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Kali talks about how much of our practice is driven by culture vs. evidence. What role does ICU culture play in our perspective, knowledge, and patient outcomes? How often do we dare to ask “Why?”, “What if?” or, “Why not?”
Episode Transcription
Kali Dayton
The first time I ever stepped into an ICU was as a zealous and naive 18 year old nursing student. I felt inexplicably drawn to the ICU and barged in there with dreams of loving people and saving their lives. My preceptor immediately informed me that this would not be a conversational learning experience. She distinctly told me, “Listen, I work in the ICU, so I can knock my patients out. I’m here so that I don’t have to talk to people.”
My heart dropped and crumbled. That was not what I signed up for. Yet, I quickly learned that such mentality is increasingly in the minority, and yet for decades has been an underlying culture of the ICU world.
So what role does culture have in our care? How much do we learn from textbooks versus our colleagues and environment? I personally feel I have learned far more about being a nurse and a nurse practitioner from the examples of others around me than in my seven years of higher education.
If I started my career in an ICU that deeply sedated patients, I don’t think I ever would have questioned that. I may go out on a vulnerable limb throughout this podcast to stir it up. But I doubt I ever would have been a visionary Polly, like in Episode 21. Despite my desires to do good, I am naturally more inclined to go with what I know and am told, especially if it is convenient and feel safe.
So would I have known it was harmful to sedate and leave patients in bed? I doubt it. Would I ever had the courage to dream of something so different that would make my team go crazy? To propose? No way. We are what we know who we are the product of those before and among us unless we consciously choose to venture outside the box and be more.
I’ve lived in a few different countries and have had varying degrees of culture shock each time. With culture shock, there is an initial initial difficulty in relating to the environment around you. It is a struggle to understand the perspective and the operation of the world you’ve been thrown into. It is having to think about every word said to you, and the inability to relate to their mentality and approach.
It is feeling crazy to be so confused about those things which everyone else seems so comfortable and fazed by in their own normality. Culture Shock makes you question yourself and reevaluate the way you’ve always lived and functioned.
Culture shock can also happen when we stepped from one professional culture to another. I experienced it when I left a culture of interacting with lay awake and mobile patients to a new ICU in which the expectation was to have all patients comatose.
I recently saw it and a new physician on our unit. He came not only from a different state but a different culture, focus and practice. He brought a vast knowledge and vital skills and can’t seem to unprepared for the shock. He experienced one of his first shifts with us. lifeflight brought us a woman from a rural area that had muscular dystrophy and was in septic shock for aspiration pneumonia. She was intubated and sedated during transport.
The nurse that admitted her instinctively turned off the sedation, because she was hypotensive and didn’t need propofol worsening that. She also wanted to talk to her inform her and comfort her as well as get a real neuro exam. I was about to walk into the room with the patient’s sister on my cell phone. When I crossed paths with this wonderful doctor. He caught glimpse of her awake and looking around the room while connected to the ventilator. His instinctive response was panic. He said, “Whoa, she is awake. We need to turn the sedation up”.
And I quickly intervened at the doorway and said “Hey, she’s okay. Her sister needs to talk to her.” And I went into the room. I proceeded to facilitate a conversation with this patient and her sister on the speakerphone as her sister asked questions such as, “Where’s your daughter? Is she safe? Do you want me to pick her up? Are you okay? Do you need us to come?”
I then, during this process, since intense eyes on me and I looked back at the doorway. That doctor was still in that same exact spot that I left him at. But now frozen. With his jaw dropped. He was in shock. He was having a paradigm shift. He was having to question the ingrained assumption that the ventilator automatically came with sedation, and responsiveness. He seemed to be trying to reconcile all that he’d ever done and experienced to what he was witnessing.
To him, it was a foreign concept to be interacting and communicating with a patient on the ventilator. Yet I proceeded to get a full medical and medication history from her and allowed him to continue processing in his mind with this patient. She needed to be awake during her time on a ventilator, as does almost any other patient. But in her case, with her advanced muscular dystrophy, the only independence she had left in her life was her brain.
This was a pivotal moment for her and she deserved the opportunity to make her own end of life decisions. She needed the capacity to communicate and arrange legal custody for her daughter in a complicated situation, she needed to decide for herself how to proceed with her care. She wasn’t septic shock and had severe pneumonia that turned it a mile a mild ARDS, she could only move a few fingers at baseline. Yet even in critical condition, she was regarded as an autonomous woman with rights.
And those first few moments after the helicopter landed culture determined her outcomes. You may be shocked by what you have heard in this podcast thus far. It may be really hard to imagine patients ever been awake and walking on the ventilator, let alone that being the norm. sedation is in the veins of our ICUs. I recently talked to a medical director of a large hospital about this process. He scoffed and said, “Yeah, research has mentioned stuff like that, but good luck pushing that here. Our nurses won’t do it.”
Can I say how crazy I get when I hear people say such asinine assumptions. I wanted to ask him, “How can you work in such a noble profession for decades, and still be oblivious to the heart of it?”
Just as Polly said in Episode 21, and Dr. Clemmer said in episode two, I also deeply believe in nurses, just like any of us, they do what they know the special difference in nurses is their desire to do what is right. So when it is assumed that the awake and mobile culture is not implemented, because nurses won’t, I am ready to challenge that. I know that it is not being done because the education support and culture is not there. When nurses know what will help and heal patients, they will not only do it, they will lead it. When we understand that avoiding sedation and maximizing mobility will increase survival and restore lives. You had better get out of their way.
The next episodes are dedicated to culture shock. We will have professionals share with us what it was like to be immersed into a new way of practicing and viewing patient care in the ICU. From travel nurses that walked into a weird dream with walking patients, to others that walked into a new world of sedation nurses that witnessed an evolution of culture over time and personally turned from incredulous to unstoppable. Doctors and nurses will share the sudden moment of questioning everything they had experienced and learned throughout their careers and their own personal rebirths.
As you listen, ask yourself, “How do I personally see my patients? How much do I expect to see their eyes see them awake and focus on their brains and bodies during critical illness? How much of our ICU care is cultural versus evidence based?” What is your personal culture?
Transcribed by https://otter.ai
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