The Making of a Nurse

by Tilda Shalof

  “Why do you bathe patients so much?” a student nurse once asked me. “It’s not like they’re dirty.”

  “It feels good to patients,” I explained to her. “Water is relaxing and it makes a person feel fresh and clean.” The hospital had been trying to get us to use new antibacterial “bath in a bag” chemical wipes, but nothing was better than water. In fact, I had been working on an invention for a portable shower contraption that could be placed over the bed and would rain down warm water all over the patient. The water will drip off all the sides, into troughs, but I hadn’t got around to building the prototype just yet.

  Researchers measure, quantify, document, describe, evaluate, in order to validate nursing and prove its effectiveness, but something seems to get lost in the process. Data is generated and numbers are crunched but the essence, beyond the tasks and skills, continues to elude scientists. Cardiac monitoring is one of those particularly invisible activities. It looks like nothing more than blank staring, or casual gazing, but it is actually a studied vigilance that requires a deep understanding of the heart’s electrical system, the skill to identify a potentially lethal problem, and the knowledge to intervene. While the attention required looks incidental and easy, the thinking behind it is anything but: why has the heart rate jumped from 80 to 110? Is he in pain? Is he “dry” and needs a fluid bolus? I better take his temperature … fever can cause the heart to race. What’s his hemoglobin? What about those premature atrial contractions? Are they causing a compromise in blood pressure? And those ventricular contractions, are they unifocal or multifocal? I’ll check his potassium level because if it’s low, that’s what could be causing an arrhythmia.

  Those aspects of nursing that are elusive, indefinable, and ambiguous contribute to a debate that rages not only within the insular walls of the institutes of education, but also in the real-life places where nursing is practised: What is a nurse? That is, what are the roles, responsibilities, and actions that define a nurse? Who is a nurse? That is, what does a nurse look like and how can you tell one apart from the doctor or other professionals? More worrisome is that patients have been known to ask, “How can I tell who is my nurse?” given that gender and clothing alone are not definitive. Most nurses say they wish to be known by the relationships they have with patients, not by their clothes. I’ve seen many nurses individualize their uniforms by wearing scrubs in ice-cream colours of raspberry, lemon, and grape. There are those who wear lab coats decorated with teddy bears, angels, or lollipops.

  Later that day after the incident with the visitor passing by, I decided to ask some of the other nurses sitting in the lounge about clothes. “Do you remember Carrie? The one who tied her scrubs with a gold lamé belt and always wore a string of pearls? What a fashionista she was!”

  “I remember her,” someone recalled with a chuckle. “That girl really knew how to pimp her uniform. She wore those white shoes with the kitten heels that went clickety-clack down the hall. You could always hear her coming. And what about her nail art? She had those long, curved acrylic ones and when she was dating that sailor she decorated them with nautical symbols! I always meant to ask how she managed to insert a catheter. Ouch!”*

  “Why do we even have to wear uniforms?” someone else asked. “We’re individuals, aren’t we?”

  “In the old days,” reminisced Phyllis, a senior nurse, still going strong in our physically taxing work, “we worked hard for our caps and white uniforms and when you put them on, you felt like a real nurse. It was like you were preparing for your role in a play. It meant something.”

  Monica kept quiet, but I felt certain she had a strong opinion on the matter. I knew her ambitions. Even with a young daughter who she supports on her own and after going through a messy divorce, Monica has returned to school for her Master’s degree in management and is a stellar student. Finally, she spoke up. “Appearance matters. How would you feel if the pilot of the plane you’re on showed up wearing track pants and a T-shirt? What kind of impression would that make? And what about all the bling nurses are wearing these days? It doesn’t look professional and surely they know jewellery harbours bacteria that we can bring in or take home with us.” A chorus of dissent flared up, but Monica continued above the din. “Besides, the hospital has a dress code and we’re supposed to adhere to it.”

  “That’s just a way for management to control us. It takes away our individuality!”

  “What’s a nurse supposed to look like?”

  Someone sarcastically offered the suggestion, “Try the ‘Naughty Nurse’ website. You can get some wild ideas there!”

  “My kids want to dress up as nurses for Halloween. What can they wear to look like a nurse?”

  “Have you seen that nurse in Dialysis who still wears a cap? What a dinosaur!”

  “Did you see that doctor who came to see my patient this morning? He looked like a geeky high school student, no lab coat, no name tag, nothing. He went into my patient’s chart. Who are you, I asked him? He looked like he’d walked in off the street. He could have been a visitor or a patient from the Psych ward!”

  Nurses’ uniforms seem to be yet another issue in the ongoing debate about what and who a nurse is. Uniforms did have a way of obliterating individuality. They could turn people into a service to such a degree that ease of recognition or the speed with which they responded to a call bell became the measure of their worth. Even I, who always preferred the generic, unisex, and equalizing qualities of my green or blue scrubs, recently purchased a pair of shiny, candy-apple red shoes for work, as much for the vibrant colour as for the comfort. Is individual expression really such a threat? Can’t beauty and function coexist? What if nurses could find ways to use Beauty and Art as capably as they use Science?

  I was pondering all of this one day at the grocery store. While I realize most people start at the produce sections, move on to refrigerated items and frozen foods last, I head straight to the jumbled bin of remaindered or damaged books. I was digging in there and happened to dredge out a book of unexpected possibility: Transitions: Unlocking the Creative Quilter Within, by Andrea Balosky, a Californian quilter. I stood there, entranced. Wow, I thought, looking at photographs of her quilts. The juxtapositions of shapes and colours thrilled me! The mix of vintage and modern! The artistic and the functional! That book sparked my exploration of quilt history and lore. Even the names of traditional blocks intrigued me: Flying Geese, Log Cabin, Broken Dishes, Hidden Windows, Jacob’s Ladder, Card Trick, and Courthouse Steps. I loved the “crazy quilts” that didn’t use uniform shapes and instead had a distinctive haphazard look. There were equally lovable scrap quilts with mismatched, chaotic colours and glaring, but appealing, flaws. Other quilts, such as in the Amish style, were balanced, symmetrical, and in muted colours. Many quilters used whatever was on hand; their intention was not perfection. Quilts have even found a place in museums as examples of both simple folk art and sophisticated craftwork.

  An idea was brewing …

  Inspiration can come from unexpected places. A fortune cookie once did it for me. “You have the power to affect the quality of someone’s day.” Nurses have that power in ways that are both obvious and practical but also subtle, even spiritual. And it’s not only nurses who have that opportunity, I discovered one morning when I rode the elevator with the housekeeping staff, who start their day as early as nurses. A cadre of Portuguese and Italian ladies in pink smocks got on at the basement floor, each one carrying a plastic bag containing a mop head. “They give us a clean one to start each day,” one lady told me with obvious pride. “We used to have to wash them ourselves at home, but now the hospital does it for us. Some of the girls weren’t cleaning them properly,” she said, showing her disapproval of such sloppy practice. “It’s so nice to start the day with a fresh mop.”

  And none of us will forget the sweet voice of the young man who worked the evening switchboard. We stopped whatever we were doing at precisely 2100 hours to listen to the public announcement:


  Good evening, ladies and gentlemen. This is a gentle reminder that it is now nine o’clock and the time has come to say goodnight to those you love. It’s a cold one out there this evening, around five degrees, but it’s more like minus twenty with the windchill factor. Brrr … We suggest you bundle up with a hat and scarf to keep warm. Have a safe journey home. We’ll be looking forward to seeing you again tomorrow when you are welcome to visit us again. Goodbye and sweet dreams. Be well. Take care of yourselves and we’ll take good care of the patients.

  We looked at each other, amazed. How long could he get away with it? As it turned out, not long. The public announcement soon reverted to the original, terse recorded message: “Visiting hours are now over.”

  I WAS BEGINNING to piece together a patchwork of ideas. What if a collective of nurses created a work of art made out of natural elements such as cotton, wool, and paint in this environment of chrome, glass, steel, plastic, and concrete? A nurses’ patchwork quilt, made by our hands, those very hands that do the work of caring for our patients? It would be inspired both by what is in our hearts and our minds. It could be a symbol of comfort, a soft place to rest one’s eyes, especially the anxious, weary ones of our visitors out in the waiting room where it could eventually be hung and displayed.

  I called a meeting of all the nurses. I took a deep breath as I opened a big plastic storage box and pulled out pens, paints, crayons, tubes of glitter, ribbon, and squares of plain white fabric. They looked at me, some dubious, others bemused, and a few annoyed. I explained my idea.

  “There she goes again,” they groaned, rolling their eyes, “another of her crazy make-work projects.”

  “Who does she think we are? A bunch of grannies?”

  “Yeah, my grandmother makes quilts, too.”

  “The time has come to appreciate these historic domestic arts, not trivialize them,” I lectured. “You’re buying into the usual putdown of women’s work.” (Funny, how it wasn’t any of the male nurses who objected to the quilt.) “It’s because we have come so far that we can feel proud of art created by our hands. It doesn’t stereotype us any more.”

  They weren’t convinced. Many walked out, laughing as they went. To the remaining ones, I turned up the heat a notch. “It will be a place to put our stories, our memories and save them from extinction. Nursing might look different in the years to come. This quilt will be a statement of our profession, a historical document of nursing today, now, in this place and time.”

  “What’s the theme?” someone asked.

  “Comfort measures,” I came up with on the spot.

  “Tilda, do you really think that a quilt can change the world?” someone else asked.

  I did, in fact, believe that Art could, but kept quiet. They’d heard enough from me. Reluctantly, they took their package of fabric and supplies. A few showed mild interest. But was it such a stretch? Many nurses had creative hobbies of some sort or another. Take Valerie. She’s such an accomplished gardener that tour buses stop at her house to visit her garden. She tends to her patients in the same way. She took care of a prisoner who was brought to the hospital from jail where he had taken a heroin overdose. He was ugly and tough and had a tattoo of barbed wire encircling his neck, arms, and chest. A policeman kept a constant watch over him, even though a critically ill patient could hardly escape. I came over to help Valerie because I knew he could be violent. However, in her hands, he was docile.

  “What’s he in jail for?” I asked the policeman, who was sitting in the room.

  “Rape, murder. The usual.” He flapped open his newspaper.

  The patient/prisoner could not have known, but must have felt, the benefit of Valerie’s profound philosophy of nursing that she once expressed to me: “I don’t care who you are. I’m going to give you the best care I possibly can. It doesn’t take much. It’s really so simple. A smile, a kind word. It means so much.” Valerie puts her gardening skills to use in other ways, as well. Her patients are always well-tended and their rooms are always clean, orderly, and nice-smelling, if possible. And I am positive that it was Valerie who potted a plant in a bedpan and placed it on the counter of the nursing station for all to enjoy.

  There are other professionals who have also found ways to allow their hobbies to inform their work in the icu. On her days off, Monique, our Québécoise physiotherapist, is an extreme athlete who participates in “adventure” races. She’s part of a team that goes four days straight without a break, bushwhacking through wilderness, running through hills and valleys, traversing rivers and streams.

  “Incroyable!” I said. “What about sleep?”

  “I got about three and a half hours on the last one. We took a few naps,” she admitted. “It was wild.”

  “What about food?”

  “Energy bars, pre-cooked bacon for the fat. Lots of water, but we have to carry it with us.”

  Her work with our patients involves assisting them to bend a knee or cough out tenacious secretions lodged in their lungs. She helps them dangle their legs over the side of the bed after a prolonged illness or do breathing exercises after surgery. These are their “Iron Man” events and Monique knows that well. Bien sur.

  “DOESN’T ANYONE GET BETTER?” friends often ask me. Understandably, they want to hear heartwarming stories. They are tired of my sighs and lamentations about my work. Why have I never told them about Dr. Margaret Herridge’s world-renowned work on the long-term survival of patients with ARDS?* We took care of those patients only during their stay in the ICU when they were critically ill, but Dr. Herridge follows the growing number of survivors who made it home. She documented their progress as they returned to good health.

  Why had I never told anyone about the son, his mother, and the liver they now share? She had a rare disease and only a transplant would save her life. The son worked with his parents in a thriving family business and they had gone on yearly family trips to their native Italy and come back tanned and fit – except for one summer when the mother returned weak and jaundiced. Her subsequent deterioration was rapid. It didn’t take long for the son to decide to donate a lobe of his liver to his mother and luckily he was a match. “Imagine this miracle,” the mother said, “a son gives birth to his mother!” A nurse brought the son over in a wheelchair from his hospital room on a surgical floor. She helped reach his arms to his mother in the bed while I lifted the mother’s arms toward the son. Together we made it possible for the two of them to hug each other.

  Why had I never shown my friends or family the calendar put out by the organ donor association? It included pictures of a kidney recipient kayaking in a lake, a liver transplant running a marathon, another smiling, sitting in her garden.

  What about that eighteen-year-old boy with testicular cancer that had spread throughout his body, who had a tumour, the size of a football, wrapped around his heart? He underwent surgery but then developed pneumonia and kidney failure and landed up in the icu. “We couldn’t remove all of the tumour,” the surgeon told the patient’s mother and brother. “We’ll have to go back in again once these complications resolve.”

  “But he’s okay?” they asked in unison, rushing ahead of him into the room.

  “For now,” he said.

  “Hey, bud, the doctor said you are okay!” The brother grabbed his brother’s hand. “I just about went boom, passed out, and Mom’s here, freaking right out.” Amidst the iv and the arterial line, he found a place to plant a kiss on the back of his brother’s hand. “I’d do anything for you, man. You’re my main bro. Maybe I’ll bring the catcher’s mitt, and we can play ball in here.”

  After the family left the room, I spoke with the surgeon. “He’s the sickest patient in the ICU right now,” I told him, trying to hide my worry.

  “He’s young and his type of cancer has an excellent response rate to the chemo plus surgery regimen. We’re aiming for total cure. There’s no other option.” He closed the chart.

  “Yes, but he’s developed so many problems
and he’s on maximum support.” I gestured around at the room full of machines, including the High-Frequency Jet Ventilator that was used only in extreme cases such as this. It pumps more than 100 breaths into the lungs every minute and makes a loud, rapid, thumping noise you can hear throughout the halls of the icu.

  “He’ll be all right. He’ll get out of here.” The surgeon got up to go. “If you nurses would be more optimistic,” he said with exasperation, “the patients would do better.”

  Maybe it was just a bad day or I had seen too many losses and attended too many “M and M” rounds of late, where the mortality and the morbidity of our patients were reviewed and we spent hours discussing all that had gone wrong and the ways we could do better next time.

  “How is he?” said the mother, rushing in later that day in her coat and scarf.

  “About the same,” I said evenly. “He’s holding his own. No better and no worse, but that’s saying a lot.” Around this place, it is.

  “Amen,” she said, clutching my arm. “Amen.”

  But the next day, I was able to tell her, “He’s getting better,” and he was, a little.

  “Praise the Lord for this miracle.” She clasped her hands up to God in gratitude and then out toward me. “Thank you, Nurse, for everything you are doing for my boy.”

  We saw that young man again just a few weeks later. Tall and shy-looking, with the requisite baseball cap turned around and baggy pants, he came to visit us under duress from his mother. Was it a miracle or merely an accurate reflection of statistics and the laws of large numbers that bore out the doctor’s confident prediction? Sometimes everything went well, not only as prayed and hoped for, but as planned and intended for also. This is what the ICU is about and one of the reasons I work here, yet these are not the stories I regale my friends and family with, when I tell them anything at all. Why don’t these stories leave as strong an imprint on my memory or as lasting a residue on my emotions as the ones that disturb me, even haunt me at times? I suppose it’s because, generally speaking, our patients are the ones with complications; they come to us when things don’t go as planned and hoped. The cures and successes aren’t the ones who need us or who keep us busy or up late at night.