Sunday, September 18, 2005

Cognitive Dissonance

Yesterday's post brought home to roost some cognitive dissonance which I've been experiencing as of late. If you read this blog regularly, you might guess that this dissonance revolves around work and identity.

In my full-time day job, I now have approximately 8o patients for whom I am responsible. A medical assistant follows about 25 of those patients, but I am still legally responsible for their care and carry them all under my license. The pace at which I live my 9 to 5 existence can be exasperatingly fast. Being a healthcare setting, everything I do must be properly documented, nursing notes being legal documents to which one affixes one's signature. I teach my students that any note which a nurse signs can later be used in a court to question your actions (or lack of action) in any circumstance in which the nurse was involved. Omission of information can sometimes be as damning as adding information. What you did not do can sometimes be the subject of inquiry. While I do not live my life worrying about potental law-suits, I always bear in mind that a prudent nurse will document well and completely, affixing a signature with as much confidence as possible.

With that in mind, I examine what a day can be like: planned home visits or office visits with patients; dozens of calls and voice-mails; spontaneous walk-in visits from unexpected patients; frequent crises which need immediate attention; interactions with other professionals; case conferences; documentation; internet research; symptom management; care plan reviews; and myriad other administrative and clinical tasks which cannot be listed here for lack of time and willingness to do so. Each call and each action necessitates documentation. The pile of unfinished notes grows throughout the day, and with my sieve-like brain under stress, doing notes the next day and remembering what transpired is a challenge. I sometimes feel like I need to explode or the information will begin to leak out of my ears in an unsightly manner.

The stress of my work is palpable. I serve a population which is poor, with low levels of education and sophistication (with a few exceptions), lives of crisis, strained relationships, financial hardship, and chronic illness. The level of dependence and need can be overwhelming and I often long to remove myself from the struggle. However, there is such life in what I do, such satisfaction in the positive aspects, that it keeps me coming back. My agency is also a pilot program providing cutting-edge care to underserved populations which is only equalled in two or three other programs in the country at this time. There is a political nature to our work which is enthralling, and while we're still figuring out how to do what we do (and convince others that it works and is worth replicating around the country), we struggle with the burdens under which we toil. Large caseloads, needy patients, and overseers who demand a great deal from us in order to justify our existence.

Looking objectively at my work, when I think of leaving for another position, I imagine how much easier it could be, how much more sane. But then I look at this team of people with whom I work, the heart and good-will at the center of our work family, coupled with the political and social ramifications of what we are doing, and I cannot find it in my heart to seriously examine other work opportunities. I've been offered a full-time position at a corporate visiting nurse agency which is begging me to work for them, but it is just that: a corporate for-profit national chain of nursing agencies which lacks a true vision other than profit and providing generally competent nursing care. While I am attracted by the small caseloads and change of pace, I'm not drawn to the people, the work environment, or the politics of the organization. I do per diem visits for this agency a few times a month, but involvement beyond that seems unlikely to me.

Healthcare in this country is in crisis. Services to the poor are consistently being cut. Disparities of race and socioeconomics are even more apparent as the aftermath of Hurricane Katrina shares its lessons. I struggle to stay afloat, to maintain my composure, but my dedication to serving these populations does not wane. The cognitive dissonance is born from concern for my own well-being, my own health, and the consequences of stress on my body and mind. For now, I stay put and make the best of it, looking for ways to maintain health, strike a balance, and save myself from long-term consequences of stress. Reading Tracy Kidder's book Mountains Beyond Mountains recently, I'm struck and awed by Dr. Paul Farmer's tireless worldwide struggle to bring healthcare to some of the most underpriviledged people in the world. It's people like him who inform my own career decisions and empower me to stay the course. It has been said that no one would want "I wish I had worked more" engraved on their tombstone. But perhaps "I'm glad to have helped so many" would be a worthy alternative epitaph. The secret lies in how to lengthen others' lives without consequently shortening one's own.
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