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The Nurses

Old Fool RN, Yuki and Dakota reflect on handling patients.

Old Fool RN worked in Chicago as Registered Nurse, having worked in the operating room primarily as a scrub nurse, on a neurological Intensive Care Unit and briefly in a forensic psychiatric hospital. He runs the blog from which this text has been adapted.

Old Fool RN: The illustration above shows the Australian Lift of which the key elements are two nurses with their arms linked together in a wrist lock - known as a death grip - and then lifting together in a coordinated effort. I think the term ‘Australian’ was applied because the lifting force was applied from down under or perhaps it referred to the way a disabled nurse could walk upon completion of the lift - by hopping like a kangaroo. Thankfully, hospitals in the civilised world have banned this type of lift.

In nursing school we were actually presented with a procedure manual for the various lifting techniques. Some of the lifts such as the dreaded Australian Lift were prohibited at our hospital as a result of the number of nurses crippled by the lift. Our beloved instructors like Miss Bruiser explained that we should learn about the dangerous lifts just so we knew them. This was the same logic applied to Professional Adjustments Class where we were told it would be wise to learn how to smoke a cigarette to be sociable with patients. The learned action could cripple or kill you, but at least you knew how to do it.

Another dangerous technique is the bear-hug lift. The lone nurse approaches the seated patient placing both arms around the chest under the arms and hugs - actually squeezes - the patient as she lifts. Not recommended for recent thoracotomy [1] patients and if any SNAFUS [2] crop up during the execution of this lift two people wind up on the floor. This lift may have been the source of the idea for semi-private rooms. A nurse was lifting a patient in his private room fell down with the patient and someone in hospital administration decided to kill two birds with one stone and wheeled in an additional bed for the injured nurse.

The key to safety in patient transfers is to avoid lifting completely. Think lateral movement and sliding rather than lifting. My favourite safe transfer technique is called the ‘demon drop’. This involves removing the arm of the chair if possible and positioning it as close to the bed as possible. Elevate the bed so that it is one or two inches higher than the chair and slide the patient from the bed to the chair or litter. For a chair to bed transfer position the bed all the way down and slide the patient from the chair to bed.

When I was a young nurse it seems like we were lifting all the time. Every procedure from X-ray to physical therapy required a trip to another hospital department and a lift out of bed into a wheelchair. This was long before workmen’s compensation and if you did get injured, you were really on your own. I think when nurse injuries from patient lifting cost the corporate hospital money, things began to change. Today patients receive more services in their room so fewer transfers are needed. Toward the end of my life as a nurse, mechanical lifts were in widespread use and manual lifting was not permitted.

There was one instance that I never used a mechanical lift. When transferring a patient’s body to the morgue cart, I always felt obligated to personally, with help, move the body onto the cart. Physically, I never had a difficult time with this. Maybe a body does weigh less after the soul departs or the patient was badly debilitated from illness. In the operating room it was possible to raise the table to a level above the cart and it was relatively easy to slide the body onto the cart. Most of these cases were failed trauma cases and as I moved the body to the cart I always thought to myself - “I hope that this poor soul can find the peace that eluded them in this life”.

Yuuki & Dakota

Yuki and Dakota (not their real names) have worked in the UK as nurses in  number of situations where patients have been unable to move for themselves including cardiac arrests, neurological conditions, post-operative care and end of life care. I was put in touch with them through a call-out on social media for nurses with such experience.

HM: What are some of the practical things you need to know in these situations?

Dakota: You need to know how to care for the patients needs where they are unable to help themselves. For example washing and dressing, moving around to avoid pressure ulcers, communicating using non-verbal methods. Always considering their dignity, and respecting their preferred name and language....

Yuki: Plus dental hygiene, clean sheets, toileting too. Pain relief and comfort is vital. It’s also important to understand how to position patients and how to move them too. The practical element is best achieved with two nurses working with the patient. Preparation is key. As Dakota says, patient dignity is of utmost importance and the ability to communicate well results in seamless care. It is vital to always explain what you are about to do with a patient who may be unconscious for example-this is best practice. In end of life care nurses will often continue this practice after the patient has died in respect of the person they cared for. I would say soothing physical touch is an important factor too but others may prefer as little touch as possible so careful consideration is required. The importance of self-care is now emphasised as we cannot care well for patients if we are not caring for ourselves first.  

HM: What sort of training do you have for dealing with immobile patients?

Y: I qualified in 1994 [in the UK]. Back then the training was very task orientated. We were taught throughout the three years how to practically care for patients. A Registered Nurse is required to have annual mandatory training on manual handling now - lifting a patient is no longer best practice. Hoists, sliding aids and electric beds are now widely used to aid manual handling - this helps prevent injuries in staff as well as comfort for the patient. Back then there were various lifts we used to move patients. A lot of the skills are picked up while practically working on the job. When I worked in end of life care we had extensive training on communication but this is something that did not feature highly in my original training. The care also includes that of the family. I have been taught from the outset, however, that ‘pain is what the patient says it is’.

D: I qualified in 1996 [also in the UK] with a diploma in nursing science which was a new more academic nursing than Yuki describes. The idea was that nurses for the year 2000 and beyond would be equipped with both the practical skills and theory for modern healthcare. It was known as the Project 2000 course. This meant less practical hands-on experience during my training compared to Yuki. At the time I didn’t necessarily see the value of learning about sociology and politics as I just wanted to get on and care for people. In my later career I have valued this much more as it has enable me to go on to achieve my BSc Hons in Cardiac Nursing and MSc in Nursing. As Yuki indicates nurses undergo statutory and mandatory training regularly such as resuscitation and must register with the nursing and midwifery council each year.  Every three years nurses must revalidate by compiling a portfolio of their reflective practice and skills.

HM: Are there things about these situations that you don’t learn about in your training?

D: Dealing with complex conversations definitely wasn’t taught but I think I had a good grounding and the right practical and leadership support to build on this each year.

Y: Yes, the communication aspect of things was not covered in enough depth in my training but we are talking a lot of years ago now!

HM: What about when patients can’t speak? Is that a bigger challenge to the nurse-patient dynamic?

Y: It can be. Of course every person is an individual. There are a variety of factors that affect the nurse patient dynamic. How well staffed is the ward? How much time do you have? How well did you know the patient before they could not speak. Are they conscious or unconscious? Do you know them as a person? Do they have neurological deficits/cognitive impairment or are they fully aware of what is happening? What has been their life story? Are they resilient? How are family dynamics? What impact do the relatives have on the situation?  My personal feeling is the nurse must always assume if a patient is unconscious that they can hear what you are saying. We were always taught from the outset never to talk between ourselves over a patient and this is something I always emphasized with junior staff.

I personally have experienced frustration and despair when trying to give a conscious, non-verbal patient the time they need to express their needs. Equally there are moments with the same patient where understanding has come easily and the joy in knowing you have eased their situation in even a little way is very rewarding.

D: Nurses become masters of non-verbal communication over years of experience. I agree with Yuki on everything else.

HM: How much does nursing involve non-verbal, somatic knowledge? Beyond the clinical observations does nursing involve other kinds of knowledge, sensitivity and communication?

Y: All of these are fundamental in nursing care. Communication is the essence in my opinion.

D: I agree. Over time I think experience leads to a high level of intuition for nurses as you have seen so much of human behaviour/situations - both good and bad.

HM: What kind of space or value does the the healthcare system give to this kind of knowledge?

Y: I think it has come along way in understanding that good communication and listening, be that verbal or non-verbal, are fundamental in delivering high quality nursing care. I think it also has a long way to go. I have personally experienced some very poor communication from healthcare professionals and some excellent communication - all in the current health service. I cannot comment on what is now provided in nurse training though. I think the rise in focus on mental health will only encourage better practice in this area. There is also better understanding of a patient’s spiritual needs now.

D: I agree, most development programmes include communication and leadership.

HM: Linked to this I’ve come across some research that is looking at how nursing might involve aesthetic or beautiful moments3.I wonder if you have anything to say to this? Does it resonate at all?

Y: Of course it does. There are many beautiful moments in nursing care where human understanding is shared. The ability to ‘be with’ somebody, to share their pain (emotional) regardless of how hopeless their situation may feel is a gift for both patient and nurse. I remember nursing my grandmother in the hospice I was working in. She was sedated and on opioid painkillers, it was days before her actual death. She appeared unconscious. I popped in to see her and brought some heavily scented orange blossom from her garden. As usual I spoke to her even though she could not respond verbally. To my amazement she rose forward from the bed with outstretched arms to hug me! This is one example of many I could share. Beautiful moments do not need to be big or dramatic, they are often small but the sharing is very meaningful to both patient and nurse I believe. Equally there are at times very difficult uncomfortable moments too.

D: Some of the beautiful moments I have had include working alongside Muslim elders to lay out a deceased patient to ensure no alcohol was involved in the process. That was an honour.  Also witnessing patients with serious heart problems having a relatively non-invasive procedure which makes them feel better instantly. And experiencing gratitude from patients and relatives every day.

HM: I’ve also been wondering about situations involving restraint -  a different kind of involuntary immobility. Is this something that you’ve been involved in as a nurse?

Y: Yes, very early in my nursing career on a psychiatric ward. It involved restraining a patient who was attempting to leave the premises when they were under a section. The patient was agitated and I witnessed the staff supporting them back into the ward after they had kicked open the secure doors. This was in the patient’s best interest as they could have presented a risk to themselves if they had left the premises alone.

D: I don’t have much experience of full physical restraint however is was common in my early career to hold confused patients hands down if they were resisting care. This usually didn’t help much if they were agitated. The guidance and laws have become much clearer regarding the use of force now and are closely linked to the Mental Capacity Act 2005 and deprivation of liberty standards. There is a move towards using devices such as hand mittens (to stop patients pulling out lines) and soft straps/handcuffs which are safer for both the patient and staff involved. Restraint carries a significant risk of harm if done incorrectly so mostly it is used by mental health professionals in controlled situations.

HM: Do you ever think about how you might deal with being in such a situation, where you are unable to move for yourself?

D: It’s my worst nightmare. I hate being dependent on anyone so I try not to think about it!

Y: Of course I have considered it many times over. Reflection is a big part of nursing care. For me I always consider how I would feel, what would I want if I were in this situation? I do my utmost to show compassion, understanding and to give hope.

[1] A thoracotomy is surgery to open your chest.

[2] Situation Normal: All Fucked/Fouled Up, a slang expression of US military origin.

All images courtesy of Peter Maleczek except the 5th image of a male nurse and female patient which is from Glynda Rees Doyle and Jodie Anita McCutcheon.  2015.
Clinical Procedures for Safer Patient Care