For Nurses in Developing Countries

You know you're a nurse living in a developing country when...

1. Every time you see a body of water you think about Schistosomiasis or some other water-borne parasite.

2. You're sitting on the commode with diarrhea and as you think about your lack of water intake and proper diet during the day, you literally say out loud to yourself, "I'm losing so many electrolytes right now..."

3. You dutifully use hand sanitizer every time soap and water isn't available, but secretly you're thinking of all the diseases only soap and water can kill.

4. You notice how dilated everyone's veins are in the hot, humid climate you're in and wish you could teleport your renal patients here for the fifteen minutes prior to starting an IV on them.

5. You're constantly telling people to change their diet to include more iron because you have a strong suspicion they're anemic after quick visual assessments, such as noting pallor in their nail beds.

6. You text your friends unashamedly about your abnormal bowel function overseas.

7. You adjust your diet according to your current bowel ailments. (More tamarind allowed today I'm constipated. More rice and less fiber when I have diarrhea.)

8. You're constantly reminding people to wear their motorbike helmets because safety always comes first, no matter the heat or discomfort. (You've seen one too many head traumas from motorbike accidents.)

9. It bothers you to the nth degree when you see people smoking on hospital grounds (considering all wards have open windows and doors and smoke can go everywhere).

10 Your heart breaks a little every time you see malnourishment. Which is pretty much every day.

11. You struggle because you have an overwhelming instinct to fix everything and make everyone feel better, but you're simply unable to. You find hope in helping one person at a time entrusting them to a Higher Power.

12. You are assessing community health needs continually, as you learn more and more about the culture, health care, and superstitions/beliefs affecting health practices.

13. Your friend in your passport country still sends you a picture of her infected eye to ask if it's pinkeye. (You reply yes, it looks like it is.)

14. Your days of running around a hospital floor getting cups of ice water so your patient will take their pills - all the while wearing a jacket because the a/c is turned up so high - seem like a distant dream.

15. Though your tolerance for super-entitled patients drops a few notches, you still respond to all with compassion and empathy because you realize in developed or developing countries, people's needs are the same: physical needs for food, water, medications, and hygiene, but also emotional and mental and spiritual needs. They just manifest in a different way. No matter if they're upset in a private American hospital room or in tears in a hot, crowded Cambodian ward, they are scared, stressed, and in need of healing and a Healer. So we respond with compassion to all. Because that's what we do. Because we are nurses.

To nurses in developing countries:

May your learning experiences, encounters with the sick, and poops be solid but not too hard.

May your heart, food, and water be purified and well prepared.

May the days you have the runs be blessed with plentiful access to flush toilets, toilet paper, and empathy for  patients with E. coli.

May your searches for soap and water, Lysol, deeper meaning in life, and a paradigm for suffering be fruitful and rewarding.

Most of all, may your compassion, immune system, and faith only be strengthened by your time overseas.

The HCAHPS Approach

Adobe stock photo

There is a problem on the floor. Not the literal floor. I mean the medical-surgical hospital floor that I work on. And every hospital floor, for that matter.

I have named this problem “the HCAHPS approach.”

For those who are not in the healthcare profession, let me briefly explain. HCAHPS [pronounced H-caps] stands for Hospital Consumer Assessment of Healthcare Providers and Systems. When patients leave the hospital, they receive a 32-question survey asking them to rate various aspects of their care. Examples include how quickly their call lights were answered, whether nurses and doctors treated them courteously, and even how quiet the halls were at night. The idea is to measure quality of patient stays and not just quantity, which is a good thing in of itself.

Here’s the catch. Hospitals’ reimbursement is linked to HCAHPS scores.

I could go on and on about the flaws in the system (like have you ever noticed the people who have dissatisfied are the ones who are more likely to complete surveys?), but that’s beside the point.

Broken system or not, I can tell you the effect it has on the hospital floor. Nurses and other staff are more stressed out, feel pressure to perform, and are always trying to please everyone, even when patients' demands are unreasonable. Hospital units track scores, huddle over scores, post graphs of scores. Sometimes we even talk about which patients wouldn’t give us a high score during shift change huddle. You would be amazed at how much time, money, and effort goes into trying to improve patient satisfaction scores.

But then again, maybe we shouldn’t be amazed. 

It’s Everywhere

When I look around myself—and more importantly, when I look within myself—everything I just described is present: high stress level, pressure to perform, working to please everyone…

Toward the beginning of this year, I sat across from my therapist and told her I felt like I was on a treadmill of perfectionism. I kept running and running and running, trying to go faster and work harder and be better, but I was getting nowhere. It was only exhausting me and made me feel like a failure.

I was applying the HCAHPS approach to life—and so is a large portion of society. We pressure ourselves and others to perform, and we measure our self-worth by what other people think of us. Many of us openly admit to being “people pleasers.” (The opposite response is also dangerous—dismissing everyone’s opinion and deciding not to care about what anyone thinks, even if they have valuable feedback. But that’s a whole different topic for another day.)

Though there’s nothing inherently wrong with ensuring quality patient care and assessing how others feel about us, there is a fine line between assessing and obsessing. 

When satisfying others and controlling their perception of us becomes the focus, toxic environments are created. That toxic environment can exist inside ourselves, in our work places, in our homes, etc.

Why It’s Toxic

When our whole focus is on what others think, we operate from a belief that we are not enough and maybe if we try harder, are nicer to that co-worker, answer that patient’s call light faster, we will be enough. We believe we will get all top scores and everyone will love us and we will feel worthy and loved.

Yet this feeling of enough-ness will never come from others. We may feel liked and valued for a while, but striving for worth is a vicious cycle that always calls for more. A little more work. A little more makeup. A little more money. A little more studying.

The truth is, we will never be perfect in the eyes of the people around us…because we are not perfect. And they are not perfect.

We carry around invisible satisfaction surveys and, gauging everyone around us, silently (and maybe subconsciously) rate ourselves based on our perception of their perception of us. I bet that person would give me a ‘1’ on promptness. He would give me a '10’ on friendliness. She would give me a ‘5’ on fashion sense. No wonder we’re stressed out and exhausted!

Toxic environments lead to sickness and death. In my case, it led to deepened depression and anxiety. For others it may manifest in physical sickness, anorexia, addiction…

Getting Out

Ironically, it’s when we stop caring too much about what others think that our relationships improve. When we direct all our energy toward pleasing others, we forfeit the opportunity to do our best work. It takes great courage to admit that we are not enough, and great humility to admit that we can never be enough. But there is freedom if we can embrace the truth that because God is enough, we don’t have to be enough.

When we believe this, we shift from operating from a place of frantic striving to a place of confidence in God’s enough-ness. We operate from a stable place rather than from a place where success is defined by others or even by ourselves. We are able to focus on doing our best rather than exhausting ourselves attempting to achieve perfection. We are able to be instead of do, and out of just being come our gifts to the world—the gifts that so often get squelched in our efforts to please others: our compassion for our patients, our ability to motivate our students, our passion for our workplaces, our unique skills and talents for serving and creating and inspiring.

Good News

The bad news is that we live in a society that embraces the HCAHPS approach to life. Regardless of whether or not you work in a hospital, I imagine that all of our workplaces have a tinge of the HCAHPS approach, subtle or blatant.

We may not be able to change society completely—or hospital reimbursement policy—but the good news is that we do not have to keep the HCAHPS approach as our approach to life. We can replace it with the liberating approach of recognizing our need and operating from a sufficiency outside of ourselves. Somehow, when our internal approach shifts, it doesn’t matter so much that the people around us—at work, at school, or at home—are hung up on performance and people pleasing. 

They can post it on a wall I see every day at work, but they cannot post it on my heart. I choose to leave the HCAHPS approach behind. What about you?

Beyond the Smiles

I remember her lying there. The bare metal bed frame. Her hair pulled back behind her head. The blood on the floor. The coughing and then the bright red vomiting as her thin frame twisted and shook. And the pool of blood grew.

This woman had no family. In this Cambodian hospital, family members are the ones who bathe, clean, clothe, reposition, provide food for and feed patients. They are the ones who faithfully stand at the bedside and move plastic fans back and forth, back and forth, creating air movement in an un-air-conditioned building and preventing the ever-present flies from landing on the sick. 

This woman had no family. 

Her eyes were closed, her body weak. There was nothing with which to clean up the crimson puddle. “Wait,” they told me. “The cleaning lady will come later with the mop and bucket.”

I remember the moral dilemma when a doctor told me they had no more blood to transfuse for this woman. The need for blood, the safety concerns if I dared donate, the fact that even with several transfusions this woman may not live because we could not correct the bleed at this facility… These are the moments that pushed me to the end of my rope again and again until eventually, when I came back to the States, I felt I had completely lost the rope a long, long time ago.

Yet, as Bethany Williams writes in The Color of Grace, “when our level of desperation becomes greater than our pride, true healing can begin.”1

It has been in the pride-swallowing desperation following those experiences that I have discovered true healing. 

True healing, I found, requires courage—and learning what courage is. Courage isn’t going without water heaters and microwaves; it isn’t forcing my eyes open to watch drivers navigate the wildly crowded streets of Phnom Penh. It isn’t becoming comfortable riding on a motorbike or even eating fried crickets and silk worms.

Courage is living the story that is happening beyond the smiles, beyond the Facebook posts and beyond the Instagram snapshots. Courage is struggling—hard—and being vulnerable with others about those struggles. Courage is walking into a counselor’s office; courage is asking for help. 

Courage is learning to acknowledge grief and wrestle with suffering, being willing to embrace my humanity, and humbling myself enough to recognize I'm in over my head. In that moment in the Cambodian hospital, standing at the bedside of a dying woman, I felt helpless and defeated. What had eaten away at me for years was shoved in my face: I was not enough. This time courage meant wading through years of lies to find the truth that although I am not and never will be enough, I don’t have to be.

True healing, I found, happens in the presence of Jesus. 

I can never do enough, say enough, sacrifice enough, love enough; I can never be enough for Cambodia, for those around me, or for myself. Yet when I relive that moment in the Cambodian hospital remembering that Jesus was present, too, I find that He is enough.

As healing happens within, grace creeps into the relationships with those around us. We don’t have to be enough, for God is enough. When we believe this truth for ourselves, we can extend grace to ourselves for our imperfections and failures. When we believe this truth for others, that they don’t have to be enough either (for God is more than enough for all of us), we can extend grace to them. True healing embraces Truth, brings forgiveness, and overflows with grace.

Healing is a process, and it requires humility and perseverance and sincerity. It is not easy. But the freedom on the other side is well worth the work. For me, it has brought freedom from the pressure to please, perform, and perfect. I am free to feel and to fail and to forgive, to be the imperfect me He created me to be.

If healing happens in the presence of Jesus, what glorious news that Jesus is Immanuel, that Jesus is here with us! And He is enough. His sacrifice is enough for our sins. His love is enough for our souls’ deepest needs. His compassion is enough for our grief. His strength is enough to catch us when we fall. His presence is enough to heal. He is enough.
 

Deepest gratitude to my wonderful counselor, Lynette, who continually ushers me into Jesus’ presence and who walks with me in this healing process. I am truly thankful, from the bottom of my heart…

1) Williams, B. (2015). The color of grace: How one woman's brokenness brought healing and hope to child survivors of war (p. 29).

The Nurse Who Lost Her Super

At my alma mater, it’s a tradition for each graduating nursing class to design a t-shirt and wear it to the nursing convocation their last semester. The shirt my graduating class designed had the Superman logo on it, except with “RN” in place of “S.” Underneath the logo it said, “What’s your superpower?”

We all laughed and joked about how nursing was a superpower. Secretly we believed it was true — it took extraordinary work, perseverance, and the grace of God to get through the nursing program. 

A few weeks ago, I sat in my bed contemplating an important realization and confession: I am a nurse. And I am not a superhero.

When I started my job, I had healthy expectations: I would have questions — a lot of them — and I would struggle at first, and I would have grace on myself, and things would eventually get better.

But somewhere along the way, perfectionism got the better of me. My desire to be a “good nurse” morphed into a desire to be a perfect nurse. I began to think it was possible not to forget a single thing in a day, for all my patients to like me, to be on top of things all day long. I wanted to be a perfect nurse. I wanted to be a superhero.

Outside of the hospital, I have been on a journey away from finding my worth in performance (the essence of perfectionism) to finding worth in who I am. I learned the reason I grieved so deeply for patients I saw in Cambodia (patients whose names I didn't even know) was that I believed they had inherent worth and value just because they were human beings; they were God’s creation. Through this I came to understand that I, too, have inherent worth and value for the same simple reason. This brought freedom from striving for worth and allowed me to embrace imperfections, grace, and Gospel anew.

Yet in the hospital setting, as stress set in, I lost track of my healthy desire to be a good nurse and bought into the alluring illusion of perfectionism once again. I began to believe it was possible to be a perfect nurse if I just tried hard enough or had enough experience. Of course, this led to a great big let-down when I failed to live up to my superhero standards. Things happened that I didn’t want to happen, things both under and out of my control. Family members got angry, patients fell, charting was delayed, meds were given late — just to name a few.

Thus I asked this question: if I could not be a super nurse or a superhero, then what was I as a nurse?

Here’s the definition I came up with: I am a human helping other humans.

I am no better than the sick patient lying in the hospital bed. I have no magical capabilities due to completing nursing school. I don’t have a 64 gig memory stick in my head to keep track of all the things I’m doing or am asked to do (maybe it would take 128 gigs, anyway). I forget things. I make mistakes. I say things I shouldn’t, or maybe I don’t say things I should. I have to fight to maintain patience or keep my cool. I give all I can, and sometimes that isn’t enough.

To my patients, I’m sorry when I fail you. That isn’t fair to you.

To my fellow nurses, we have unrealistic expectations set up for us from many different sources. In a way, we encourage these unrealistic expectations. We put “I’m a nurse. What’s your superpower?” on mugs and t-shirts and all kinds of nursing paraphernalia. We glorify nursing. I’m not talking about appreciating nursing; I’m talking about taking such pride in our work that we begin to believe that we are or should be more capable and intelligent than non-nurses.

Though this makes us feel special and important and needed, when we buy into the dangerous lie that we have superpowers, we set ourselves up for disappointment.

We may not even recognize this disappointment, but it steadily adds to the detrimental cycle of striving for worth. As nurses, we face massive expectations from those around us. Why add to them and sabotage our profession by becoming the frontline advocates for enforcing those unrealistic expectations upon ourselves? 

Are our actions important? Absolutely. Are there things we do that no one will ever understand except other nurses? Yes. Does what we do at work define who we are as people? No.

Though this post is primarily about nursing, the premise is true for other professions and roles. When we believe we can be perfect super-nurses or super-teachers or super-writers or super-______ (fill in the blank), we are guaranteed only one thing: failure.

When we identify ourselves as our profession before identifying ourselves as humans, we are bound to fall. As someone recently reminded me, we are human beings, not human doings.

When we identify first as humans rather than as nurses/accountants/managers/etc., we gain permission to fail and make mistakes and learn and grow and be enough all in the midst of our imperfections. Isn’t that the best kind of nurse, the best kind of professional? The one who isn’t perfect but who is always learning and improving?

So, let’s not be superheroes. Let’s not pretend we’re superheroes. Let’s not spend our lives striving to achieve superhero status. Let’s be humans. And let’s help other humans the best we can.

What are some unrealistic expectations you face on a regular basis?

How do you respond to these expectations?