you’re in the ICU, you’re doing better. But this is your lifeline right now. This is what’s gonna keep you alive. Could you have Could God have worked? Instead of just putting him back back to sleep? I’m putting air quotes here practice. Yeah, yeah, what looks like sleep, but we know is not?

Kali Dayton 28:16
Well, this is why your perspective is so valuable. Because you’re coming from medical surgical step down unit where you are used to talking to patients, you trust patients, you involve patients in their care. That’s your norm. What’s unfortunate is that when you do this for decades, when you sedate patients for decades, subconsciously, you stop expecting patients to be involved, or have any kind of engagement or control and their journey. You don’t trust them to understand.

You just cut it’s a little bit dehumanizing. I don’t think anyone intends to do that. So that’s the first thought that comes to your mind is well, can we just explain it to him? Because I explain all sorts of things to my patients all the time. My patients in the past have had devices. I taught them what it was they didn’t pull it out.

But for seasoned ICU nurses, you have to appreciate that this is a very new concept. Most of their patients with no tracheal tubes are sedated. And then when they’re coming out of sedation, they’re delirious, they do not have the capacity to understand. So the proposal that you tell the patient what’s going on is a new concept for many.

That’s one of the things that I even trained teams on and this isn’t demeaning to anyone. That’s just the reality is we need a set second to question those beliefs. So this is why and I don’t mean we put them plugged in for my services. But this is the problem that we’re always trying to address. What I do webinars. We have to address that misinformation.

“April” – Anonymous Nurse 29:50
Yeah,

Kali Dayton 29:51
It’s not misinformation that the truth is that comfortable. That’s a given. That is undeniable. That is absolute truth. What nurses and everyone on the team needs to understand is the alternative. They need to hear from survivors what actually…. Were they actually comfortable under sedation? Not usually. Did they have pain that went untreated? Oftentimes.

Was it worth the price of his brain injury of psychological trauma later on? Right? That’s the information that nurses do not have. Are you really hearing about long term cognitive impairments from sedation? Are you really hearing about long term disability in your training? Is that part of discussion at rounds? No. Does that nurse had any idea what happens to these patients?

“April” – Anonymous Nurse 30:34
No. And I thought about that, because our patient, you know, kind of to fill out this picture a little bit was in his 50s, with COVID pneumonia. And he was, you know, otherwise healthy individual with no cognitive deficits at baseline. And he’s been sedated, intubated for over two weeks. And he, I think, is going to be checked and paid. So if you could approach the, you know, someone like my preceptor who, who is so you know, diehard Patient Advocate, maybe you could advocate like, hey, let’s let’s change this trajectory, from discharging to an LTACH, to going home.

I think if the provider could have, you know, maybe not just the provider, don’t just put it on the provider, maybe the charge nurse or, you know, physical therapy, any, anyone in that, in that huddle, could have presented that, like, you know, we’re at a fork in the road here. We’re talking about check pay versus excavation. So your choice here, like the result of this LSAT is dire, in my opinion, because he is this close to getting tricked and paid, and that changes total trajectory of the next few months, a year years of his life.

Kali Dayton 32:07
So to be part of the discussion, I mean, you know, we’re talking about problem lists, we’re talking about organ systems and rounds, we need to be talking about what’s the big picture? Yes, it come from what was his baseline function? What are we doing to preserve that? What’s going to happen next week or two. So in the wake of walk in ICU, it was, I mean, discharge disposition was part of the discussion.

It was always usually assumed that patients we were getting them headed home. But if patients were having complicated courses that came from an outside facility, and they became deconditioned, or something happened, or deconditioned, early on, or saying, Well, what if he had to go to an attack? I mean, not not to say attacks are the worst case scenario. It just was so uncommon there. And we really wanted to prevent it, we really wanted to get them home.

So it was always saying, What can we do today to determine what they’re going to where they’re going to be in two weeks, or in a few days. So when we just have this narrow sight of our shift, so they breathe eight times over the over the ventilator that should determine the entire rest of the day? Or the next few days or the next few weeks? That should be what we determine whether or not they get a trach over?

Really, is that looking at the big picture.? So I think your inquiries are totally appropriate. Again, this is a value of a fresh perspective coming in. And I’m sorry that your voice is not valued. It’s just shut up and stick to the protocol.

“April” – Anonymous Nurse 33:35
Yeah, for now, for now, you know, like, like I mentioned earlier, like I really wish and dream of where, you know, I really hope that I can get to the point of acceptance and authority and ice to start addressing that culture. But for now, I’m not there.

Kali Dayton 33:58
When any of us that started anything new, it’s always hard at the beginning. Obviously, you’re facing barriers that are exceptionally difficult, that are very distressing, morally distressing, cognitively challenging. But it’s easy for me to say from here. But I would hope and I would think that once you get on your own, you have your own footing.

You build relationships with people, things will change. But what you’re facing right now is very common. And I think it’s harder because you do know better. You have different insights when this is just normal. You don’t really have to go through the moral distress when you don’t know. So I’ve had travel nurses come to me after their contracts and say, I loved my experience here. I almost kind of wish that I didn’t come here because now I don’t know how to go anywhere else.

“April” – Anonymous Nurse 34:50
Yes.

Kali Dayton 34:51
How do I go back to what I was doing before after I’ve seen what’s possible, especially in our COVID unit, right? They’re about to go to a different COVID unit where they saw somebody COVID patients, probably all their COVID patients walk out the doors, how do they then go? So there’s a challenge and knowing what would that come it can come with a lot of power, but also a sense of obligation.

So I don’t I don’t know how to how to give the best advice and navigate that. But I just think I just know that listeners can really relate to it. You’re not the only one. facing this challenge. And I think this explains a lot about why we’re so stuck. A lot of the politics, the culture, the dynamics, don’t ask questions, just do it. You’re new, you don’t know anything, right? I mean, there’s, you know, you have to be teachable. And I, I’m sure you are.

“April” – Anonymous Nurse 35:43
I’m very teachable! I’m constantly asking expert opinion, about something like, I don’t accept things as I like, I’m always questioning “why” but it’s not from a place of like, I don’t trust you. It’s like, I want to make sure I’m doing the latest evidence based practice.

Kali Dayton 36:04
Right, and your whole, all your history testifies to you, to you being a Knowledge Seeker being inquisitive, being hungry for knowledge, that’s why you’re in critical care medicine. So I would never challenge that. But the fact that the culture doesn’t allow that this is what I’ve heard from many is that, when they want to elevate practices, they want to engage their team, they hit a wall, where it’s, this is the way we’ve always done it, you are just a nurse, or you’re just a physical therapist, or you’re just quote, quote, blah, whatever, fill in the blank.

And we’re not allowing for our colleagues to be esteemed. To bring you the evidence, we’re not flexible and open to new information. We don’t like our practices that we’ve done for decades to be challenged or questioned, because it’s, as we heard from Dr. Murphy, I don’t know about 10 episodes or so ago. He’s done this for 50 years. And he said it’s it is hard to look back and say, and be open to the fact that you’ve hurt patients. There’s something that’s so obviously difficult about that. I think that’s a barrier.

So for you, it’s hard to navigate, saying, “Hey, you’re hurting people!” which has to be said to a certain degree, but how do you as a new person say that? How do you suggest that you didn’t do it a different way and provide the why without being accusatory, and having people get defensive? It is so challenging. “April”, I don’t envy your position. But I think a lot of people can relate to it.

“April” – Anonymous Nurse 37:41
And I, that’s why I’m here today is because not only is this very therapeutic for me to talk through this, and to have kind of this litmus test of like, okay, I’m not crazy, I’m not a bad nurse, here, but also to help other nurses who are in this position that I am, you know, to give you support. And that, I hope, I hope it will get better.

And that while promoting, you know, some of the practices that you promote, daily with, you know, early mobilization and delirium prevention, but it’s going to be a hard road, but also one that’s very rewarding. Very rewarding, I can think about some of the highlights of my bedside experience have been getting stroke patients outside of, you know, those there’s moments, you know, those.

Yeah, I’m trying to think of that were quite of, you know, humanizing that patient. And it is so, so rewarding. So, I’m up for the battle I’m up for I shouldn’t I shouldn’t say battle. I’m up for the challenge. You know, I’m here to stay. There is one thing I wanted to talk about before we leave in and this is something you brought up in your webinar was about RASS scores.

Well, I went in and did a neuro exam for a patient of mine who had a stroke and I gave her a RASS of minus four. And my preceptor came like running and she says “You charted minus four! She is like a minus one!” and inconsistently. Every shift, I am scoring a patient at a lower RASS than she is.

And to the point where I’m like, “Am I crazy? Am I Am I totally fundamentally misunderstanding RASS scores?” I’ve watched YouTube videos. You know, I’ve looked up to the criteria and I’m like, “I really don’t think that she’s scoring correctly, just because the patient’s eyes are opened isn’t mean RASS of minus one.”

Kali Dayton 40:05
Right. So if they’re, I mean, negative one to negative three technically is when they open their eyes, or rouse to voice. negative four, negative five is when they opened their eyes or negative four is when they respond to touch. Negative five is when they don’t respond at all.

So what’s often happening that I’m seeing when I’m training teams, you know, you have really seasoned nurses that know so much. But when I when I go to assess a RAS they touch the patient said, Hey, Hi, are you there? You know, wake up or whatever, like, “Hey, Mrs. John, like, I’m the nurse…”, whatever, they’re touching the patient as they approach them.

So when they flutter their eyelids to that touch, they’re like, “Okay, yep, see their negative one.” When that’s really… you don’t know what they are. So to do a RASS, you shouldn’t touch them at all. And just talk to them. If they keep their eyes open for 10, over 10 seconds, and then close your eyes.

Again, that’s negative one, if they keep their eyes open for less than 10 seconds, and don’t give too if they kind of like flinch to voice, but don’t necessarily really make eye contact, that’s a negative three, if you have to touch them, to get them to open their eyes or to respond, that’s a negative four if they don’t respond to negative five, so that it’s very unclear. So when we explain it that way that there’s touch, here’s voice people are like, “Oh, I didn’t know that.”

And it’s so I mean, I think I’ve done the same thing. Because when you talk to patients, you connect with them, you touch them. So we’ve missed this key part. And I think that’s why our patients in sedated deeper than I need to be because we’re not really clear about how to do the RASS. So I’m sure the nurse really believes that this is a negative one.

But we don’t know what a negative one is. Even if it pops up on the computer, when you go to chart it. No one’s really reading those fine lines. And you just kind of go with what you know, what’s the previous shift charted what’s prescribed, you just kind of chart that. So what you’re observing is not just that nurse, this is not about one person. This is about a whole systemic problem throughout the community.

I’m bringing you on, to really dive into it to give your perspective on it. But this is very common. So you’re gonna have lots of physical therapists, lots of nurses nodding their heads, lots physician saying, Yep. April, you’re not alone on this is happening in our unit, as well. So you’re not crazy. I remember feeling like I was crazy. When I was asking why are they sedated? Can we get them up? Why can’t we get them up, I felt like I was crazy. And I had years of experience. And I thought I was crazy. And I just shut up for two years, I regret that you are so needed.

So I feel when I have, you’re not the first one to reach out to me, I’ve had many people reach out to me over the years saying I am such a hard spot, I don’t know whether to leave. Because I don’t know if I can do this if I can see this harm, and be feel powerless to change it. Let alone be involved in it right?

One, you’re not accountable for your entire team’s practices. You don’t have the power to change everyone all at once. So you’re not liable for that. Don’t put that on yourself. I think that’s really important. It’s easy to do to feel like, okay, I’m supposed to come in and change this entire unit. But that that might be an opportunity you have in the future. But that’s not your responsibility. So you you’re not accountable for what’s happening right now. Whether even to your own patients, because you’re not in charge at all.

When you get to be on your own. And you have your own patients, you’re gonna have opportunity to do weakening trials properly, you’re going to build relationships, you’re going to have an opportunity later. So what happened is happening now not in this that necessarily what the future is going to be I also don’t want to pressure people and are saying in an unsafe environment. I don’t want to sacrifice people’s mental health and well being and relationships and families. For this mission, I’ve seen that happen.

And I don’t want it to get to that point. So I don’t want to beg people to stay to make the change. But I do feel optimistic that you can make a difference, that this can change and that you can be a leader. But I also would want you to take care of yourself and this applies to everyone that’s listening. Take care of yourself too. You can’t bring these changes if you’re not in a good place. And if your team is not ready to make those changes, and it’s too distressing for you. Don’t don’t sacrifice yourself over this.

“April” – Anonymous Nurse 44:40
Thank you, Kaylee. Thank you for taking about weight off.

Kali Dayton 44:47
Absolutely, This is far bigger than you This is far before you.

“April” – Anonymous Nurse 44:53
Yeah, but if you’ve if you if you can stay I’m gonna try

Kali Dayton 45:00
But if you can’t, it’s okay. You take care of you. But thank you for caring about this. Thank you for entering Critical Care Medicine, even knowing this is going to be a challenge. Thank you for caring about patients enough to ask questions about all the things, but even about the ADF bundle when it’s such a touchy subject.

Thank you. Thank you

Transcribed by https://otter.ai

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