By this letter, the 4EF Magnet Committee would like to respectfully nominate the entire staff 4EF for the DAISY Team Award. Over the past year, the staff on 4EF has gone above and beyond to provide holistic, patient-centered, and compassionate care to a very special patient (from here on referred to as "Daisy") whose one year admission date anniversary is fast approaching. This has been done by working collaboratively with the interdisciplinary team overseeing her care as well as partnering as a unit to provide Daisy with the best possible experience in an unfortunate situation.

Daisy is an undocumented, uninsured, Spanish-speaking immigrant admitted to ASLMC last December after having suffered worsening weakness, fatigue, and debilitation for a year prior to admission. Daisy was initially admitted to the ICU where she underwent a tracheotomy and was placed on a ventilator due to respiratory distress. Shortly after, Daisy no longer needed critical care so she was transferred to 4EF which is a ventilator equipped unit. Challenges to the nursing staff in caring for Daisy presented themselves immediately upon her admission to the floor.

Not only was Daisy non-verbal due to the ventilator, but she is also Spanish-speaking only. Although we are grateful to have in-house Spanish interpreters, non-English speaking patients always present a unique challenge to staff as immediate dialog is not always possible. 4EF is fortunate to count some bilingual nurses among its staff who are always willing to lend their skills whenever possible to ensure Daisy's needs are met in a timely fashion. Many of our staff have learned basic Spanish terms through Daisy (i.e. bathroom, pain, breathing, anxiety, nausea, etc.) to better communicate with Daisy when interpreters, Spanish-speaking staff, and/or family are unavailable. Additionally, Daisy and the staff on 4EF have inadvertently developed their own "sign language". Whether she wants to fix the pillow under her feet, her trach collar is loosened, or she wants her sleeping medication at a specific time, interpreters have been astonished at times that we can interpret what she wants before they can!

Weeks turned into months, and unfortunately Daisy's diagnosis continued to elude physicians. Unit nurses worked together diligently to review and evaluate assessment findings, and report the same to the interdisciplinary team. By continuously advocating for Daisy in Outcome Facilitation Team meetings, bouncing ideas off of each other, and collaborating with the entire healthcare team, Daisy was ultimately diagnosed with ALS. Although this diagnosis was devastating to Daisy, her family, and the unit staff, we take pride in having been an integral part of the team responsible for coming up with the best plan of care possible.

Coordination with every department has been key in providing Daisy with the most patient-centered care. Physical and Occupational Therapy have played essential roles in Daisy's well-being. In order to get Daisy some "fresh air", unit staff worked with therapy to help get Daisy and all of her equipment to the healing garden several times before isolation precautions restricted this. Staff also worked with therapy to take Daisy to the Inpatient Rehab unit once a week where they have a large handicap-accessible shower stall where Daisy can feel refreshed in a "real" shower instead of a sponge bath. When this no longer became possible due to isolation precautions, our staff asked maintenance to install a handheld shower head in her bathroom so we were able to safely shower her with her tracheostomy. Showering Daisy is no small task, as it takes the coordination of numerous staff members to assist her as well as a nurse to manage her airway and breathing. Several times staff members have stayed past their shift to help make this possible for Daisy.

Throughout her stay, Daisy's family has been present at the bedside in one way or another for almost a year. It may sound cliche, but Daisy and her family have become like family to all of us. We learned through nurse-attended Palliative Care meetings that family is extremely important to Daisy and she worries about them. For example, she worried about the care of her minor son. She worried she was becoming a burden to family and staff. She worried she would not be able to see all of her children before dying. Daisy's concerns soon became our concerns as well. After all, nurses realize it is not possible to meet a patient's needs without addressing psychosocial needs, in this case family.

The staff on 4EF also worked with the Palliative Care team to facilitate a letter written to U.S. immigration allowing Daisy's daughter who lives in Mexico to travel to the U.S. to see Daisy. A petition was written to the U.S. embassy in Mexico in order to facilitate a visitor visa for Daisy's daughter. One staff nurse in particular worked closely with the Palliative Care team to ensure all of the petition requirements were met. The petitions were successful and Daisy's daughter was able to come and spend several weeks with Daisy, whom she hadn't seen in several years.

The staff on 4EF has also taken Daisy's youngest son under their wing as he spends many days and nights at the hospital. He is a senior in high school and is now applying for college. Staff has fielded questions from him regarding financial aid and various scholarship opportunities. We have provided him with various resources, and often check in on his progress. The numerous male nurses on our floor have also provided a great role model for him and spiked his interest in becoming a nurse, while yet another staff member encouraged him and provided him information on the Nursing Assistant course.

In our attempt to make Daisy feel as "at home" as possible, we have coordinated with other departments in the hospital to help Daisy and her family. Once we learned about Daisy's love for dogs and her desire to see pictures of the staff's pets, we coordinated with Pet Therapy who has come several times to brighten her day. When Daisy appeared to be getting sad and bored sitting in her room, we coordinated with Art Therapy who came and crocheted with her and provided her with hours and hours of entertainment through crocheting. Chaplaincy has also played a big role in Daisy's spiritual health. Staff members spoke with the pastoral care to provide regular visits by a Spanish-speaking chaplain. Several times the chaplain has come with his guitar to sing and play for Daisy which brings so much joy to her and her family.

Our staff has also gone out of their way to help Daisy "off the clock". One nurse brought in a hairdresser to give Daisy a haircut when she was complaining about her hair getting too long. Another staff member provided Daisy with a pedal exercise machine to help her stay active. Yet another staff member has brought in special lotions and body soaps throughout the year, while another brought a manicure set and nail polish. The staff has never ceased to go above and beyond to treat Daisy as a member of our 4EF family, including a small birthday party that was held for Daisy in her room with many family members at her bedside and special birthday cupcakes provided by a staff member. It is also important for Daisy to maintain her sense of autonomy; one nurse has even taken it upon herself to launder Daisy's personal clothing weekly.

It is not only the nurses who play a vital role in caring for Daisy. As Daisy's health continues to deteriorate and it becomes more difficult for Daisy to participate in her cares, toileting and repositioning Daisy has become more challenging. Our hard working nursing assistants rotate care of and always help each other in Daisy's daily needs. Even our Health Unit Coordinators are important in facilitating patient care for Daisy. One HUC has even stated that she is sensitive to Daisy's needs throughout the day based on her use of the call light- how frequently she calls and at what time of day.

Caring for Daisy has been a challenge. Staff has struggled at times to provide the best care possible. We are proud that we have been able to adapt through teamwork and brainstorming. Given Daisy's extensive medical needs coupled with her undocumented immigrant status, long term placement has become an issue. We find ourselves learning how to and exceeding at providing long-term care given our staffing limitations in an acute care setting.

We end this letter by honestly and candidly stating that this letter has been very difficult to write. As we are sure you can relate, nurses are not always good at taking credit for all they do. In fact, we have yet to meet a nurse who has said he/she pursued a career in nursing for the glory, for the pat on the back, or to hear "job well done" at the end of the day. On the contrary, we are nurses because at the end of the day we care about people, their families, and their health. Just like having recently worked together as a team to help aid Aurora St. Luke's in achieving its fourth Magnet recognition by taking credit for everything we do as nurses- the DAISY Team Award nomination has provided the 4EF Magnet Committee an opportunity to step back and reflect on the nursing care and hard work put forth as a team on 4EF.