Yesterday was the first day of a new adventure.
I no longer have a job and I’m OK with that.
I volunteered to be part of a “reduction in force”, business speak for “laid off”. Why? Many reasons, but mostly it was beyond time to leave. Also because I things have become clearer to me with regards to what is important in life. It’s like the axiom goes, no one lays on their death bed saying, “Boy, I wish I worked more.” Work was overwhelming my life, permeating every nook and cranny and luckily I had the clarity to realize that wasn’t what I wanted out of my life and this was the first step in doing something about that.
I woke up yesterday though with an odd feeling of freedom. Nowhere to be I just sat around in my sweats and relaxed. Then the reality set in. I had a momentary burst of panic of when I was going back to work, then realized it was never.
I then had another more sustained burst of overwhelming panic realizing that I no longer had a job.
Then came the calm realization that it was going to be OK.
Things would be OK.
…more to come…
This is post 501.
Yeah, five hundred and one chances to see into the inner workings of a nurses’ mind.
Five hundred and one attempts at humor, pathos, cathartic screaming, ranting, introspection and education.
I’ve been writing a blog of some variety since nursing school, most of those older posts are lost to the Internet ether and frankly, they weren’t any good to begin with so it is no true loss. This blog has been with me though since I started at my current job, nearly five years ago. I’ve gone from wide-eyed new grad praying not to kill anyone to a slightly crispy-crittered, nearly burned out charge nurse.
So much has changed on my floor that I hardly recognize it somedays, just like I hardly recognize myself somedays. I’ve grown and this blog has grown with me. Soon, I will be into another phase of my career, new fresh things to learn, new fresh things to complain about and teach about, and I’ll be taking everyone with me. It is no longer a question of if, but when. Not yet, but I hope soon.
Thank you all for being on this journey with me. As the saying goes, “This is only the beginning.”
To: Unit Manager
From: Wanderer, overworked charge nurse
Subject: Monday’s Meeting
I guess one of the included functions in the Managerion™ 2000 automated management toolset randomly creates meetings and requires our attendance. This would explain relative randomness and recurring frequency of such meetings and their lack of cogent concept or agenda. Having meetings just to have meetings about meetings is pointless and a waste of all of our time.
In the last 4 meetings we have decided absolutely nothing, but keep referring to later meetings to “work out the details”. Would it be so hard to make a decision? Yes, you have multiple units that these decisions will affect, but sometimes you need to throw caution to the wind and make a decision – call it an executive mandate. There is something to that y’know?
This said, I won’t be coming to any more meetings. I’m not going to spend an hour each way commuting in to work for a meeting that lasts 45-60minutes and decides nothing. It is not as easy as some might think. Whether I drive or not it is at least 45 minutes in rush hour traffic and if I use transit it is even longer. Now if we were going to decide something or the meeting was going to last 2 hours, things might be different. Also if I didn’t have to come back to work the night shift at 1900 it might be different as well. But the last 4 meetings have done nothing of the sort.
I realize that it is part of your annual review to see how many meetings you presided over, ran or otherwise were engaged in, and I know management is in agreement that meeting indices are not quite what they should be for this fiscal quarter, but please, enough already.
So unless the next meeting will actually accomplish something, or is held in a local pub during happy hour, I won’t even be phoning it in. I am a nurse, I take care of patients. I am not a paper-pusher, drone, meeting junkie or have any aspirations to management so just let me do what I’m good at – no more meetings.
Wanderer, overworked charge nurse
All so boring. So trite and normal. There has got to be a better, more descriptive way to classify it. Hmmm…
How about beer? Stay with me here.
Cloudy, amber with a slightly frothy head. Could be a nice IPA or a patient with high bilirubin. Am I right? I live in a town that prides itself on its beer. Hell, we call it “Beervana” and has the most breweries per capita. We can call it the Portland Urine Scale, or “the P.U.S.”
It’s not a perfect system, but it makes giving report more fun. “Yeah, I’d say it was like a light IPA, not too amber, hazy and it smelled strong.” Engaging, creative and descriptive, what a great way to share information?
Yes. docs need to learn to say, “No.”
Case in point…a 90-something year old patient, recently had a pacemaker implanted for mild tachy-brady syndrome. They had some occasional mild tachycardia and rare episodes of bradycardia which were non-symptomatic for a big reason: they were never out of bed or chair. Yes, this lovely patient was completely dependent upon others for every aspect of their care, not to mention completely demented. If your idea of quality of life is being 100% dependent on your family and having absolutely no meaningful interaction with them, then this is great.
I can understand doing procedures on folks with whom it will make a positive outcome – like the 80-something year old CABG mentioned in the above link. It makes sense. But to do these kinds of procedures on those with poor quality of life is just cruel. It only delays the inevitable.
In this case, the family convinced the doc to do the procedure. What makes my blood boil more though is that this same family had another member in and out of our facility spending nearly half of the last year of their life in the hospital in multiple lengthy admissions. They would not accept that this family member was dying and insisted on all measures being done. And now that there is a new one heading down this same road, it will probably be the same.
End of life costs are avoidable if we as society realize the death is a natural part of life and accept it. Instead we claw and fight to eke out the last painful years many have, enduring lives of bed sores, PEG tubes, nursing homes and hospital admissions. For what, a couple more years? Years that can’t even be enjoyed because of the multitude of illnesses? It doesn’t make any sense to me.
Scrubs are pajamas. Initially a simple garment to be worn and left in the operating arena, the scrubs are now available in many a color and pattern to be worn by nurses, billing agents, medical assistants, doctors and anyone else in any way associated with physicians.
The fact that most people have no idea the difference between the girl who takes their copays and the nurse that evaluates them, most people assume they are all “nurses.”…
I get it all the time, “Well, you get to go to work in your pajamas. How cool is that?” I’ve worn many different uniforms in my work career from slacks, shirt and tie, to industrial workwear and just plain old jeans and a t-shirt and now I get to wear “pajamas” to work. Sorry, that’s bullshit. I am required to wear a uniform that happened to have been co-opted as pajamas. To me, a uniform signifies that it is time to go to work, I call it “getting on my game face”. Those “pajamas” tell me it is time to work, leave the world behind and focus on my job – my patients.
Now there are those that spoil this for those of us who take it seriously. Since everyone and their uncle who works in health care gets to wear scrubs, there are bound to be the one’s who abuse it. I cringe when I’m out shopping and see people in scrubs, it sets the wrong idea, especially when those wearing them are misbehaving. It is still bad behavior to break HIPAA whether you are wearing scrubs or not, it just makes it more conspicuous when you are in scrubs.
There are two issues here that get intertwined and blurred. First there is professional behavior. It doesn’t matter what you do for a living, you need to maintain a professional mien when representing that job/career/profession. And yes, health care workers are held to a higher standard, get used to it. It’s even more important when you are clearly identified by the public (by your wearing scrubs to the bar/lounge/grocery store/porno shop) to be a professional, because they associate scrubs with nurses/doctors.
Acting like an idiot in scrubs makes a bigger impression than it does in street clothes – people notice. Second is the proliferation of scrubs into so many different fields. Are they the doc/RT/PT/housekeeping/CNA/RN? You can’t always tell. Not to mention those outside of the hospital like vets, dental folks, office staff and the like where this has spread into. Too many people wearing scrubs makes life confusing. And due to this proliferation, clamping down and restricting use will be near impossible. All that is left is some sort of uniform – like our friends in EMS/Fire/Police, or hospital color coding by job function.
As long as the color is not white, I can get behind this. More so, I think that institutions need to require changing at work. You get to work, change out of street clothes into hospital uniforms, then do the reverse when you leave. If we are so worried about the spread of superbugs, why isn’t this a common sense idea? I leave my work shoes at work and change clothes (partly because I usually commute by bike) on arriving and leaving. It goes to the idea of getting my game face on.
The lesson here? Scrubs are every bit a uniform, just like other professions. Unfortunately there are those that wear my uniform that are unprofessional and act like idiots when in public. Painting all of us with the same brush is just as bad.
It is never the BIG things that will drive you mad, it is the little things, those continuous little irritating reminders that get under your skin that make work so damn frustrating. It’s the little idiosyncrasies of some nurses practices that will drive you up a wall. I’ve mentioned the “freak out over nothing” otherwise known as Chicken Little, but almost worse is the “I forgot the basics of nursing school.”
C’mon! The basics, turns, intake/output, taking a temperature with vitals, all in all really easy simple things. But it is like these don’t matter to a couple of my colleagues. And lately it seems like I’ve gotten the shit for it.
Case #1: obtunded patient. On continuous IV fluids and a crap-load of IV meds. Intake charted for entire shift: nothing. Nothing was charted. According to the charting, they were incontinent 42 times. OK, they’re basically hospice, but we have nothing official, shouldn’t we be doing the typical charting as if they were a regular patient? Thanks for that, when the docs ask me if they had any intake at all during the day I look like the idiot. Luckily I can point to my charting. What gets me with this, is that it is the easiest thing to do on an obtunded patient. If you can’t track accurate I&Os with them, how are you going to capture that on a mobile CHF patients – where it is really important?!
Case #2: Afib patient, on an amiodarone drip. Something doesn’t jive in the orders and when asked, they say, “I don’t know, I’ve never hung amio, just followed what pharmacy wrote on the bag.” First, I have to explain typical protocol is 1mg/min for 6 hours then a decreases to 0.5mg/min for 18 hours, standard loading protocol. It’s not like I’m pulling it out of my ass, it’s from the book. So what that the 1mg/min has be running for like 9 hours? Second, why didn’t you look it up? You admitted to me that you had never hung an amiodarone drip, we have a resource book that details floor protocol for initiation and maintenance, it’s all there, black and white. Again, I get to call the docs, explain the situation and get new orders. Truly it’s not a big deal, but it is the principle of it all.
If you can’t effectively manage simple situations, situations where you have available resources and ability to follow-up, how will you function when the shit hits the fan? I now know most of the meds I give on a regular basis, but I get ones where I have no idea. So what do I do? Look ‘em up. It’s not like our patients are crashing and need them now, we have time to be thorough. I&Os? Yeah, on our basic patients I don’t always record. But if they are getting fluids/meds/drips you’re damn sure that’s getting recorded. I’m not perfect, never claimed to be. I make bone-headed mistakes and overlook stuff. Those are the exceptions though, not the normal. I bitch about it because for some it is normal. That’s the scary part. When it happens I try to talk to them, but too often it gets left by the wayside, pushed aside and taken care of.
To me the leaving of the little things (these are just two recent examples – from multiple nurses), tells me that you’re either A.) not paying attention, or B.) don’t get it. The little things are what differentiates the good nurses from the mediocre. The little things are the keys to catching our patients before they crump. The little things are what sets nurses apart and why techs can’t do our jobs. And it’s the little things that piss you off the most.
Not all that long ago I was a fresh-faced new grad, eager to explore the great wide world of nursing. School was done, externship was over and I had passed the dreaded NCLEX on the first try. I was ready.
My first year was brutal. Trial by fire, eating of the young, stress migraines and an overwhelming urge to run screaming as fast as possible away from my job and go work at McDonalds, that encompassed the first 6-8 months. Then as if by magic, I realized I wasn’t struggling, I wasn’t hating work, I didn’t get sick on the way to work and people were asking ME for answers instead of the other way around. I couldn’t tell you when it happened, just that it did. Having been through it I know that it made me a better nurse. That hell I went through toughened me up, made me become organized as a survival technique, taught me how to juggle the needs of my patients with the duties I needed to perform whilst maintaining a sembalnce of sanity. And it worked. It was kind of like boot camp: break you down to build you up.
Since then I’ve precepted new grads, been a mentor of sorts to them and tried to make their first year a little less harrowing, but still instilling the fire they need to survive. I don’t practice eating of the young, it’s counter-productive and will drive promising new nurses right out of nursing, or at least off of your unit leaving you back where you started: short handed. But I do believe a little bit of “tough love” is needed. Our job is not easy and the sooner you accept that it isn’t all candy and rainbows the sooner we can build you into a competent nurse. Not saying that you’re crying on the way home everyday, but not shielding from the rough days either.
Our system just bought into the Versant Residency Solution, which is a systematic residency program intended to rapidly prepare new nurses. “After only 18 weeks, trained observers report that Versant RN Residency graduates achieve Nursing Skills Competency ratings that are slightly above new graduate comparison groups who have been in professional practice for nearly a year and a half (17.1 months).” Sounds awesome. Wish we had something like that when I was starting out. That would have made my first year a little bit better. Or is it just delaying the inevitable?
Our RN Resident is with us for 18 weeks. 18 weeks of being precepted before they are on their own. 2 days a week in classes, 2 days a week on the floor. It’s a tough schedule, worse for those that drew a night shift slot. But in our over-saturated market many new grads were willing to sign over their first and second born to get a nursing job. For 50 something slots, over 500 newly graduated nurses applied. It’s that desperate here. Truly these are the cream of the crop. But for 18 weeks they are coddled into nursing on the floor. I had 12 shifts with a preceptor, and was told straight out that by shift 9 or so I would be taking a full load with the preceptor merely supplying help when needed. Our poor resident is struggling still to take 2-3 patients a night and they are already past day 12 and those running the program have told the preceptors that the residents aren’t expected to take a full load until the final weeks of the residency, if even then. For 18 weeks we expect less, are allowed to expect less and not to push as hard as we might have before. We’re coddling.
Do I expect new nurses to go through the same shit I did? It sounds like it. But I truly believe that there comes a point where you can no longer hold their hands, no longer allow them to sit idly by, skimming along with help from their preceptor: it’s time to fly! The 18 weeks is doing a dis-service as it is not making them fly on their own. What made me a competent and efficient nurse? Stress. Pain. Being kicked out of the nest and having no choice but to fly. Did it suck? Yeah, but I know that I’m stronger for it. This coddling aspect is so ingrained in our culture, from the “everyone wins” school of thought in sports, to getting a 4.3 GPA on a 4.0 scale, to overprotective parents, that we can’t just let people go and see how they function on their own.
Since I started on my floor, it has changed drastically. The old battle axe nurses have moved on, now you’re more likely to get help when you ask rather than a dirty look or eye roll and generally it’s a better place. Being let fly here is far less daunting than it was when I started, there is support whereas previously you really were on your own. But, due to the rules of the program we can’t let our residents fly on their own.
I know that people will ask, “So, are you doing anything to help the resident?” Yes, the preceptors (there are three of them) and a couple of the charge nurses have talked about ways to help them. We don’t want them to fail, but we don’t want the end of the 18 weeks to be a huge issue either, where all of a sudden you’re flying free and haven’t developed the skills to keep aloft. Who knows, maybe this idea is great and it will produce incredible results – that’s at least what the program developers say. But I have one lingering question: how can you be as good as a 18 month nurse at 18 weeks when you’re only spent 12 of those weeks actually caring for patients? Book learning is great, but it means nothing until you get to use it. It is the actual act of caring for the patients that brings the book knowledge into focus as Ricky Gervais said, “Without application, knowledge is pointless.” We’ll see how it end in about 3 months.
The other night I was getting report from the say nurse on a post-pacemaker placement patient (try saying that 5 times fast!) who was all in a tizzy. Scattered and doing things that really didn’t make a whole lot of sense. It had been a busy day, but it seemed like she was making more work for herself than she needed. Almost like running in circles. Not productive at all.
When the excreted fecal matter hits the proverbial air oscillator, I make sure I take a moment to assess the situation. Following the and then begin to gather the situational information. It seems that the ability to do this was lost upon my colleague and she went from zero to “Holy Shit!” in about 30 milliseconds. Over what? A simple 5 beat run of V-Tach. , I check my pulse
Yes, V-Tach is bad. We all know V-Tach is bad. 5 beats though? Self-limiting in a patient who just come back from getting a pacemaker? With a slightly low potassium? Not all that surprising. But no, flew off the handle she did. Called for labs, called the doc and worked herself into the fore-mentioned tizzy, Through this the patient is fine. Happily chatting with his wife about this or that. He’s on the monitor, already has a K-rider infusing and is about as content as one can be in the hospital. Why the drama?
Because all to often people don’t think before they act. Had the nurse been thinking things through and not reacting several things should have gone through her mind. First, the ventricular ectopy in the form of multiple PVCs and a single run of VT was caused by two different things, the hypokalemia – the patient was 3.6 on the AM labs and the fact that the cardiologist has just been poking and prodding and electrified piece of wire inside this dude’s right ventricle. Or in other words they had been pissing it off. Second, she already was correcting the hypokalemia with the running rider and if she really wanted a magnesium level, a quick add to blood still in lab would have sufficed. Third, she needed to look at the patient. Vitals OK? Feeling OK? No chest pain or discomfort? Yes, yes and no were the answers. Simple isn’t it?
I think why this got under my skin so badly was that the nurses isn’t exactly new. She’s been a nurse far longer than I and has been in cardiology for nearly the entire time: she should know better. But it seems that my day shift has been functioning in the fight or flight mode for so long that any little issue, real or imagined, gets turned into a full-scale shit storm. It’s like when the LOLs with delirium are extra hyper-alert that the slightest thing sets them off. So it is with the day shift. They forget to think. Unfortunately many nurses are in the same boat, we’re running scared and rile ourselves up faster to make sure Bad Things© don’t happen. So stop, think, then act.
As for the pacer dude, well, things worked out just fine. All that drama for nothing.
hmmm…drama for nothing and chest pain free… h/t Dire Straits