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What is like for a seasoned ICU nurse with decades of valuable experience to completely change their sedation practices? What is like to then re-enter a “normal” environment and strive to continue the best practice? Paula shares with us her personal shock and conversion.

Episode Transcription

Kali Dayton 0:28
Hello, and welcome back. New listeners, thank you so much for joining us. And for all the listeners- thank you for your growing support. It is exciting to see how many people across the globe care about patient outcomes. Those that are new at this, start from episode one and don’t miss the great content we’ve had thus far.

Listeners have reached out with lots of wonderful questions. And some of them have been about an established culture in the ICU and seasoned nurses. They’ve asked questions like can you teach an old dog new tricks? And I believe that when it comes to well-intended nurses, you definitely can. Paula joins us now to share with us what it was like for her as a very seasoned nurse to step into an environment that defied decades of experience in practice. Paula, thanks for joining us. Can you tell us a little bit about your career timeline and where it all began?

Paula 1:24
Hi Kali, my timeline, let’s see, became a nurse in 1991, graduating from a diploma School of Nursing and went to work at a community hospital in the state that I lived in, did a year of practice on a cardiac step down unit telemetry unit, which was required back then before ever going to the intensive care unit. Had to get you a little bit of background in basically med search type nursing, the build your good base to take off on.

I was at that facility for eight years before joining the travel world in nursing and traveled for a couple years to some great teaching facilities across the United States. ended up back at Ohio State University in Columbus, Ohio for another eight years in a 42 bed unit that we did cardiac, respiratory pulmonary well burn trauma and medical surgical type nursing. So we were quite a multidisciplinary unit. I left that facility and came to Utah and have also worked at some teaching facilities multidisciplinary, surgical ICU burn trauma, and some Standard Generalized medical ICU since then. So 29 years later, I’m still in the ballgame for now.

Kali Dayton 2:51
That is a lot of experience. So you’re you’re kind of a hidden treasure in our ICU community. And before coming to the “Awake and Walking ICU”, after all those years of practicing, what was your perspective and practice with patients who were on mechanical ventilation? What was normal for you?

Paula 3:13
Normal for me, and also wide for the you know, basically generally ICU and somebody that was ventilated, is they were receiving sedation, either with morphine, fentanyl, versed, a paralytic some time, depending on the situation. And the only time that they were sedation was lightened was with possible anticipation to see if they were ready for extubation or remove all the you know, the breathing tube.

Kali Dayton 3:42
And after all your travels and throughout decades of experience that that is normal, right?

Paula 3:49
Yes, that was that was the normal. That was the norm. You know, you were intubated. You got the sedation package that went along with it. One comes with the other. Correct. No other option. ventilated, you were sedated and restrained. And that was that was that was the whole situation.

Kali Dayton 4:09
And so what was your first impression when you came into an awake and walking ICU?

Paula 4:16
Well, I was forewarned. When I came to the awake and walking ICU, that they don’t sedate their patients. And you know, I thought then, “Well, what’s so bad about that?” I did not. I kind of grew a lot of it, hopefully over the years of nursing and went through a lot of changes, especially during the years of evidence based practice nursing, that went away from, you know, you still had your textbook nursing, but through trials and things like that.

They found that certain things were a lot better if you didn’t do things, or if you did them a different way. Which after years of nursing, you know trying to tell as an older nurse or have you need to change that’s a little bit harder. Well, you know, I did some research into what they were talking about, and read a lot. And I thought, “Okay, well, I’ll give it a try here and, and see exactly if this is supposed to be the best way. Let’s see what happens.”

And I found that, yeah, you could deviate from certain things because things, basically they’re not written in stone like sedation. Why sedate somebody if you absolutely really don’t have to? And so when I came to the ICU, the walking awake ICU, part of me part of it surprised me. And some of it didn’t, I thought it was a great concept simply because I’ve seen a lot of patients that have been sedated for days or a week, become very deconditioned, not only pulmonary-wise, but overall physical was, you know, they muscle strength and decondition to their extremities, and they were crazy in the head, if you want to say because they were delirious with being off sedation, you actually still can interact with them, other than the fact that they can’t talk back, they can write, and I saw they did so much better, so much better.

Kali Dayton 6:20
And what ways did they do better?

Paula 6:21
They did better, they came off the ventilator quicker. Emotionally, I think they were better. Physically, they were a lot better because, you know, even setting up on the side of the bed and, and having them brush their own hair or, you know, performing their own mouth care. Even though that, you know, not every patient, in my opinion needs to be restrained. They were able to wash their face, do their mouth care, suction their mouth, they had some control over their situation. They weren’t helpless. In my opinion. They participated in their care. They were alert, they were oriented, you interacted. They knew the day to day happenings, and mentally was I think I think it they did 100% better.

Kali Dayton 6:21
Yeah, that is so interesting. And I, I love that you mentioned even all those self cares. And I noticed working with you that you spent a lot of time your patients rooms, that just that one on one bedside. And so what does that do for your personal fulfillment, or your connections with patients when they weren’t sedated?

Paula 7:28
Well, you know, looking back over the years, even, you know, when somebody was sedated, on the ventilator and restrained, you know, hopefully, the nurses were, you had a nurse that you know, did that every two hour turning mouth care, repositioning type nursing functions, that is a standard practice. But a lot of times you didn’t you…. there were nurses that did not participate in fully in patient care, and delivering, you know, a full 100% good package to them and giving them what they needed.

And what I mean by what they needed is range of motion, positioning properly, releasing restraints and in, you know, moving their arms and flexion and extension, you know, a lot of that I don’t think sometimes people realize how quickly you can, your muscles can atrophy, and lose muscle strength. Even simply head positioning can cause some issues, especially if you had shortening of the muscles in the neck and the tendon.

You know you could have a head jack to the one side and you know, you’re not able to raise your arms, because you’ve had shortening of the muscles in your, your shoulders and everything. It makes it hard to even you know, raise your arm and put a shirt on. And I don’t think a lot of nurses are being taught that. It’s basically a lot of in and out, do what you need to do and get out of the room. And then you find the nurses that do like to spend a lot of time I like to spend a lot of time with my patients because I think it’s what they deserve. And it’s what I’m paid for. I want the best outcome for them. Possible. So that’s why, you know, I always felt that, you know, that’s why I became a nurse, you know, if it takes going the extra mile to do it, I will do it. And if it means you know, not getting a launch because the patients in need. That’s the way it goes.

Kali Dayton 9:26
And I hadn’t even thought this is a silly but you know, I hear physical therapists talk about helping prevent contractures and things like that, but I just don’t see it that often because our patients don’t really get them in their moving themselves. They don’t lose the capacity to put their shirt on or to put their hands over their head or things like that. And like you said, a lot of them don’t have to be restrained. So those are just things that I think…. we’re more programmed to have “Ambulate TID” be the standard rather than “Turn q2”.

Paula 10:02
Right. And that works very well when somebody is in if the if the condition allows someone to be up in a ambulating, up in the chair, sitting on the side of the bed, you know, obviously, supervised, it’s so much better to do that than to have somebody in the bed sedated and turning them every two hours.

Kali Dayton 10:23
Did you see any pressure ulcers in the awake and walking ICU?

Paula 10:28
know, I didnt, no. That’s also a big thing is when someone’s able to move and shift their hips or turn over themselves for you assist them in turning over, but they’re awake, they if they’re awake, and they realize like we normally do when we’re asleep in our own beds, when pressure or something stimulates us to turn over to change our position when they’re awake, their cognitive cognizant of needing to turn over and they can turn a call light on and say I want to turn it over. And that works so much better in prevention of pressure ulcers, which is you know, a huge financial burden, and a huge life altering issue with a patient that winds up with stage two or three pressure ulcer.

Kali Dayton 11:22
Yeah, such a good point, they forget that that is such a problem in in this population, because when you get different treatment, you get different outcomes, even down to pressure ulcers and skin breakdown. And you worked as night nurse, I mean that that’s your groove. And so one of the big focuses on delivering prevention is sleep. And so What benefits did you see to sleep when you were walking people before they went down to bed?

Paula 11:49
Well, it kind of kept their kept somewhat of a normal circadian rhythm effect. You know, they were up through the day activity kept awake, when we come into the evening mode, and they do some activity with a walk, up in the chair, get their teeth brushed mouth cleaned out. And then most of the time, they were tired, and they just wanted to go to sleep. And hopefully you could keep them up to at least 10 o’clock, which always worked better. And they would get sometimes, you know, several hours uninterrupted sleep, which I think plays a huge role and delirium prevention, as well as instituting a sleep hygiene protocol.

Kali Dayton 12:35
So you saw people get real sleep, that’s one of the concerns is that there’s a lot of confusion as far as people believe that sedation sleep. So that’s a problem to begin with. And there’s a concern, and it’s a valid concern that people will be so uncomfortable that they won’t be able to sleep on the ventilator without sedation. So I saw patients sleep and getting real sleep.

Paula 12:56
I don’t see it. Yes, I did. I don’t think sleeping on a ventilator with with a breathing tube to some people is no different than sleeping with a BiPAP or CPAP. I think they’re just as …they can, if they’re able to tolerate it psychologically, which most the time I’ve seen that happen, they’re psychologically they are able to tolerate it a lot better than sometimes even just being on BiPAP with a facemask one. But they do- they go to sleep, and I’ve asked them before, you know, “Do you feel you are rested?” And I’ve had many tell me “Yes”. Versus someone being chemically sedated. And then you waking them up? I don’t recall that anyone’s ever said that they felt like they slept the best they ever had.

Kali Dayton 13:45
No survivors say that they it was very unrestful and not peaceful at all. Well, it’s scary to think of going days, two weeks without any restorative sleep. Anyone would lose their minds. Yeah. And so before coming to the weekend, what can I see you you probably hadn’t really walked people on ventilators. Then here you are as a nightshift nurse walking people on ventilators without physical therapy because we don’t have physical therapy at night. What was that like for you?

Paula 14:13
It was just you know, honestly, it was just rearranging your time and incorporating that into your evening plan. I have no problem in I feel that I’ve always been very proactive with with things that would benefit my patient. And if they’re able to get up and you have the capacity or the means to ambulate them. I’m all for it. I was actually quite excited about it. I felt like it was a it was a major turning point in a learning curve for me that wow, look what we are doing here. And I’ve even you know, told friends that are nurses back in my home state, “We don’t sedate we walk. They’re up”- and they’re they’re totally surprised. I’ve said, “We have less incidents of delirium patients come off the ventilator sooner. And it’s totally I think 100% better.”

Kali Dayton 15:12
We’ll try to imagine, they try to imagine their condition patients jumping out of bed. And I think it’s hard to imagine never letting people get deconditioned, or how much safer it is, and that they are able to throw their legs over the side of the bed stand up, some people walk out of the ICU stronger than they rolled in. So we think I mean, there are precautions you have to take. But did you feel unsafe walking patients? Did you feel like they were gonna collapse on you? Or Was anyone army crawling blue on the floor?

Paula 15:47
No, you know, part of a good nursing assessment is assessing, you know, the capabilities are their ability, are they ready for this? Can they do this? If they weren’t, if I felt that they weren’t ready to do, let’s say, a complete walk around the unit? Let’s move up to selling on the side of the bed for a minute, let’s stand. Let’s walk to the door, let’s walk back.

Kali Dayton 16:12
Yep.

Paula 16:14
And then, you know, it’s like deconditioning happens because we allow it to happen. We allow it to happen in people that come in the facility into a hospital, that is ill becomes critically ill and or ill enough that they require assistance with breathing. But physiological wise, or body mechanics wise, they’re just they’re still strong, but we allow that become weak, even within a day or two of laying in a bed. And I think nursing in general, needs to come up with a new idea on evaluating these people. And beginning early ambulation, as soon as possible.

Kali Dayton 17:01
Yeah, it’s a, again, a multidisciplinary approach. I think sometimes physical therapy isn’t even ordered until days after admission, because people are really intubated. They have high ventilator settings, or we’re just, it’s just not on the radar of on admission. But you’re probably getting people that had just been admitted that afternoon, and you’re walking in that night, right? They’re newly intubated, and you’re walking them,

Paula 17:27
Yes. And if they’re capable of doing that, you don’t come to a bed and sedate them to make your night easier. That’s not what we’re there for. That’s not what I was there for.

Kali Dayton 17:39
That is powerful. I mean, what a disservice to patients to take away their capacity to walk they come in with their critical illness. But why does the rest of the body have to decline because they have pancreatitis, sepsis, pneumonia, all these other things that have nothing to do with total body strength, though it all plays a role, but if we can do our part to combat the effects of those and keep them functional? Why wouldn’t we do that? Why would we take away their capacity to walk? Paula, that’s so powerful. And so you had all these experiences there, and then you went to a different ICU? And so what was that like? Hitting a whole new culture again?

Paula 18:23
Well, it was a basically like a bounce back, bounce back into an era of, “no, we sedate and when we’re on the ventilator, we get we start sedation.” So I tried to have the the, like the approach, while we’re sedating them, let’s see what they do.

propofol is such a short acting medication. And if you’re using that, to sit to sedate somebody to intubate them, let’s let them wake up and see how they’re responding to you. And I have had a lot of, once again, a lot of people, they wake up and they’re waking up slowly and you, you’re talking to him, you’re telling them, you know, “Relax, and just nice breathing easy, you’re doing great.”

And I’ve had a lot just wake up and be like, look at us, okay, you got your breathing, too. And why honestly, that facilities aren’t promoting more slow wakening like that. Just let them wake up. And if they’re tolerating it and everything is good, their physiological numbers are in place are not having any problem. Why not let them ride like that? You know, why put sedation on someone that doesn’t need it.

Kali Dayton 19:39
Our other former colleague, Jim, he had said and then post something like “I’m waking my patients up and only anxious people, or my co workers that don’t get it.”

Paula 19:51
He’s exactly right.

Kali Dayton 19:54
Is that what you found? Or what? How did the team receive your approach when you were waking up their patients?

Paula 20:00
Well, I remember one morning, I had worked. And we’re one night and morning was come and new shift was coming in. And the patient that I had was ventilated wide awake, suctioning her mouth, watching news, her call light, you know, motioning for me and writing things. And we were communicating. And she, you know, her pressures were good. Her heart rate was great. Her respiratory effort was much easier.

I mean, she was, you know, the ventilator was helping her. And she was psychologically was, I should say, dancing with the whole thing. Yeah. Right. And the looks on the oncoming shift face was, oh, my gosh, I’m sick, pay no attention, walk on, you know, she’s fine. Everything’s good. It was shocking to them. And it was it was a I should say, thank goodness, the oncoming nurse that received my patient was very open to leaving her as he is good.

And, as a matter of fact, it was I believe it was Jim, his wife. Oh, and she was very open to that, and a little apprehensive. But when she took my advice, and, and she did, and I think later on that afternoon, the lady was extubated and was doing fine. So she gets a breathing tube out. And she’s still, I mean, it’s just like, you’re going to the physician to a dentist and having a filling. You know, we we take the breathing tube out and exchange it for a nasal cannula.

Was she was she confused? No. Was she able to get up in the chair? Yes. And what she anxious? No. No. And it’s, it’s those things that I think some of the some of the general, I don’t know if it’s generational with nursing, or just the climate that people work in, that they’re taught one after the other, this is how we do it. And they don’t think Well, let’s try deviating a little bit. And let’s see what we get.

And I know the facility, they still sedate. Nursing is not as interactive with the patients as what, you know, perhaps it would be lack of tiring lack of physical mobility. Then, like you said, on the weekends when physical therapy is not there, or you know, so considerable therapy can be there once a day, PT or OT. So does that mean we neglect our patient as far as you know, range of motion or sitting on the side of the bed? Or say, hey, let’s get up in the chair for an hour? No, I think that’s part of the standard of care that’s evolving, that nurses need to adapt to change their attitude towards and be proactive.

Kali Dayton 23:01
Yeah, a couple episodes ago, we had Chris Perme. She’s a physical therapist that teaches ICU rehab. And she kind of has this catchphrase that “Mobility is everyone’s job”.

Paula 23:12
Right?

Kali Dayton 23:13
Nurses already have so much going on. But other nurses that I’ve interviewed have said, it’s part of my assessment, it’s just part of my treatment, it’s just part of our flow. They make it kind of this natural process, it doesn’t feel like it’s a whole new chore, it does require effort to get a patient up. But it’s a lot easier if you do it from day one than if you do it five days later, once a week, you really can do it with one other person, sometimes by yourself, when they can actually participate.

So you don’t take away their capacity to do it. And then the patient themselves can do it for themselves or they can help you help them. But it’s it’s so much of the climate, like you said, it’s the environment that you work in the mentality and the culture of where we’re raised where we worked before what we’ve experienced. Did you find people be excited about learning something new or your approach?

Paula 24:05
Not exactly. I think they I think they took into consideration what was being said, but as far as actually being self motivated to perform activities. It was easier to keep someone sedated and restrained on a ventilator than it was to make that extra effort. Meaning it was a I shouldn’t say it was a baby setting method. But it was a it was a way if my patients sedated, ventilated and restrained and I want to have an easy night. But you know, what’s an easy night and easy night to me is if I take care of both of my patients and get my charting done, without sedating them or restraining them.

Kali Dayton 24:57
And an easy night for you is not necessarily an easy night for the patient. If we don’t we have this misconception about what is going on during that with that patient, they look like they’re asleep. So that makes us feel like we’ve tucked him in the sheets are nice and tidy. All the lions are in place, and we don’t have to mess with them. But is that really comfortable for the patient? Is that a good night for the patient? They’re not actually sleeping. They’re having terrorist hallucinations. But we don’t see that.

Paula 25:26
No, we don’t. And, you know, I think with some of your one of your other podcasts I listen to, you know, the lady was talking about, you know, the, you know, thought people were trying to kill them, and they were being held against their will and in your minds a powerful, a powerful origin. And you get somebody, you know, you you alter their mental mental thinking with drugs? And we don’t understand or we don’t, we don’t know.

And that’s what’s so good about what you’re doing, to bring about awareness. In these people that are recovering, what is going on in their head? You know, are we psychologically torturing them, or trying to physiologically get them better? And I think psychological torching and physical healing, they don’t go together.

Kali Dayton 26:22
Right.

You gotta, you’ve got to be willing to take that time. And one thing that I found myself falling into very easily, which surprised me, was performing guided imagery with with patients. And you know, they’re scared there, and they don’t know who you are, should they trust you? You were the nurse that was there last night and, you know, strapped into the bed, but actually taking the time to mentally relax them. And to get them in a zone that they can relax and feel comfortable. I think he’s just as important as I could, I could not imagine what someone who was possibly alert enough to hear the going ons, and the sounds and the beeps, the other patients yelling and staff laughing and that type of thing. What are they thinking?

When they don’t know where they are? What’s going on?

Paula 27:22
Exactly. I had I had a lady tell me one time this was many, many years ago, back when we use yellow isolation gowns, that when we went into her room, she thought we were big yellow birds coming into our room. And that’s what she told me. I was like, “Oh, my gosh,”

Kali Dayton 27:41
It makes sense.

Paula 27:43
Yeah. So you know, what we what we perceive to be “normal” is not normal.

Kali Dayton 27:50
Right. And I have heard from nurses around the country that they sedate because “it’s more comfortable for the patient”, “it’s more humane, it prevents PTSD”. They say things like, “I’d rather be ‘asleep’ on the ventilator than awake and experiencing the ICU.” And so I think, yes, it’s much easier to sedate. And it makes for a much easier shift, than having to actually talk to patients or move them.

Yet I deeply believe that nurses are so good. And a lot of the cultural barriers come from a lack of awareness. They don’t understand what it’s like down the road have the PTSD, the cognitive deficits, the weakness, they just don’t have the big picture. But as we continue to talk about this, and just show that it is possible and completely feasible, to mitigate a lot of this harm while patients are in ventilators, those good nurses, which is the majority, if not all, are going to catch on to it and totally change the culture. But I think it starts with awareness first, and then our own convenience. seems insignificant compared to the actual success of the patient.

Paula 28:58
Oh, yeah, I agree. I mean, I think there’s there are nurses that are nurses and are caring and will go the extra mile. And I think there’s nurses that are mechanical, meaning you, you do what is on the A-PM checkoff list, and you do nothing more. It’s just it’s a culture, and it’s a culture that needs to be changed. And, you know, to change that culture, in a in a, let’s say, perhaps a unit that has never done such behavior, activities, like, you know, it takes people that are willing to physicians, especially to allow you to experiment. And what I mean by that is, you show your teaching, you’re showing them let’s we’re lightening the sedation by this, this, this this and you get the patient nice and awake and, you know, you move forward with activity and mobility, that type of thing, communication In reorientation, in you, you teach these nurses.

Kali Dayton 30:07
Yeah, it really is a skill set, I think we just kind of get used to doing these things. But we forget how moving patients is not an innate skill set for ICU nurses, especially when you first come in, right. And you’re used to just having patients be immobilized and comatose. In bed, it’s a whole new skill set to figure out how to move the tube around with a ventilator, and just have the comfort and the instinct to do that. And then it says, new skill set to wake someone out of sedation, who’s delirious and agitated, and have a confidence that you can work them through that that that sedation will wear off, the delirium will clear and that they will be calm. It takes a whole nother set of experience perspective and patience and skills to do that. And so I think you’re right, it takes more than just one nurse and one unit at the bedside, it’s going to take some support people that have done it before or really believe in it, and that can stay calm and see through the fog. And look at the big picture of the patients outcomes.

Paula 31:11
Yeah, you’re right, it does. It you know, I know in the in the era, or the way things are kind of now with with not only with multiple facilities, his lack of support staff, and I think that’s where places need to go back and really evaluate how important support staff are in assisting the nurse to help the patient accomplish a goal that in ultimately will reduce hospital time, delirium hospital, you know, financially, it’s going to reduce the cost of prolonged hospitalization with multiple complications.

Kali Dayton 31:54
And we’re, we’re starting to touch on some episodes that are down or that are coming as far as how to change the culture, the financial repercussions of these practices, there are just so many rabbit holes that we’re going to dive into as this podcast unfolds. But you’re so right about everything. And I, it for me is exciting to hear about. Goodness, like you had so much experience and brought such a wealth of knowledge. But also you were still open to learning and changing. And then you were willing to bring that elsewhere. And so that’s exciting to me, cuz I know that our field, whether they’re doing it or not, people are going to be willing to do it, I think nurses just need the opportunity to to know, and the support to do and then things are gonna roll.

Paula 32:39
That’s great. And, you know, a lot of the newer nurses that now are coming directly into the ICU, their learning habits from the ones that’s been there longer, or perhaps just within even a year. And we need to be very aware of what we’re teaching our new people, our new nurses, and we need to teach them how to do certain things and in the wild, right, and how to interact with your patient appropriately, how to get them how to get them over a hump.

And I’ve told many patients that were like, awake and maybe having some anxiety, if you will follow me and bear with me, I will get you through this. Just listen to what I’m asking you and what I’m telling, okay, I’ve got a lot of people through that. And that’s, you know, that’s one thing with like, learning to guide someone through a bad situation. And I think a lot of new nurses even don’t know how to do that. They don’t know how to do even with patients off the ventilator, like in a death situation, they don’t know how to guide, a family member, you know, on this journey. And teaching people how to guide people is hard for some and they don’t do it.

Kali Dayton 33:58
Yeah, that would probably be good Podcast, episode two, like how to truly connect and walk patients through anxiety, fear, death, all those phases. Oh, Paul, you’re giving me so many good ideas. Thank you so much for all your good work and being willing to share all of this with us. I I’m excited for everything that’s to come in your future and the future of our community. Thank you so much.

Paula 34:25
You’re very welcome. Very welcome.

Transcribed by https://otter.ai

 

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