November 30, 2016

Welcome To Critical Care | How To Effectively Communicate

I have been in critical care for over five years, and that experience brings about an abnormal normality when I hit the floor for work. When I get to work and look into my patients' rooms, I see machines, drains, lines, tubes, screens, and pumps. Each item expresses a particular set of values or numbers, with all articles presenting a full clinical picture. I see the patient twitching, the pumps buzzing, and the alarms sounding. It can be overwhelming for non-medical individuals. But not for me, because this is my foundation, my home. When a family member or loved one arrives, I always try to turn off that side of my brain and view it from a human perspective. Remember, this is possibly the worst day of this person's life. My goal is to respect that sentiment and not to neglect them. Over time, I created a system that helps me to explain what people see when they walk into the room. Here is my system:

Note: All the information is disclosed if the individual(s) are one of the following: next of kin, healthcare power of attorney, health care surrogate, spouse or significant other. 
If not, consent is given by the patient or family member to disclose such information. HIPAA is still in effect even if the patient is sedated and unconscious during your care.

1. Introduction

Before I introduce myself, I ask for their name. The name request makes the experience personal and authentic. After obtaining their name, I introduce myself and ask if they have any questions. The goal is to allow them to lead the conversation. In a setting of medical chaos and uncertainty, this is a small amount of control. Following the opening, I offer a handshake or hug. Whether you're a daughter or friend, this is a rough moment in your life and sometimes a hug matters greatly. When my husband was in the hospital, I was numb. I was there intellectually but not emotionally. It wasn't until my husband's nurse gave me a hug and said, "Hi, I'm Amy." It melted something within me and allowed me the ability to see the situation for what it was. My husband had his chest opened up and heart repaired. It was a massive, scary event in my life, and it was okay to feel that.

2. The Actual Visual

After the niceties, we move on to the patient. Who the person sees laying in front of them. Before I go off and explain the lines and pumps, we just talk. We discuss the patient's physical presentation. The discoloration, the bleeding, the paleness. We verbally go through a head to toe assessment (in laymen's terms). I try not to use medical terminology, and I try to keep it basic. Nothing else will make sense if we skip this part of the discussion. For example, a patient is admitted with severe sepsis. We will go over the clinical presentation concerning infection and what it does to the body (e.g., low blood pressure, hypothermia, skin discoloration). I want to explain the visual before I go into what supportive measures are in place. Mentioning a vasopressor will not make sense to the common person if you don't explain why it's needed in the first place (e.g., infections cause low blood pressure). Don't be robotic in your explanation - this is a human being in peril. Understand this patient is someone's brother, husband, or uncle.

3. The Hidden Visual

Now, it's time to explain the supportive measures. Support measures include intravenous infusions, central or peripheral lines, drains, room monitors, machines, and medical equipment. Your job as a nurse is to explain this setting and for the viewer to understand it entirely. You don't need to say "serosanguinous drainage" or go over wedge pressures. You are simply explaining why things are where they are and why they're needed. Nursing isn't just about doing things. It's about revealing and illuminating. Nursing is a social profession. The first step is to explain the vital signs and their WNL (within normal limits) ranges. You move from the patient toward the external numbers reflected. Even if no one asks about it, I go over the vital signs. There is a calmness that takes place when one understands what they are seeing. Anxiety and stress occur with the unknown. I try to explain it all and avoid that.

When you break down the infusions, drains, lines, screens, and medical equipment in the room, you are an anchor to that individual(s). You are not simply a nurse. You are a support system. Respect that role and educate. Don't get caught up in explaining alpha and beta receptors. Keep it simple: "This medication improves your son's blood pressure. It keeps his blood pressure within an adequate range in order to supply blood to all of his organs. Without this drug (Levophed), his organs would shut down due to lack of perfusion."

4. The Team

The next step is to explain the consultations (specialties) and physicians on the case. I define their roles and how this case is a collaborative endeavor. For example, nephrology is working on your son's acute kidney injury and will be managing his continuous renal replacement therapy (CRRT). I will be the nurse administering the care at the bedside, but the nephrologist will provide me with orders and direction of care. I explain that there will be many individuals walking in and out of the room and that this type of movement is normal. I emphasize that each specialty has a specific goal, but the providers are working as a team for an optimal medical outcome of all body systems. I go on to say something along the lines of, "This might seem like chaos, but it's an intricate dance moving at a rapid pace." Meaning, critical care is about timing and catching things before they are permanent. We move quickly in order to save lives, not because we don't care. We are all here for one goal and one person, the patient. We all have our strengths, and we are using said strengths to help your loved one survive this medical threat.

5. Conclusion

We have reached the end of the conversation, and it is overwhelming. You need to allow time for the individual(s) to absorb what you just said. I always say, "Do you need a moment to yourself? I know this can be overwhelming." Again, I'm putting the ball back in their court and allowing them to tell me what they need at this time. I always open and close the conversation with the individual(s) telling me what they need and not me telling them. I've had many family members in the hospital. They were admitted before I went into nursing school, while I was enrolled in nursing school, and now that I'm a critical care nurse. Explanation and education were the only things that kept my family and myself sane and calm. Don't underestimate the power of general conversation. You might be a great nurse but what matters is what's untold and unsaid. This patient passing might momentarily haunt you but the effects will be with that family member for a lifetime. The unknown is what eats at people - don't be apart of that pain.