Code Blog: Interview with Gina Rybolt
Our midpoint of this series brings us to talk a bit with Gina Rybolt – a nurse for over 14 years with her BSN and over 13 years direct experience in the ICU. Gina has been regularly blogging since 2002 at Code Blog, where in addition to many wonderful posts, you can find many interviews Gina has conducted with different nursing specialists.
The bold statements are taken directly from her posted works, followed by our questions and her responses.
After over a decade of being an ICU nurse, I had never before been the one to make The Call to the family. Are there many aspects of the job that are like this call – necessary and happening every day, but things you may never actually do yourself? Is it possible to intentionally avoid certain “unpleasant” aspects of the job, or do most things eventually find you?
I don’t think there are many, actually. I thought and thought but the only other thing I came up with is that I have also never had to disimpact anyone 🙂 I haven’t actively avoided patients that might have to be disimpacted or anything. I’ve just never taken care of one! Seriously, though, we are usually given the choice of what patient assignment to take on my unit. I tend to avoid patients that are withdrawing from alcohol if I can help it; I’m just not good with those patients. I think eventually most things find you, however infrequently.
There are also things that simply just don’t occur often enough for everyone to get a crack at it… It’s more likely that a patient’s family is going to be there if the patient codes. That was an unexpected code blue and with all the technology we have these days, unexpected code blues are rare. I believe it’s more likely that a nurse will be able to ascertain when a patient isn’t doing well and will alert the family, who then usually comes to the bedside. Although my unit does open heart surgeries, and we have had patients code where the surgeon comes in and cracks open the patient’s chest at the bedside, in over 13 years of working in a unit that cares for open heart patients, I have never once seen this thoracotomy procedure at the bedside. It’s just so rare.
So being a highly trained RN is a bit of a double-edged sword when healthcare becomes personal. Other than treating family members, have there been any other instances where your personal feelings made it difficult to be objective/effective as a nurse?
I think it was difficult to be an objective nurse when I was inexperienced. It’s only until you’ve seen a situation time and time and time again that you can become truly objective. The first few times I withdrew life support from a patient, I was a mess inside. I kept it together for the patient and the families, but it took some practice to become an effective nurse in those situations. It can still be heartbreaking to remove someone from life support; but now I have the benefit of having done it many times and have a better handle on my feelings and know what to expect from myself, the patient, and the family.
My boss informed me that I am to start training to be charge nurse. She didn’t ask if I wanted to, just told me. Then said that I was already on the schedule to start next week. Have you found that in professional situations, this example (being moved into a supervisory position as needed) has remained the norm, or was it more of an exception? Is there generally any professional risk in refusing to take-on additional responsibilities, or can nurses generally set their own professional pace?
I honestly can’t tell you what that was. That particular boss also “told me” that I would be precepting new nurses after only having been in that hospital for about 6 months. I think at the time I thought, “Well, if she thinks I can do it….” but I was scared to be responsible for someone else’s training! On the other hand, it turns out that I do well at precepting and charge and probably just needed to be pushed. Other skills were different – I had to practically beg to be trained on CVVH (continuous hemodialysis) before getting to do so. On the other hand, I adamantly refused to train to take care of post-op open hearts and patients on balloon pumps at my current hospital and was not forced to do so. When I worked in CVICU in Illinois, every nurse in the unit was expected to learn how to take care of post-op open hearts, balloon pump patients, pulling femoral lines out post-angioplasty. At my current position, there are enough people that want to do a wide range of skills, so not everyone needs to learn every skill. I think that’s as it should be. We are all competent enough to take care of critically ill patients of any kind. I am completely proficient to help during an emergency with a patient who has a balloon pump, even if I don’t know exactly how to work the balloon pump – the nurse who knows how to work the balloon pump focuses on that and the rest of us focus on everything else that needs to be done. So it may depend on the unit. I believe I have been able to set my own professional pace with some encouragement to learn skills I may not have had the confidence to sign up for myself, so to speak.
When I first began nursing in an ICU, I was very naive. I remember as a young naive new ICU RN that VADs scared me but were also very exciting. Are there any specific lessons you learned that might help a newer nurse get past their own naiveté a bit more quickly? Tips to avoid a rude awakening?
I don’t know why this is, but when I was training, I felt as though I was supposed to already know everything. That’s very counter-intuitive, but I felt that if I didn’t have the right answer all the time I was going to look stupid. Turns out, that’s an unbelievable amount of stress to put on yourself. I realized when I started training other nurses that I didn’t expect them to know anything! I specifically remember wishing that I hadn’t been so hard on myself when I was new. When you’re new, that’s the absolute perfect time to ask stupid questions. I wish I hadn’t been so afraid to just be inexperienced. One of the things that scares a preceptor the most is a nurse who doesn’t know what she doesn’t know.
I can’t really say I felt great about “saving” her. Does that sound a bit callous? I’m just not sure what I saved her for. More bedrest? An amputation of her foot? More infection? More dialysis? You talk a lot about patient rights and dignity in decision-making. How do you tend to convey difficult information to help them understand the gravity of their situation – ideas not made clear on a chart? Is it usually the patient or the family that has the hardest time making difficult decisions, and what is a nurse’s role in this situation?
Actually, the doctor conveys the gravity of the situation more often than not. I do get asked this a lot: “Have you ever seen someone this sick recover?” And depending on how sick the person is, I usually have to say no and watch the heartbreak on their faces. The patient is often obtunded or minimally conscious, if conscious at all, so the difficult decisions fall to the family. Every once in awhile I’ll get a patient who’s had The Discussion with their doctor and all the ducks are in a row, forms filled out. As for how I convey difficult information, I try the most direct route possible. I try very hard not to sugar-coat or make it sound better than it is. I’m not shockingly blunt, but beating around the bush is counterproductive. I’ll say, ‘You know, her blood pressure is really awful, and I already have her on several medications to support it, so this isn’t looking good at all.” As for the chart – the gravity of the situation is spelled out very clearly most of the time. “Prognosis: poor” or “guarded” is something I see often.
The nurse’s role in the situation is to be there when the doctor is talking with the patient and/or family about the situation. A lot of information is being thrown at them, very unfamiliar words are being said, and although they appear to understand at the time there are ALWAYS questions later that they didn’t think to ask when the doctor was there. So if the nurse is there for the conversation, they can help to clarify or answer questions about what the doctor said, or reiterate if necessary.
The patient stated that he no longer wished to be a burden on his family and was ready to go. At which point I thought Uh oh… now we’re going to establish depression and an inability for the patient to make decisions in his own best interest. When a patient reaches this state of mind, how does a nurse offer proper guidance and information to help them make the best decision? How “clinical” (opposed to emotional) do situations like this remain from a nurse’s perspective?
Unless the patient in question is literally (sorry) rotting in the bed on maximum life support (and then some), I have no personal feelings about whether they should fight to live or decide to throw in the towel. So my personal feelings almost never differ from what the patient is going to think, if I understand your question correctly. I more often deal with families struggling with these sorts of decisions rather than the patients. The patients are typically barely conscious, if at all. That particular patient was a rarity. As for helping them understand fear, I have little experience with this as well. I can help reassure a family that they are making the right decision to continue with or withdraw life support, but I don’t deal with the patient’s actual fear of death very often at all.
I think there’s a balance between clinical and emotional for these situations. I tried to present him with as much information as he could handle in his condition, answer his questions as thoroughly as possible and offer reassurance that if he started having pain at all, we’d address it and treat it. There’s a way to deliver this information in a sensitive way – making lots of eye contact, not doing anything else while talking to the patient (eg, not straightening the bedsheets, charting on the computer, playing around with the monitor), holding the patient’s hand if he or she seems to want that. You have to read body language and pay attention to nonverbal cues. You don’t want to get overly emotional and have the patient think that YOU are the one who needs comforting. There are ways to show concern and care without getting all teary and crying.
I realize this may sound bizarre to laypeople, but we ARE critical care nurses for a reason. We thrive on stress and excitement and chaos and mayhem. You made that statement when you were less than one year into marriage and no kids. Seven years later, you have a lovely family of your own. Did having children temper your natural attraction to chaos, and is it affecting your professional direction?
Yes! Having children absolutely tempered my attraction to chaos. I have enough chaos in my life here at home (good chaos!). But sometimes I wonder if I wouldn’t be tired of the adrenaline whether I’d had children or not. I’m definitely looking into changing my profession direction within the next few years to something less … exciting 🙂 On the other hand, experience has made many situations less stressful than they were in the past, simply because I know better how to handle them now.
I had no idea, as a young impressionable eager nursing student, that I would eventually be SO inundated with paperwork once I became a nurse. For the love of God and cotton candy, this has all gone WAY out of control. Is there anything a nursing student can do to better prepare for the profession’s inherent bureaucracy?
No. It’s only once you are actually 100% responsible for the patient that you get a real idea of the amount of paperwork involved. It’s mostly on computer now, so I’m not even sure I can call it “paperwork.” We call them “flow sheets,” but everything that was on paper is now on the computer and it still needs to be done – we just type it out now instead of write it. Actually, now that it’s all on the computer, they’ve managed to integrate a lot of it. We don’t have to keep coagulation or blood gas flowsheets anymore – the physician can just look at the labs on the computer to see the progression. But we still have to keep blood glucose flow sheets, wound management sheets, intake/output, restraints, etc etc etc.
You have collected years worth of stories and interviews from nurses all over the nursing field. Has any specific story or interview inspired you personally to look into a new direction?
Not that I can think of. I did an interview I haven’t posted yet with a nurse volunteer organization, and that sounded really neat but not for this time in my life with small children. I have incredible flexibility with my job for now that would be hard to match anywhere else, so I’m going to stick with where I’m at for now. I think I’d like to eventually get into hospice or palliative care, but I’m finding it’s difficult to switch to another area of nursing.
What have been the real game changers for you as a nurse, professionally?
I wouldn’t call it a “game changer,” but attending conferences such as NTI (National Teaching Institute – they organize a conference for ICU nurses every year with classes and expos) can be very inspiring. There’s lots of camaraderie, networking, and education opportunities at this conference. I have been to a couple of them and they can really ignite a passion for your job. I’d recommend any nurse to attend such a conference in their specialty every few years.
I feel that nursing school barely touches the tip of the iceberg in preparing someone to be a nurse. I think the best preparation you can do to be a nurse is to work as a nurse’s aide or tech in the hospital. And if the nurses you work with find out you are going to nursing school, many of them will go out of their way to seek you out and show you different things. I’ve learned more in one CNA shift than a week’s worth of school clinicals. Also, if you are an aide/tech and work with patients, you are that much ahead of the game when you do start clinicals in school – you already know how to relate to patients. And that can be quite a hurdle to overcome. (I think I went on a rambling tangent there!)
I think my exposure to patients who are being subjected to futile care has shaped my own personal nursing philosophy over the years and has made me more interested in palliative care and educating patients and families about their choices and the possible outcomes of those choices. And letting them know that it’s okay to use some treatments and refuse others.
Thanks for your personal insights and observations, Gina! Be sure to visit Code Blog to see more of Gina’s work, and spend time reviewing her interviews to see if there is a nursing specialty that answers to your own needs.
Come back tomorrow for part six of our series, where we will be talking with Nurse Teeny, a popular blogger at Makings of a Nurse, as she talks with us about her experiences in nursing , family, and more.