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It goes without saying that nurses are the gatekeepers of patient outcomes in the ICU. Do ICU nurses *really* aspire to care for unresponsive and atrophying bodies? How does the ABCDEF Bundle impact the nursing role, skillset, and job fulfillment? James Fletcher, BSN, RN seems to fit the mold of a nurse that would thrive solely with the flashy skills of an ICU RN. He shares with us the impact nurses can make by using “soft-skills” and human touch in the ICU. He is brining joy back to nursing with the ABCDEF bundle.
Episode Transcription
James Fletcher, BSN, RN 0:03
James, thanks so much for coming on the podcast. You and I have been talking for what years now via Instagram. And I have just really appreciated your insights and all the great work that you’re doing as a nurse. And I would love for you to introduce yourself to the listeners.
Hi, folks. Good morning. I’m James. I am a bedside ICU nurse. I’ve been a bedside ICU nurse for five years. Before that I worked in the emergency room. And before that, I was an EMT. So I’ve been a professional “butt-wiper” for a little while now.
Kali Dayton 0:41
And I not not to stereotype, but I would think that someone that comes from an EMT, er perspective, you really like the immediate front-end sexy things, right? The immediate resuscitation? Probably devices, the big flashy stuff. How did you become interested in changing sedation and mobility practices?
James Fletcher, BSN, RN 1:07
You’re absolutely right. It was even just coming to the ICU initially, I was like, “Oh, what do you mean, they’re not actively bleeding to death in the lobby? Stand? They already have a central line. This is weird.”
For me, it was really eye opening when I left my community hospital for an academic center. At the community hospital level, yeah, you know, we did a fair amount of surgeries. We were doing hearts and vascular stuff. And we did have an SPT, a daily awakening trial and all that goodness. But the majority of your patient population was still convalescent home septic shock intubations.
Folks were, to an extent, mobility and sedation isn’t, isn’t there for I guess, not going to cure them. So when I got to an academic hospital, and I was just like, What do you mean, my patients 37? What do you mean, they’re 42? What do you mean, they’re 32. And they were just getting extubated.
And they were up. And I was like “That dude’s in the chair on the ventilator. I never seen that before!” And the order of the day there when I got there was already you know, extubate, as soon as possible, you know, your typical heart stuff, like extubate, get into the chair up for meals, get them walk as soon as they can walk or de-line them, and they’re gone.
And that was just like a different way of doing things than I had been trained at. And you know, my small little MICU that I was just, you know, full of questions. I was like, Well, you know, the basic ones, I think, everyone, “Is this safe? Is this safe, can we do this? What do you guys mean, you’re, you know, cutting off all that sedation and getting them up?”
And and then from there, you just got a whole bunch of questions. So I started asking questions and seeing how effective what they were doing was getting people up and going. And by that measure out of the ICU, and I think that’s what got me interested in it.
Kali Dayton 3:01
So you’re actually seeing the benefits of it?
James Fletcher, BSN, RN 3:05
Yes, definitely.
Kali Dayton 3:06
And now you’ve worked in a number of different units, right?
James Fletcher, BSN, RN 3:10
I am a float pool nurse. So I go to my hospital has, I believe, eight ICUs. And they’re all heavily specialized. So I bump into all of them.
Kali Dayton 3:20
And do you see a contrast and practices cvicu seems to always be on the front end of this stuff, because they’re focused on getting them promptly excavated mobilized out the doors, I think they track data really well. We need good outcomes, low delirium rates, high function scores in order to keep the those programs going. But what do you see in the other ICUs in comparison?
James Fletcher, BSN, RN 3:45
Um, it varies. I mean, the hospital in that we have three cvicu is of varying acuity and varying device usage. So even just amongst them, you know, we have a lot of FEM fam. ECMO, we don’t get our ECMO up super often. We do a lot of Kreg bed stuff, but in the other ICUs, it gets more challenging.
You know, we do have a MCICU pulmonary type ICU, and those I think are your hardest patients to get up because they’re just, they’re just so weak and they just don’t have any when we’re looking for there, they don’t have any reserve like you’re not even if you’re getting them up and moving them. You’re probably just leaving them on full support. And it almost feels like glorified, passive mobility for them.
Like, I’m sure there is still a benefit. You would know him by that like if you get the little sling in and you sling them up with the crane and you are Joe them into the chair and they’re on full support the whole time and they barely even have any tone. Does their stomach still drop down? Does their diaphragm have the chance to open up? Yes, I’m sure that’s all good. But that is just much more laborous than you see. In the walkie talkie heart ICUs.
And, like the abdominal transplant, ICU. Oh God, these poor little liver patients, they’re just they’ve been weak and sickly for so long, that beyond being physically weak and sickly, they’re just, it’s hard for them to visualize themselves and like,
“What do you mean you don’t think you can get up?” “Well, I just haven’t been a burden forever. And I’m like, well, let’s f***** change that!”
Kali Dayton 5:22
Yeah, there’s a trained helplessness.
James Fletcher, BSN, RN 5:25
Exactly. They just been so sick. And everyone’s trying to I was trying to be nice. They’re doing things for them. That, like you said, it’s a trained helplessness. And that’s a big obstacle to every ICU, has different barriers. And then I’m not even gonna talk about neuro. They’re just they’re special.
Kali Dayton 5:41
The A2F definitely still applies to them. But you know, you’ve got your intracranial hypertension, you’ve got some real indications for sedation, a lot of those patients. And yet, we can really still get hooked on sedation in those kinds of cases.
You know, it’s when you start it, it’s hard to stop it. And how have you seen that be the case? You know, you you’ve talked to me a lot about awakening trials. And you’ve been pretty progressive in your approach, what are some of the barriers that you see when it comes to mastering the ABCDEF bundle and doing those awakening trials and things like that?
James Fletcher, BSN, RN 6:23
I would say the overarching regardless of unit, and also, regardless of hospital, this was still a problem in my old job to less so now. But the biggest issue I find is that there’s a disconnect between where the attendings and where the physicians want the patient to be going.
And where it is communicated to the nurses that the patient is.You know, they might be saying, “Okay, well, this patient is ready to get up and move and we’re going to, I’m going to turn off your sedation order before I even come to rounds. Because this patient should be off sedation, we should be up and moving.”— but you haven’t come by and seen that they’re losing their f***** mind. And I need to keep them calm while we coach them through this extubation. So now I have the fun, you know, decision of, “Do I just keep infusing this drug that I’m certainly need until you get there?”
Kali Dayton 7:18
That’s, that’s a really good point. That’s something that I am constantly on a rampage about is how we are conducting these awakening trials. And how we’re pushing this on to nurses. I experienced that as a travel nurse as well. We’re doing it at five o’clock in the morning. No one else is by the bedside, you hardly ever have even an RT available to help you. You’re one lone nurse.
And you’re ripping off the band aid. You’re unmasking that delirium that’s happening. And they’re, like you said, losing their mind. They’re thrashing, they’re agitated. And so for this to be mandated, without any kind of support. How does that affect your job as a nurse?
James Fletcher, BSN, RN 8:00
It makes the job a lot harder. I mean, I, at first glance, I love the idea of every patient 5am, doing awakening trial, see where we are. Because that way, you have something ready, when they do come around, it’s like, you can be like, “Hey, we are here. We aren’t here. This is my thoughts.”
And I think that’s the other disconnect, too, is that and I’ve I’ve fallen victim to this at times. A lot of folks don’t know how to properly assess RASS and pain. They are different scales, and they take different medications and telling your doctor your patients agitated and getting a Dex order, when really they’re in a fuck ton. The pain doesn’t help anybody.
Kali Dayton 8:41
Oh, no, it we I’ve had people say, “Well, we can’t avoid sedation on our patients because they have pain.” And that, yeah, the understanding, even from the nursing side that the “less psychomotor activity there is, the more patients do not move, the less pain that they’re in. And if there’s any kind of movement they require sedation, and if we sedate them and they stop moving, therefore, we’ve treated their discomfort and their pain.”
James Fletcher, BSN, RN 9:07
You’ve masked it, you haven’t treated anything.
Kali Dayton 9:15
Are you struggling to have these conversations at the bedside with your team?
James Fletcher, BSN, RN 9:20
Most teams know most teams I find very receptive to….. Okay, it’s nice too because right now you have the new residents and fellows who are kind of leaning on you to help them learn how to assess a patient. So they’re kind of following your thing, which is my favorite time of year actually.
But I find that the teams for the most part are very receptive to like, “Hey, here’s my assessment of their pain, including what night shift said all night about their pain. Here’s how I am interpreting their awakening trial and this is this is what I got. What do you guys think we should do going forward?”
I don’t get a lot of pushback on the presenting it I, I struggle sometimes to understand when I think a patient is ready to move forward, and they don’t think so. And I’m like, “Can you explain to me even in like, simple, ‘I’m-not-a-surgeon-terms,Why?”
Then they’re like, “Well, because they aren’t ready.” What the f*** does that mean? Like? Can you tell me what makes them not ready? So maybe I can spend my next 11 hours trying to fix that something?
Kali Dayton 10:33
Yeah.
James Fletcher, BSN, RN 10:34
But no I, and you know, every every team, every place is going to have their people like there’s one service where it drives me nuts. I go through the A through F. And then the NP verbatim, almost verbatim, goes through the A through F and just happens to be talking now to the attending instead of listening to me tell them and I’m like, “What are we doing here?” Like, if we’re just going to read the A through F off of the previous like service’s note. Do we not? I don’t know….
Kali Dayton 11:02
“Why am I even here?”
James Fletcher, BSN, RN 11:03
Exactly. But there’s not a whole lot of…. I am really happy with the A through F bundle and the physician colleagues listening to what we’re saying where I am. The pushback I get is when I’m I’m trying to move them forward. And they’re hesitant and want explain why
Kali Dayton 11:22
Do you feel like there’s fear behind that? Are they afraid of having patients awaken mobile? Do they….do we… are we still associating with sedation with acuity?
James Fletcher, BSN, RN 11:36
I think in certain ICUs. And definitely when you get farther away from the heart ICUs and you go towards like, Gen surg or abdominal stuff. There seems to be a…..Yeah, I don’t know if they’re, you know, sedation is acuity, but they definitely seem scared to move the patient forward. Before they’re perfect.
Kali Dayton 12:02
Right, I’m really concerned about sedating for ventilator settings, sedated for blood pressure. So they knew for certain things that aren’t sounded indications for sedation, that we’re not doing awakening trials and many units, and other people’s less than 10 fi02 less than 60%.
Or I saw me I was even at a conference. And a team was presenting their their work on mobilizing patients with femoral lines for CRRT. But they showed their mobility protocol. And it showed that they could not mobilize a patient on a ventilator unless their PEEP was less than five, and fi02 was less than 60%.
And we were like, “Well, then they’re gonna be ready for extubation!” You just it those are your parameters we feel…. if we’re afraid of taking off sedation or mobilizing patients because of those numbers, which is not found in the evidence. But culturally, that is our threshold. That is our fear. How do you navigate those conversations? And you’re asking for a reason. And maybe they can’t articulate they just feel like they’re quote, “too sick?”
James Fletcher, BSN, RN 13:11
Yeah, the worst reason you ever get is if you ask a fellow, “Hey, I think XYZ. I’m ready to do this. I just want to make sure you all think it’s an okay idea.”
“Oh, well, I have to ask the attending” and I’m like, I get that it’s their patient. And at the end of the day, it’s their decision. But if that’s your whole reason for holding this up, and quite frankly, what good are you?
Kali Dayton 13:36
But they’re not trained on these things. Right? I mean, it’s not part of..
James Fletcher, BSN, RN 13:40
Neither is the attending!
Kali Dayton 13:42
Yeah,
James Fletcher, BSN, RN 13:42
He’s a surgeon. He’s not a “mobilityologists”!— for lack of a better term.
Kali Dayton 13:45
Absolutely. Yeah!
James Fletcher, BSN, RN 13:48
I think it’s frustrating too that there isn’t a gray area. “Okay. So they’re on a PEEP of 10, their fi02 is 70%. Yeah, I’m probably not getting them up and marching them in place on the vent. But I don’t know why that needs to prohibit me from anything?”
Kali Dayton 14:09
Why do they still have to be sedated?
James Fletcher, BSN, RN 14:12
Yeah. Or well, though, they just need to lay in bed at 30 degrees and get turned left and right. I’m like, No, we could we could do some cardiac chair. I could see if they can get some some arm and some leg kicking going on. Like, just because they’re sick doesn’t mean they have to do nothing until we can get those numbers down. Maybe the part maybe there’s they’re not doing anything is why those numbers aren’t coming down.
Kali Dayton 14:34
Absolutely. I was on site with a team that we’d done webinars, and I showed up and they were already really well progressed. They just needed some extra guidance to maximize their mobility.
And they had a patient that day one had a peep of 14 70%, ARDS, aspiration pneumonia, newly intubated, and they were talking about Pronin, paralyzing them and said what, before we do that, let’s see how he does when we get him up. Got I’m up an hour later in the chair, his he was down to a 12 and 50%.
But you don’t know until you try how they’ll respond to those things. So when you are having this vision, you as a nurse, you want to have your patients as awake and mobile as possible. You understand the bundle, you understand what the objective is, what do you wish your colleagues were trained and educated about in order to work collaboratively towards that objective?
James Fletcher, BSN, RN 15:38
Not to throw my colleagues under the bus, I think, I think there’s plenty of education. I think sometimes the 30 year old, a 30 year in old, “They’re-intubated-they’re-not-moving-nurses” are just stuck.
And this is not groundbreaking stuff, there are some things that you can adapt to your 30 years of practice. Just do it, I get that it’s easier for you, I get that we can just sit in our chairs and watch the devices all day, but that’s not the job anymore.
Um, I don’t know. And this might just be the benefit of being at a very well funded academic hospital that has a fantastic PT and OT program. The informations out there, there is no, there’s no pleading ignorance where I work that you didn’t know that they were supposed to be awake and moving and doing stuff.
I’d even go so far, as you know, most of the surgeons, most of the teams put in a early mobility protocol order. And then that is supposed to free you up to follow those guidelines to do all this. For me, less like sciency didactic thing, the one thing….
I wish they knew, I wish they knew how good you’re gonna feel like there are a lot of times I cannot make your ventricle stronger, I can sit here and watch you on these devices all day, I’m not physically going to be able to make your heart stronger, I can’t make you stop bleeding from your liver, like whatever, like medical problem you got going on. I can’t necessarily fix that in these 12 hours. But I can get you up and you’re going to feel better as a nurse.
When you feel like you did something that day and your patient benefited from it. A lot of times the surgical patients you don’t get to actually, quote unquote, do much. And mobility is a big chance for you to feel like you’re going to do something and you’re going to feel good at the end of the day about it.
I wish I could just like package that up and like give it to these people who are just like scared and timid and don’t want to like know, but you’re gonna love it. You’re gonna love it! And I wish you would understand that.
Kali Dayton 17:51
Yeah, and especially the ones that….. I didn’t know how to say it….. talk the big talk. That say “I just want an intubated and sedated patient. I don’t want to talk to my patients. I don’t care about patients.”
You know, they have these guards up these barriers, their hearts are so protected. Right. And to me, it just screams trauma. We’ve been traumatized, we’ve been seemingly desensitized, because it’s been so hard. And we’ve seen so many patients fail with, we feel like we’re, we can’t turn this around. But if they could experience for themselves, what it was like to have that kind of fulfillment and connection with their patients, would that change our culture?
James Fletcher, BSN, RN 18:31
That’s, that’s a hard question. I mean, because that’s a, that’s a tough line to, you know, you get your patients up, and you’re moving them and you’re keeping them awake, inevitably, you’re gonna end up talking to them and learning some more about them. And once in a while, that’s gonna bite you in the ass when those don’t do well. And you’re like, “Oh, that wasn’t just 8103. That was Bobby Joe, who was a music teacher for 25 years.”- yeah, that does hurt a little bit more.
And I don’t have a great answer to that question. But tough. Like, you’re gonna have to figure out how to compartmentalize and deal with that if you’re going to be a nurse long term. Because it is better for them. And the ones that do make it will make it better, because you kept them awake and talk to them and learned about them and all of that stuff that comes like ancillary reward, but an ancillary thing of mobility and sedation decreasing is you’re gonna have to talk to the schmoes like 12 hours of silence is not going to cut it.
Kali Dayton 19:31
Yeah.
James Fletcher, BSN, RN 19:31
And does it does it suck sometimes? Yeah, man, if I woken some patients up and learned, “Oh, man, you are unpleasant.” Absolutely. But what are you supposed to do, like? Tough?
Kali Dayton 19:44
They’re human. Yeah. And they’re in a crappy situation. They’re gonna have some bad days. I was working and this patient was awake on the ventilator had been newly intubated. He wasn’t delirious, but he had…… boy, he had some psychosocial problems. He had some baseline PTSD from other things he had, he was hard of hearing. He had some cognitive impairments at baseline. And he was really sick.
And most of the team had participated in the webinars and knew what we were working towards. The nurse that took care of that patient that day, somehow missed the memo. He didn’t participate in the webinars. He had no idea what we were working towards. He had no idea what that patient was not sedated.
And this is a nurse that’s a cultural leader. And we all know what that means, right? We all every unit has a few of those nurses that they’re, they’re culturally the leaders. They set the tone for the unit. So leadership was like, “Oh, he is a cultural leader. And he’s not sure about this.”
And he, I heard him in rounds. He was like, “This guy is anxious. This guy’s upset. I don’t want to move him. I don’t want to rock the boat. Why isn’t he sedated?”– He was really upset and I could feel it was it was compassion. He was genuinely concerned for him. Without knowing the risks of delirium, the reality of sedation, the high price of immobility—- without knowing that he just saw a guy that was having a bad day, and he wanted to fix it with sedation. So I was really nervous. I thought
James Fletcher, BSN, RN 21:11
That’s so correctable! That’ a good situation to have. We can we can fix that!
Kali Dayton 21:19
Oh, yeah! We were excited about this situation, because we’re like— this is a really good patient to learn from he is so vulnerable to delirium. If he develops delirium, and he’s hard of hearing and he has PTSD. I mean,
James Fletcher, BSN, RN 21:31
Oh you’re screwed.
Kali Dayton 21:32
How will you get sedation off later?
James Fletcher, BSN, RN 21:34
You won’t. And you’ll start stupid things like Zyprexa and Seroquel in the meantime, which will only make it worse. I am so tired of off label use of seroquel.
Kali Dayton 21:41
Preach! Amen. Absolutely. So the chemical restraints, it’s not going to work. Today’s the day, the hours after intubation. This is the moment to prevent that to change, of course, but he didn’t understand that.
So I was worried that he would have….. he would be exhausted. I’m sure he expected, “Okay, my patients intubated. I’m they should be sedated. I don’t have to talk to them.”
But that wasn’t his going to be his day. He had to spend a lot of time writing things out for him so he could read it. The guy was trying to write to him discern his handwriting. I was like, “Oh my gosh, if I was a nurse, I’d be exhausted.”
You know, that was it wasn’t just your normal… One: vented patient period. But two: most patients that are not delirious that on the vent are easier. They can hear. They can process things. They don’t have so much trauma, you know, this is a whole mix.
Anyways, I was nervous. And I could tell he worked so hard that day, the next day, he didn’t have the patient again, they, you know, changed assignments. And he came up to me, he’s like, “That was the hardest shift I’ve had in a long time.”
And I was like, just wincing them, like “I know, but the benefits are….” and he’s like, “but…” – he cut me off. And he said, “That was the best shift. Probably the best shift of my career.”
James Fletcher, BSN, RN 22:52
Yay!!,
Kali Dayton 22:53
“I actually felt like I did something.”
James Fletcher, BSN, RN 22:56
Yes!
Kali Dayton 22:57
And I was, I just it. It was so profound to me, I guess, coming from an awake and walking. And I see I’ve done this with so many patients. It’s not hard to convince people to do that, because it’s just what we do. But in that moment to say, “Yeah, you could have had someone completely unresponsive, you could have just turned them q 2, hang an antibiotic, and that would have been your job.
He did so much work, but it showed his true colors. That that’s what he enjoyed. He actually connected with him and got fulfillment from that connection, rather than just exhaustion. Now, he did say “I don’t need him to again tomorrow. I can’t do that again tomorrow.” And I think that’s fine.
James Fletcher, BSN, RN 23:32
It’s tiring. It is mentally tiring.
Kali Dayton 23:36
But he but he was enthusiastic about it. And he said “I’m in. Who else are we gonna do this with? Let’s do this.”— And he has a culture leader is now bringing in that enthusiasm with the rest of the team.
So what have you experienced this, James? I mean, you’ve shared with me some really exciting stories just from your own your own creativity, right? You’re working in the A to F bundle, and you’ve had some really neat moments with patients. Can you share some of those with me?
James Fletcher, BSN, RN 24:13
I mean, there’s, there’s a lot and I think the fun thing, too, is that the more like….. I’ve got some big examples that I’ll talk about. But I do want to throw in the caveat that the more you do it, the more it doesn’t have to be:
“You coached the patients through the breathing trials and extubated them and they were so thankful that they said they’re going to name their firstborn after you. ”
No, it’s so many of the little ones like there was one long term pulmonary fibrosis patient, she stuck on the vent. Like, we don’t really have a plan moving forward. We don’t know how we’re going to liberate her?
Kali Dayton 24:48
Right.
James Fletcher, BSN, RN 24:49
But she was awake. She’d been vented for way too long and she was fine being on full support on the event so she was awake and that part was done. But you was grouchy and she was unpleasant. And she was, you know, borderline getting herself a dex drip for something.
And, you know, I’m very thankful that this hospital allows a lot of one to ones for, quote unquote “soft one to ones for the psychosocial patients.” Because I’m like, “Well, you know, I’m awake and I got 12 hours.”
I just pulled up a chair, I just got out the the big sharpie and a big whiteboard and “What is going on?” And after some discerning eventually I got the answer, “I want to feel like me. Bed baths and oral care don’t feel like me.”
So she’s on full support, her numbers look fine. I had a, I was very blessed that day to have a really gung-ho and hard working CNA. So I said, “Hey, man, we’re gonna get this lady up. And we’re going to inch her to the sink and I want her to brush her own teeth. And I want her to wash her face. And I think that will do wonders for her.”
And it was a challenge. Like, she’s quite weak. And you know, you got the central line, you got the trach, get all this stuff. And it’s not easy, but you get her over there. And she does it. And you know, she’s missing half the time. She needs some help. But like, it was long, I think like two hours later, we put her back in the bed.
And the whiteboard was back out. And it was a “Thank you. I feel human today.” And that’s just one of those things where like, you read that in, you try not look at you got the mask on, so they can’t see it, but on your facial like “Wow…. they are humans and we’re supposed to treat them like humans.”
Kali Dayton 26:37
Wow.
James Fletcher, BSN, RN 26:39
And there was like, you know, like, there was one too, like, you’re not always gonna have successes. I had a dude on multiple pressors. Just multi-organ system, multi-organ failure, just not going well. Probably heading towards like, a real bad outcome.
But he’s relatively awake. And he’s agitated and we’re on like a max dose a Dex and they’re contemplating just knocking them out. And you know, I’m just, I’m just scrambling here. This dude’s got a beautiful window in his room that he can’t see. Yeah, you make a few extra phone calls.
“Hey, man, I know you’re doing a treatment on another floor…. But when you come back, do we have extension tubing for the BARDS? Like is there any way we can get like just two more feet for this guy is vent or is there an oxygen to the wall hookups so we can move the vent?”
You just make those calls. And I remember by the afternoon, we were able to move his whole situation just 90 degrees and turn this guy so he was just staring out the window, feeling some warmth on his face.
And it didn’t fix everything. We weren’t suddenly off the dex, but we weren’t fidgety? We weren’t, you know, banging against the bed.
Kali Dayton 27:55
You didn’t have to escalate.
James Fletcher, BSN, RN 27:56
Yeah, it was just a little bit of self soothing you could do for him.
There was one that I liked a lot too. I wrote this one down so I wouldn’t forget it. Young lady, middle aged lady, she was there for I don’t even matter at this point, some sort of like abdominal surgery. And it was her first day PT OT was there it was their first case we were there. 9am. Up out of bed. Relatively Max assist.
I’m trying to help out too. But it was called a success. She was up. She got out of bed. She marched in place. She did all of her stuff. OT was able to help her like comb her hair and all that good stuff. And then very easily, that could have been it right those your two therapy sessions.
That’s a big step. Yep. Later in the day, you know, she’s communicating with me. And she’s like, “Hey, I can use the commode like I stood, can I just stand and use the commode again?”
I’m like, yeah, why not? And we got her up, we got her into the commode. And then we stood her up, we got her cleaned. And then she’s kind of like, “I feel really good. Can I kind of like…. can I just walk around in here a little bit”
And, “Yeah! Let’s do it!” We just did some forward and backward marching. And then I was, you know, “Well… you know, you can’t We can’t leave the room. You’re on CRRT.”
But she’s like, “Well, what about that…”- You feel stupid sometimes. And the patient say this—- but like, she’s like, “Well, can we just bring that big recliner that I’ve been looking at in the bathroom out of the bathroom? And I can sit in that instead?”
and I’m like, “Ues, yes, we absolutely can.” And she didn’t explicitly say it, but I, you know, maybe not want to but I think she felt accomplished. Like, “Yeah, I’m in pain. Yeah, I’m still on CRRT. Yeah, I’m still in this terrible corner room with no good windows. But I’m up and I’m wiping my own butt and I’m sitting in a lazy boy. And I feel like I’m getting better. I feel like I had a good day.”
I can’t tell you the science behind it. But I think most nurses would agree. Most clinicians would agree. When your patient feels like they’re getting better, they tend to get a little bit better. So whatever we can do to encourage those feelings. But I got one more if we got a moment.
Kali Dayton 30:18
Oh, yeah, absolutely hit me with all of them. And totally with you that we haven’t studied. I don’t think the will to live morale. I swear by showers. I mean, having a shower room in your ICU, I think saves lives. I’ve seen people go in just in the throes of depression and come out, rejuvenated, and willing to give another day another chance to impact your outcomes.
One patient during COVID with a max ventilator settings with COVID, and was not doing well. And they really thought it was the end, in this Awake and Walking ICU.
And per the stupid protocols, the family couldn’t come in until that point. So assuming that this was the end, my colleague, Louise Bezdjian, nurse practitioner, called the family and she left and she was off for a few days. And she assumed that that was the last time she would see him.
She came back a few days later, and he’s extubated. And she was a complete shock. And she said, “What? You were so sick, that’s why we were able to bring your family in.” And he said, “I needed them.” So as soon as his family was there, his ventilator settings started to change.
I don’t understand that. There’s nothing in the science to really support that. But it’s undeniable that when you treat patients like human and when they’re not…..there’s something about being in bed and just being sick that makes you feel so helpless, hopeless, but giving them the chance to work out their own, like fight for their own lives. That has to change mortality beyond just avoiding delirium and ICU acquired weakness. There’s something spiritual with that.
James Fletcher, BSN, RN 31:50
Absolutely. I got two more positive stories if we got a moment. So one of them is an ICU one. This particular ICU, it’s the worst two because there’s an NP there. She’s a part of the CT surg team. And she knows she’s like, “Oh, you’re the delirium whisperer.”
And I’m like, “Ah, f***. I know what that means for my assignment.” I’m on some guy who’s like, you know, down to nothing of epi and just chillin. But they can’t get them off. They can’t get him…. You know, he’s just that close.
And they put me on this dude. And this dude was unpleasant. Like, during bedside handoff. I’m like, “Gonna be one of them days.”
They like just snarky little comments. “All right, I’m gonna kind of take the blankets off you.”
“I don’t know. Can you?” — “Oh s***.”— And I’ll be quite frank, I didn’t like him. Like, some of the things he was saying. I was like, “Oh, boy, we have different world views. This is going to be a long 12 hours.”
And it like you were saying about that in your story. To an extent it is just so da** draining, because you’re just sitting there for 12 hours, coaching them through things, trying to find something to talk about that’s not going to bother me or bother him.
And by the end, like we had found, like, a couple of little things like, “Oh, dude, you think everything about here is awful because you were flown in from 400 miles away and you think Los Angeles is the pits? Well, that’s fine. I’m gonna steer clear of everything. But you told me where you where you came from. And I know there’s a lot of fish in there.”
I don’t know sh** about fishing. And I don’t know how you coach this in nursing school, but sometimes little soft lies are okay. “Oh, you’re been fishing, kid?”
“All the time! Love to go fishing, sir!” And he just needed something someone to talk to him without being medical doctrine “Oh well, you know, your heart’s just not recovering the way….”
dude, he doesn’t give a s***, and he just want to talk about fishing. He just wanted to be himself. And a couple hours into just BS in my way through fishing and boats.
You know, we were just sitting there chatting. And by that point, I figured out the sports teams he liked and it was a lot of redirection and a lot of like, “No, no, no, remember, we’re not at home!” You got to you know, keep them there too. And it’s mentally exhausting.
Kali Dayton 34:11
Did he have delirium?
James Fletcher, BSN, RN 34:13
He that was the tricky thing. He passed the CAM scale, but he definitely was delirious.
Kali Dayton 34:21
I’ve seen it, yup.
James Fletcher, BSN, RN 34:23
Like he’s not “Yeah, the rocks don’t sink” or….. are they do say I can’t recall the exact question off top my head
Kali Dayton 34:27
Hit a nail the hammer.. but your wife’s in the trash can.
James Fletcher, BSN, RN 34:31
Yes, something is still off. Yep. And, you know, he also had a history of substance abuse. And you know, I don’t think we’re appropriately dealing with any of that at the moment.
But by the end of the day, he was still gruff and I still wouldn’t want to go out and hang out with them. But we had like, a begrudging respect to where he was like, “Okay, this kid doesn’t suck.”
I’ve been able to and that’s the thing. Again, these little white lies in nursing that I think are okay. I just stopped telling them what I’m turning down the dex, because I think that was worrying him too. He was like, “Well well, as was keeping me calm!”— you don’t know that.
So I just go over there and I do it. And then a couple hours later, we’ve cut the dose in half. And he’s doing just fine, because we’re talking about fishing and boats, and whatever crap is going to keep him calm and reminding them where he is and why he’s here.
And I didn’t happen the next couple of days. Remember, I came back like later in the week, and I was like, “Where’s my guy?” And they’re like, “Oh, he left for tele!” I’m like, “Excellent.”
Like, that was a hard day. I left that day, thinking—- and I know, don’t kill me on this one. Like, the next day, I was like, “Okay, can I get someone who needs to be paralyzed tomorrow because I am out of it. So I’m tired of talking.”
Kali Dayton 35:45
No, everyone has their max. Their, you know, their, their social reservoir can be tapped pretty easily, but you changed his outcomes.
James Fletcher, BSN, RN 35:54
And maybe the thing too, I’m gonna segue right into the next one… Is it doesn’t stop, when she leave ICU, you could argue get stronger. One of my best friends. His wife has some medical issues. And she was hospitalized earlier this year for a couple of weeks. And we were all catching up.
At one point when she got out of the hospital and my my fiance’s a med surg tele nurse and they were talking and my friend’s wife was saying, “There were particular nurses who would come in, and I knew I was getting up like they were, they weren’t asking a question. We were going for a walk, and I hated it.”
But then this part still sticks with me. Now, months later, she said, “Every single following morning, I felt better. It was like that soreness that you get when you work out. That’s what I felt overall, on the days after these nurses would come in and not ask if we’re going for a walk, they would tell me ‘we’re going for a walk.’ ”
And I think that’s something too. It’s like, “Guys, we can’t wait to start this tele. If we started now, by the time they get to tele they’re ready. They’re gonna go on these walks, and they’re gonna feel good.”
Kali Dayton 37:10
Absolutely. Hospitals coming to me. And they’re, they’re wanting to start delirium and mobility protocols. But I think it’s going to be easier to start on tele- on the medical floors. And I’m like, “You’re setting those nurses up for failure. Because if you don’t nip it in the bud, if you don’t start in the ICU, we’re then dumping off the ICU disasters onto them and they get to rehabilitate them.”
James Fletcher, BSN, RN 37:33
Oh, I got a comment on that one, too. So my fiancee is a med surg tele nurse and I’ll come home and she always likes all the big brain ICU nurse. “What did you do today?”
And I’ll just tell her some like, “Oh, you know, like, like, one of these days, I’m like, oh, you know, I was really good. I was able to get my patient to the side of the bed, and we kicked his little feet, and we stood.”
She’s just, and she laughs sometimes she goes, “You fu**** ICU nurses. That’s my every day, we are walking all of our patients, my patients are awake. And there’s four of them.” And she just likes to make fun because like, this is something I’m excited about. And I haven’t been excited about nursing in a long time. So I just I get a chuckle when she makes fun of me for the fact that she’s like, welcome to what every other nurse is doing and every other specialty.
Kali Dayton 38:18
” Like I had human connection, my humans did something for themselves and acted human!”
James Fletcher, BSN, RN 38:24
Yeah, exactly.
Kali Dayton 38:26
Okay. No, absolutely. But it but. But don’t take away from that either. Because changing the culture doing those practices, that is saving lives, that’s, that is something to be excited about. And you as one nurse, you’re saving lives and you’re being ingenuitive about it. The innovations-rearranging a room, finding things that talk about with them, and that that’s a whole different kind of challenge.
One of my on my heroes is a nurse educator in Maryland at Methodist Hospital, her name is Jill Storer. And she’s been fighting to change these practices in her unit for a long time. And she calls what you’re describing “soft skills” that nurses need to also be taught and encouraged to use “soft skills”.
Everything you’ve described, are sometimes not what we’re trained. We’re focused on how to manage the devices and how to titrate the drips. And those are defined as the ICU nurse, job descriptions. But the soft skills are essential in order to help patients survive and thrive.
And they truly change outcomes, the ability to get someone off the sedation, to work them through the delirium, to have human touch. We know at the beginning we talked about this, this culture of like the “wham bam, big sexy stuff”.
But the soft skills can actually completely change the trajectory on top of the big life saving things that we’re doing. And so what do you wish nurses were provided when they entered the ICU? and throughout their time in the ICU, how can nurses be supported in having this approach to care?
James Fletcher, BSN, RN 40:09
Well, I think soft skills are superduper important. I don’t know how you teach that. I mean, frankly, nursing school doesn’t teach you anything anyway, certainly doesn’t teach you soft skills.
It’s, it’s, I don’t know how you teach that. But what do I wish they knew. I wish they knew that 99 shifts out of 100, the impella is not going to go wrong. The balloon pumps not going to go wrong. If your CRRT clots, it’s five minutes to change it like yeah, there’s tips and tricks and all that.
Don’t get so bogged down, learning all of these like one in a million scenarios, and just focusing on all the hard skills that you forget, like, they’re humans.
And part of the thing that I’ve had to kind of swallow too is coming from a small community hospital, especially during COVID, where we were just given kind of open reins to like, “Hey, there’s more patients just do what do you think is best?” to then coming to a very well controlled academic hospital?
Where it’s like, “Oh, no, the clinicians are making all of the decisions on your drips and your devices and your settings.” You kind of look back and you go, “Well, what am I supposed to do?” And it’s those soft skills, and you need to have them.
What do I wish they knew? I can repeat myself a little bit, but I wish you knew how fulfilled you’re going to be in., I don’t understand sometimes how these nurses just sit and watch an ECMO for 12 hours and turn the patients and are basically just being paid for the what if something goes wrong.
That just sounds so unfulfilling to me, if… that’s cool, but you’re gonna have a long career. You got to find a way to be fulfilled. And yeah, you can do more.
And, again, I wish, like the nurse you spoke about, and like the stories I felt learned, it’s going to feel so good for you, it’s going to feel like you have a role to play in this big cog of healthcare. And by having that role, you’re going to feel fulfilled, and it’s going to be fun and exciting to watch your patients get liberated from the devices, watch them get up and walk and smile, and there’s going to be so much good in it for you.
Almost as much as your patients, when you get a patient up to the chair, before their family comes in before they know they can do that. Oh my gosh, the hugs that they’re gonna exchange the tears a family member is gonna have.
Iif that doesn’t hit you, the same way. A good resuscitation hits ya,. you got to look inside and go and wonder why. They’re both they’re both gonna feel good. And you’re gonna have far more people getting up to chairs than codes.
Kali Dayton 43:04
And having quality of life after.
James Fletcher, BSN, RN 43:07
Yeah,
Kali Dayton 43:08
You know, they’re on the right. Course and that you’ve put them there.
James Fletcher, BSN, RN 43:11
Absolutely.
Kali Dayton 43:13
And I started my career in an Awake amd Walking ICU, I thought that was normal to have these moments with patients and I loved it. I just thought I had gone to heaven.
I was, you know, the first few years of my career as an RN, it was just so great. And when I became a travel nurse, after I think my first year travel nursing, I was really considering whether or not to stay in the field. I sincerely thought I would stop being a nurse for a few months, I just hit such a low because I was working so hard.
And I didn’t fully identified at the time. But it was really because I was not fulfilled, I wasn’t having human connection. I was just busting myself to keep atrophied bodies somewhat alive in the bed.
And then after a few years of that, I went back to the Awake and Walking ICU. And I had humans again. And I could connect with them. And yeah, there were different challenges. But it was so rewarding, fulfilling that, I realized I didn’t want to leave nursing, I want to leave the conveyor belt approach.
And I felt more powerful as a nurse in an Awake and Walking ICU because I was much more autonomous. Not just because of the structure of the team, but because what I did every little thing I said or did impacted with that patient and could determine their their outcomes.
And that’s power. That’s the power of nurses and I love the example that you’ve said of nurses really turning things around for patients and leading teams to humanize their approach to care. Anything else that you would add James?
James Fletcher, BSN, RN 44:45
Yes. Just piggybacking on what you said, I think not only are awakened walking ICUs and all of these best mobility and sedation decreasing practices, good for the patient and will be fullfilling.
But you said something just jarred in my mind. It makes it not an “assembly belt” every delirious patient’s going to require a slightly different different puzzle. And I think that’s a good way to keep your head engaged.
Just coming in and titrating, the Levo and hanging the antibiotics. No one’s gonna want to do that for 30 years. But figuring out new and creative ways, nearly with every case, to fine tune it to that particular person that’s gonna keep you stimulated.
It’s going to keep you wanting to try it again and again, as opposed to just monotonously coming in and doing the same thing over and over.
And maybe the last thing I would add is your experience of going off and travel nursing and being like, “Oh, my gosh, they’re all just sedated, and in the bed!” That made you want to leave nursing.
Aside from the rampant death. I think that’s a big factor of why so many people in our profession were turned off from nursing during COVID. Because everyone just ended up, sedated, intubated, paralyzed on max pressors. And aside from the sadness of the human loss, man, we weren’t doing anything.
We were just, we were all on autopilot. intubating first presser, second presser, paralytic, third presser. And that was just not fun. And if we kind of take that as a microcosm of the problem, I think you’re gonna get people wanting to stay in nursing when they feel good about it. And they feel like they can do something for the patients, as opposed to just getting in the drips and titrating the machines.
Kali Dayton 46:42
Absolutely, I personally experienced it. And I’m seeing that happen in teams that I’ve worked with. The biggest thing that they can see, they don’t always see their data and their outcomes right away, right? But they immediately report an improvement in morale, collaboration, environment, fulfillment, those are the first things that are notable when they truly practice this evidence based approach.
And it’s not just keeping your head in the game, it’s keeping your heart in the game. And Dr. Awdish, I don’t know about 10,15 episodes ago, when she wrote the book “In Shock”. – She shares that we’re so afraid to give of ourselves, because we’ll think it’ll suck us dry.
But what actually happens is the gratification, the return is more than we’ve initially invested. And that’s what keeps us in the game. And I hope that some of these teams that I’ve worked with, and teams in the future, do studies on retention.
I think this is going to be key in building those relationships, and improving the workplace environment the workload is to…. and to be able to retain our clinicians, because we’re actually going to enjoy our jobs and enjoy our teams.
James Fletcher, BSN, RN 47:52
Absolutely, well said,
Kali Dayton 47:53
Dan, thank you so much for everything you’re doing and keep us posted. I want to hear more success stories because I know you’re going going to have them. Thank you.
James Fletcher, BSN, RN 48:02
Thank you. Have a great day.
Transcribed by https://otter.ai
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