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In this episode, Nancy talks with Kali about her transition to the awake and walking ICU as a nurse manager. She explains the nurse manager’s role in preserving a culture of humanity in the ICU. She shares with us how sedation cessation saved her own mother’s life.
Episode Transcription
Kali Dayton
Nancy, thank you so much for joining us. Nancy was the manager of this medical surgical ICU for many years, and have so much great experience as an ICU nurse herself, and really built up and helped maintain a culture within the ICU. And so I’m so grateful, Nance that you’d come and share your experiences with us.
Nancy
Thank you, I’m really excited to be here.
Kali Dayton
Tell us a little about your history in the ICU and how you came to be the manager?
Nancy
So my background, and I was a thoracic ICU nurse for years. And then as my kids were small, I did a little bit of everything and ended up the nursing supervisor of this hospital. And I, as I would go from unit to unit to unit, the ICU was the place where I was obviously very drawn to because that was my background in thoracic. And so I would come and help the nurses and then a manager position came open, and they said, “You should apply!”. And I never had thought before that I would be an ICU manager. But that’s just it. I thought, “Okay, maybe I should.” And I did. And the rest is history.
Kali Dayton
And what was it like to transition not only to that role, but to this culture, you’d come from a different ICU that had a different focus and different kind of patient population then to a different unit that had a different vision. What was it like for you to shift that perspective, and then maintain that culture?
Nancy
So the thoracic ICU, taking care of postop heart patients, I mean, it’s very surgical, and oftentimes, you know, very protocol driven. And I, you, you had it, you got a schedule every day of what was coming through the door, right? This was different. I, you know, I had worked in a big hospital where this, you know, the medical surgical ICU was part of that hospital, but those were patients that I really didn’t interface with very often.
So coming to this was different and unique in the types of patients that we saw and the journey that the patients had before. It wasn’t something that they signed up for, like heart surgery, or you know, sometimes our heart surgeries were, who were going to schedule this a week out, your surgery will be on Tuesday, we could prepare them for it. But the patients that were, you know, coming to med search was different. They had gotten very sick and deteriorated to the point that they needed the ICU. So that was a little bit…that was different for me.
And when you realize that these patients were NOT comatose on the ventilator.
Kali Dayton
What was that like? And what was like to see them up and walking? What were your first impressions?
Nancy
I remember hearing So back when I started nursing in 93, I heard about our ARDS patients and the great things that our hospital in our organization was doing with ARDS patients. But I knew that they oftentimes were long term patients that they spent months in the ICU and then would end up going to the long term care facility after I remember one of my first moments in this ICU where a patient came through was admitted. And the patient was on, you know, in the 20s on peep and 100%, oxygen, obvious ARDS and came in via lifeflight. And then I think the patient had been here for about an hour and the team had him up walking.
And that patient ended up getting out of the ICU in just a couple of days. And they had come in on 20 of PEEP. And I remember thinking, “Okay, how is this possible?”
Kali Dayton
Yeah.
Nancy
So it was pretty amazing to see that and to see. I mean, also to see what it took to say, “We’re not going to sedate this patient. We’re just going to get them up and walk them.” And they came in sedated from having flown in than flown in.
Kali Dayton
Did it scare you at first? Did you see this team being intimidated by that situation?
Nancy
I did not see the team be intimidated by the situation. What I was amazed with was the passion that the nurses had that they just did it. I had come from ICUs and seen ICUs where it was like, “Ugh, we have to give our patient up. You know, we’re gonna sit him at the edge of the bed”…. it was such a chore. And you know, they were usually so sedated that you couldn’t have even tried to stand them up. But you would sit them and rub their back and change their bedding and get them back in the day. I just couldn’t believe. Like, these were things that nurses avoided. And here, nurses were running to it, not avoiding it. And so that was quite unique.
Kali Dayton
Brandy made an interesting comparison that this was just as important as an antibiotic.
Nancy
Oh, yeah.
Kali Dayton
That and that’s how they see it, they see that this is a life preserving and saving intervention.
Nancy
Yeah, yeah,
Kali Dayton
Even and especially in extreme cases, where the peak of 20 and 100%.
Nancy
Yeah. And, and then nurses take that on. Like, they know that. And they know, that’s their responsibility. And it’s just part of their day. And despite being so busy, and sometimes having patients that are still very weak, and it takes a team to walk them, they didn’t skip it, like this was, this was part of a patient’s routine in this ICU.
Kali Dayton
And that was years ago. And that is still a very unique practice and perspective and culture. The ICUs, you don’t keep the same staff for 30 years, except are were a lot of nurses that have been there for 20, almost 30 years. I mean, they, they know their stuff, and they’ve been there for so long, because of the culture there.
Yet you still had people coming in and out. So when you have nurses coming in from elsewhere with a different perspective and practice. How did you as a manager handle that or how did you determine staffing? In a way to preserve that culture?
Nancy
So hiring was, was something that I think… it’s an art, and I think we perfected it here. I think that we, and it was because we always interviewed usually as a team. And, literally, it was the same people that we that would interview everybody knew that came in. And one of the things that we talked about was culture.
And it was very much a part of the interview process to talk about how we don’t sedate our patients here. And we we keep our patients comfortable. And we take care of their pain, but we don’t sedate them. And we ambulate all of our patients. And so that was something that we said to everybody who interviewed and we said “It is hard work.” And so physically hard also, and we wanted them to go into that eyes wide open. Like this is not this is not going to be a job where you can sit back and manage drips, you know, on a patient, but this is a job where you will you will be physically tired at the end of the day.
Kali Dayton
What kind of responses did you get when you would say that?
Nancy
And most people would say, “That’s so cool!” I mean, I think a lot of times and well those are the people that you wanted to hire right? Like it was those kinds of responses. I don’t remember. Those we don’t want it didn’t hire and remember the great hires we had. And it’s funny, because amazing team here, but our new hires, they would say, “I’m up for it!”
You know, I remember, you know, one nurse in particular, who was just like, I can do it. I do spin classes every morning. Like, you know, I teach them and I can do this. And that was the person that we that we brought to the team.
Kali Dayton
Yeah. Well was my first nursing job as a nurse and I didn’t know anything. And I were you specifically asked me, “Will you walk patients on ventilators?” And I didn’t really know what that meant. And I was like, “oh, yeah, totally. I I could be all about that. Whatever that is.” But I saw that you…. you sometimes hired people that didn’t have all the experience, though. Experience is so valuable. But you’ve hired people that were going to be willing to passionate to do it. How did you know?
Nancy
Well, since my time as ICU manager I don’t think I knew then what I was doing. Now I think I know better what worked and because of learning more about leadership itself. And we built a team of leaders here and we hired for values. We hired people that came in passionate about taking care of people and part of taking care of people was the whole person and knowing that they came in with this huge passion and such strong dedication to taking care of the whole person, then it was easy for them to do the right thing.
And ambulate the patients because that was truly what was going to help the patient walk out of here and have a long fruitful life afterwards
Kali Dayton
Literally walk out of here.
Nancy
Literally walk out. Yeah, yeah.
Kali Dayton
Um, and how has this impacted your personal life, this kind of perspective?
Nancy
So, and, I mean, I’d love to share the personal example, my with my mom. I think, I learned a lot from our nurse practitioners and the physicians who really helped educate us. And, and, and really drive this mission home. It kind of became just part of who we were. And everyone became like these passionate advocates for this.
And I was still managing in the ICU, and I got a phone call that my mom was, my mom and dad were traveling. She’s in her 70s At the time, and, and they had pulled off to this very small hospital in a very small town. And she was diagnosed with urosepsis. And just in a few short hours, she ended up on a ventilator, and levophed and epinephrine and they were gonna fly her to a bigger hospital.
So I immediately got on a plane and met them and met, basically, right after the plane landed. I was there as the team was around my mom trying to figure out what they were going to do. And they had her on a lot of fentanyl at the time. And she was intubated and on maxed out on levophed and epinephrine.
And I and the doctor basically said, “We’re doing we’ve done everything. She’s pretty much maxed out on all of her vasopressors there’s not really much more that we can do. And I just don’t know that. She’s gonna make it.” And I said, “Why don’t we turn the sedation down?”
And he said, “Well, we don’t really like to do that. She’s intubated. We want to keep her sedated.” And I said, “I want you to turn the situation down. I come from an ICU…” and I was I would be right out there with like, who I didn’t want to be that way. I didn’t want to be that nurse, but I knew I had to advocate for my mom and it couldn’t help that and so I said, “You know what, in our ICU, we don’t sedate these patients that come in,”. And and he really hesitated.
They allowed to back up and she started to kind of wake up and it made him nervous. And they wanted to go back up on it. And I said, “No, no, don’t. I want you to come… like we’ll, we’ll keep her calm. We’ll walk. We’ll get her through this.” And she, I believe the levophed started coming down the epi started coming down. We basically turned the propofol and fentanyl off.
And, and then my brothers and I stayed with her through the night. And in the middle of the nigh she had to go to the bathroom. She could tell she needed to go to the bathroom. She’s still intubated. And so I called the nurse and said, “Can we get up to the toilet?” And they said, well, “we’ll bring in a bedpan.” And I said, “Well, we can get up to the toilet.” And they didn’t come for a bit. So I told my brother, “We’re getting her up to the toilet.” So we did and the nurse came in, and there was my mom sitting on the, you know, toilet intubated, and I think it blew them away.
Kali Dayton
It probably terrified them.
Nancy
It terrified. I mean, they really just didn’t know I’m sure I was driving them crazy. But um, but the reality was, my mom got extubated the next day. And she was out of the ICU. The very next morning.
Kali Dayton
Wow.
Nancy
Everybody was like, “Tell me more about tell me more about where you’re coming from.” And I was telling them about the work we did.
They had lifts, and every single one of their room to walk the patients and I said I would give anything to have a lift for every one of our rooms. And they said, “Oh, we don’t use those.” I said, “What do you mean, you have no idea how lucky you are.”
Kali Dayton
“But we don’t get our patients out of bed. It’s not relevant.”
Nancy
And they said they didn’t walk any of their ICU patients. And so the next morning when she was discharged, they brought a bed to transfer her to the room. They were going to just transfer her on the bed. And I said “No, she’ll walk.” and they said “no, no, we can’t do that.” And I said, “She’ll walk out of ICU.” and we walked her to her room. And she was weak. But the orderly that helped us he said, “I have never ever seen a patient walk out of the ICU.” And I said, “Every one of the patients could walk out of this ICU. We have to just not sedate them and keep them walking.”
Kali Dayton
Don’t take away their capacity to walk.
Nancy
Yeah,
Kali Dayton
and they don’t stop walking.
Nancy
Yeah. And she is 81 years old and doing great. And, you know, I just I’m so thankful and grateful that I had had this experience, I would never have known to advocate for that. Had I not seen it for my own, I’ve seen the power of what we did. And I knew that….
I just knew it was the right thing, that was the right thing to do.
Kali Dayton
Wow, that is so profound. And truly, I mean, when patients are admitted to the ICU, they are at our mercy. The mercy of our experiences, our culture, our practices. If they knew that their outcomes would be so different if they were awakened walking…. they would do it. The families would advocate for it, but no one knows to do that.
Nancy
Yeah.
Kali Dayton
So what a blessing to be able to change that situation so much from being kind of almost written off to walking out the next day.
Nancy
We had to teach I remember, as a manager in a week, watching the nurses teach the patients and you know, they would say, “No, I don’t want to walk.” And it was, “No, it’s not an answer.”
Kali Dayton
“Now, or in 10 minutes.”
Nancy
But we taught people why. They didn’t always like it. But if they knew the alternative, yeah, like you said, they would do it in a heartbeat.
Kali Dayton
Yeah. what are some of the obstacles that you’ve seen, in maintaining the culture within the staff?
Nancy
I think the obstacles come with changing priorities.
As, as in healthcare is changing so fast. Charting, electronic medical records, all of that is changing so fast and takes more time. And so the challenge is taking care of your staff, so that they can keep doing this hard work. Because in addition to everything else they’re trying to keep up with, to keep them walking the patients and keep that at the forefront, the “why we are here” at the forefront.
Despite some of the challenging things…. that make it more challenging- to spend more time charting in the electronic medical record, that’s time that you could be walking your patients. And it takes a team. So coordination of care is also very important, coordinating with families, coordinating with the team, coordinating with physical therapy, and, and, and always educating the entire hospital to what we’re trying to do.
So that if changes are made in other parts of the hospital, like physical therapy or pharmacy or you know, we things are changing organizationally all the time. But to make sure that all of those areas understand the work that we’re doing here so that the changes that are made don’t impact our ability to continue to do this.
Kali Dayton
I kind of forgot about that aspect. I remember years ago, it was a constant struggle, we would send patients that we had worked so hard to keep mobile and strong. We’d send them to the floor and they would stop walking. And so they would get weak, their secretion clearance would get poor there. They would develop pneumonia, or worse pneumonia, and they would end up back to us. I don’t see that anymore. I really, that’s hardly ever see that. And I know that it’s because the culture on the floors have changed.
The oncology floor has like a marathon program where they track how far they’re walking and accumulates over time and have big celebrations for hitting a marathon or more. I mean, just the culture has changed. And that has changed the readmission rates.
Nancy
Yeah.
Kali Dayton
So we couldn’t just do this alone. We were, you know, keeping our patients strong, but we’d send them to the floor and they would go backwards. Yet that doesn’t happen anymore because of the collaboration.
Nancy
Yeah, yeah. And the education, our physicians I think, are also a big driver in that because they spend their time educating others. The patients that they follow out to the floor, they they continuously are educating. It’s unique to have such an interdisciplinary approach to this. You know, where nurses, physicians, therapists, everybody working together.
Kali Dayton
We all have the same vision, the same a same goal in mind.
Nancy
Yeah. Yeah.
Kali Dayton
And now that you’ve, you’ve transitioned to more of an administrative role, what has happened to your perspective, or what have you learned since?
Nancy
The power of that interdisciplinary approach, I think is huge. I think my passion for patient safety, and high reliability all came from working in this environment. And also, you know, I remember when I first came here that the nurse practitioners would say things, they’ve talked about evidence based care. Like, this ambulation was “evidence-based”. I didn’t know what they were talking about. Because I didn’t have that education.
They probably didn’t know, that I didn’t know, they had forgotten that they learned that getting their master’s degree, right. And that just is one of those things like it’s, it’s one of the biases, you know, that we that we’ve formed that, “oh, they should know this.” Well, we didn’t go to school for that, right. So after I, I left ICU, I ended up going back and getting my master’s. And all of a sudden, it’s like, oh, evidence-based care!
And I think what that did for me, though, is now as I teach others, and help other leaders, it’s for them to remember those biases that we have and to, to remember that when we talk about evidence based practice, when we’re trying to drive forward some of these amazing things….People may not really know what we’re talking about.
And so we have to, we have to give them, “what is that?” Right? It’s the next level, we really have to get below that, you know, and kind of go back in time to when we didn’t remember and figure out – “how do I get them from here to there?”
Kali Dayton
I think that we assume that people won’t do it. Whether they can’t do it, or they don’t do it because of malicious intent, or because they’re too lazy or things like that. But I think you’re right, it becomes all about understanding, I genuinely believe, if nurses and the whole team if they understand the why the big picture of everything. They understand that they can get patients to walk out of the ICU and go home. Yes, they will find how it will happen.
Nancy
Yes.
Kali Dayton
But we can’t just assume that it makes sense. It’s all about understanding.
Nancy
Yeah. And I think there was one piece of advice I would give to any manager or any nurse practitioner or any physician trying to lead these efforts. It is not to put those labels on people- that they’re “lazy”, that they “don’t care”, that they, you know, “they just want to punch in punch out”, you know?
Those are not true. Yeah, I believe. And I think that was the other part here is I believe that every single person has the potential to be the best that they can be, and do the best that they can do. But you have to give them the tools, the knowledge, the skills and the ability to do that.
And so recognize that we’ve had such an amazing opportunity to know what we know. How do we help others know that same thing so that they can have that same passion?
Kali Dayton
I love it. And I think everyone gets in the medical field because they want to help patients go on to thrive in their lives. Thank you so much.
Nancy
You’re welcome.
Transcribed by https://otter.ai
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