1. Paradisi, Julianna RN, OCN


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"This book is about interpreting what you see and hear in order to make better judgments."


It's my opinion that every nursing textbook should open with the above statement. However, it's from the introduction to Sibley's Birding Basics, by David Allen Sibley.


During home isolation due to the COVID-19 pandemic, my husband and I took up bird-watching as a way to get out of our home and entertain ourselves while maintaining our "bubble." Armed with binoculars, David's camera, and my artist's field bag, we visit local wetlands and wildlife reserves, recording our finds. That led me to read Birding Basics.


Experience coupled with pattern recognition. As a nurse, I can't help but link the idea of "interpreting what you see and hear in order to make better judgments" as a definition of a nurse's intuition, commonly referred to as a "nurse's gut."


While there are times when a nurse's clinical intuition borders on the psychic, many of these revelations are a product of bedside experience. For instance, patients, including infants, sometimes exhibit facial grimaces or say words that a hawk-eyed bedside nurse rightly interprets as signs of impending doom, such as a cardiac episode or intracranial hemorrhage, before the monitor alarms.


Once, while I was precepting a nurse new to our pediatric ICU, she and I took report on a newly post-op patient. The day-shift nurse described how she'd administered normal saline fluid resuscitation several times during her shift. As she spoke, I noted that on the monitor the child's central venous pressure remained low-level normal, as did the blood pressure. While we took report, the heart rate incrementally increased.


This was a long time ago, when nurses could access some medications without scanning a barcode. After report and assessing our patient, I placed a liter of normal saline, a bottle of 5% albumin, and the appropriate tubings on the counter in the patient's room, leaving all of the packaging unopened.


Hours later into our shift, the patient decompensated. We called the surgeon, who ordered 5% albumin IV. We hung the bottle that had been waiting on the counter, and the child stabilized. Impressed, my preceptee asked how I knew to have the albumin on hand. I revealed the "field marks" in the change of shift report and how they correlated with the subtle changes observed in the patient's vital signs.


What appeared prescient to my colleague was actually experience coupled with pattern recognition. The lesson wasn't lost on her, and later she became one of us nurses with a strong gut, too.


In birding, as in nursing, we learn from mistakes. More recently, while birding, I was excited to "get glass on" a bevy of swans. They were far enough away that I couldn't get a clear visual of the facial field marks necessary for definitive identification. In Oregon where I live, tundra swans and trumpeter swans are fairly regular winter visitors.


I asked a fellow birder nearby what kind of swans they were. He told me they were trumpeter.


At home, I excitedly logged my sighting into an electronic bird list that's submitted nationally. When I put in the number of swans I'd counted, the program red-flagged it: "This is an unusually high number." I delved back into my field guides.


That day, I learned that trumpeter swans are most commonly observed in pairs, or small family groups of no more than three or four. However, tundra swans gather in larger groups such as the number I had counted. New to birding, I had lacked this experience and pattern recognition.


Although misidentifying a bird species is less consequential than some patient care errors, nursing and birding each require experience and pattern recognition to achieve expert level. Age doesn't have as much to do with gaining experience as a willingness to put yourself out there and learn as much from mistakes as from successes.


For nurses, learning the field marks of COVID-19 on the fly. This month, as we mark the one-year anniversary of the first COVID-19 cases diagnosed in the United States, I think about this often. Nurses in the ED and ICU have experienced enormous levels of stress during the pandemic. There is not a living nurse who has had such an experience in the past 100 years. Experienced or not, these nurses have been learning the field marks and pattern recognition of COVID-19 on the fly.


I can't imagine what this is like for newly graduated nurses, pushed beyond reason-and possibly without an experienced colleague available to guide them, because those experienced nurses are pushed to the brink themselves. No one could have imagined signing up for this when they entered nursing school.


There are no recent textbooks to teach nurses how to cope with a pandemic. I can only offer these words: Use "what you see and hear in order to make better judgments," and give yourself the grace to learn from your failures as well as your successes. You're doing the best you can, and it's enough.