By Amanda Anderson, a critical care nurse and graduate student in New York City currently doing a graduate placement at AJN. Her last post on nursing and patient satisfaction surveys is here.

by runran/Flickr Creative Commons

by runran/Flickr Creative Commons

During this hospital stay, how often did nurses listen carefully to you?
1. Never
2. Sometimes
3. Usually
4. Always

Listening Carefully About Patients
“Her crit is dropping with each bowel movement, and she just won’t stop bleeding,” said my night shift colleague during the early moments of my shift.

As soon as she finished telling me the rest of my new patient’s care, I got on the phone for the ordered blood. Waiting for the first of many products to be delivered, I went to see her. As I poked around the hanging drips and fluids, checking dosages and orders, setting alarm limits, I heard my patient’s voice:

“Hello, hello? I’m so anxious. I just fell asleep for a moment and now I’ve woken up and I’m terrified. I think I need to be changed again, and I just don’t know what to do, and who are you?”

My colleague, busy with the details of resuscitation, hadn’t said much about my new patient’s anxiety. Anxiety, too often coded as neediness, is clinically important, especially in a patient with questionable stability, and doubly in a patient whose nurse must focus on speedy resuscitation more than handholding. I braced myself for what felt, just then, like an extra factor in an already challenging situation.

“Good morning,” I told her. “I’m Amanda, your nurse. I’ll be caring for you today, and my most important priority is getting blood into your body, because I’ve been told that you’re bleeding quite a bit. We want to stabilize your blood volume and stop your bleeding. We’ll do that with blood products in your IV.”

Listening Carefully To Patients
I start most of my shifts listening first, and then telling, setting a plan of care for the day together with my patients. But I didn’t like the slight bluish tint to this woman’s skin , or her heart’s steadily increasing beat. Her blood pressure was holding, but (applying Maslow’s hierarchy), I believed that she needed blood more urgently than she needed comfort (and antianxiety medication was out of the question—the resident would never agree to anything that might drop her pressure).

As I prepared to help my patient turn in the bed, she sent a million words in response: anxiety, questions, doubts of my actions and capabilities. With an eye constantly on the heart monitor, I gave the tersest of answers, my worries seemingly confirmed when I pulled back the covers and found a pool of bright blood.

Blood products came, and I pumped them into my patient’s flat veins. I was the only one in the room and I worked silently as she talked. And talked. If I had been a more experienced nurse, I would have welcomed her talking as a sign that her blood volume was sufficient enough to carry oxygen to her brain, and I would have engaged her more fully, both as a means of assessment and as a way to relieve her anxiety. But I was entirely wrapped up in the physical realm—stopping the bleeding and resuscitating the volume.

Listening Carefully With Urgency
After I’d been running, infusing, checking, and turning for a few hours, with little attention to my patient’s stream of talk, she started to cry.

“You do not like me!” she said. “I can tell: you think I’m so annoying!”

I stopped and truly looked at her for the first time. Her hair was set in tired two-day-old curls, and a pair of those funny gold-rimmed glasses slipped halfway down the bridge of her nose. I noticed her soft white skin, and the age spots on her arms that my own grandmothers shared. She was right, I wasn’t showing her warmth that she obviously would have found comfort in. Even as my stance began to soften, a part of me resisted—after all, didn’t she understand that I had just saved her life?

I sat down beside her. She was stable now. She had stopped bleeding, and the worst of my work was over. The work that was needed then was careful listening. Sure, I’d been aware of her words and her tone from the moment I’d assumed her care, but I’d been more concerned by her clinical status than her emotional needs.

Was I wrong? Technically, no. I carried out the orders given to me, and stabilized her life. Did I fulfill her care in a satisfactory way? Maybe not.

Learning to Listen [Carefully]
It’s amazing, the different forms that listening takes at the bedside. Over the years, and the endotracheal tubes and the strokes, my ability to listen has grown and changed. Every ICU nurse knows the challenge of a semi-sedated patient attempting to write words on a piece of paper, sending markers and pencil sprawling across white sheets, letters distorted and often illegible. Few of us have not experienced the effort of lip-reading a patient with a tracheostomy, or the agony of listening to a dysphasic patient who believes that the indecipherable sounds leaving his mouth are completely coherent.

Listening at the bedside, more often than not, takes time and intention, even in patients with a physical ability to clearly speak. There are a million tasks on a nurse’s brain, and listening can easily be coded last. Throw clinical instability and a high patient ratio into the mix, and the attention involved in really listening can cause us reflexive anxiety as our work mounts around us.

Busyness is our baseline condition, especially when we’re caring for unstable patients. But careful listening can be brought into even the most acute situations. This patient helped me learn that sitting for two minutes in the first moments of our day together would have helped me build crucial trust between us, saving me time, and her anxiety later on.

Explicit narration of what I was doing to her might’ve helped, too—I learned the importance of talking to her about the mechanism of action that the fresh frozen plasma had on her clotting ability, and how closely we were watching her vital signs for a reaction to the many products, despite the need to complete these tasks quickly.

Careful listening comes with presence and touch, too—each turn and wipe can become healing if each carries the weight of intention.

Listening Carefully to Yourself
My mistake with this woman was to think that listening and critical care couldn’t be paired. Her constant flow of words did not require much response, but they did warrant moments where I showed that I heard them. Recognizing my own anxiety may have helped, too—in moments of clinical instability and volume, we are often driven by our fear of the worst. Constructively sharing our sense of urgency (if we can do so in a way that doesn’t inspire more fear and anxiety) can help some patients and their families see that our job is highly technical and sometimes requires great focus.

My work saved my patient’s life that day. She left the unit and went home, where she likely filled out an HCAHPS survey. I’m sure she had many nurses who listened to her carefully during the course of her stay in my hospital. Did I contribute to whatever score she gave?

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