This week I attended our first custom building session for
our hospitals EMR system. As an independent community hospital, we had pushed
off the hospital-wide EMR mandate until we were financially ready to commit to
a dependable product. With our state deadline approaching, we selected a system
a few months ago. From now until the fall, we will be custom building our
templates and training staff in a fast-paced system rollout that kicked off
One challenge we have already identified is the shared
usability between each area of our hospital. Since telemetry, med/surg, critical
care, OB/NICU, and pediatrics all have significantly different issues of focus,
there are limited choices to streamline standardization on certain areas of the
I can see that although an EMR system will limit the space
taken by paper charting, initially, the system may take much more time than
expected. As with all new additions to a work environment, the EMR we have
selected will be sure to have some issues when presented at our hospital and
with our staff. By no fault of the software, every hospital and patient
population requires specific needs and this has already identified some issues
on our first day of building.
There have been other changes on our unit as well, more
specifically with our patient population. Over the past few months we have had
some memorable patients. Some have stayed longer than others, and a few much
longer. When I went into the unit on my last shift I noticed that every patient
was a “newer” patient. It’s interesting how the census in the ICU sometimes
goes in cycles. At times people almost seem to have a claim on their room,
staying for weeks and even months. The best thing for the healthcare system is
to get them out and on with their lives, but not every case in critical care
can be so simple.
I'm almost three months into fatherhood, and it's been an awesome experience thus far. I'm not going to be one of these people who say their life didn't start until they had kids - I enjoyed my first 28 years very much - but I will say that my little Cassandra adds a great deal of joy and excitement to life.
It's amazing how being a parent has affected the nursing side of my life and vice versa. Of all the classes I took in nursing school, I did the worst in pediatrics. I'm not exactly sure why - maybe it had to do with how specialized all the basics are. My other classes built on one another, but pediatrics contained so much unique information that it was sometimes hard to keep everything straight.
Just a few months with my own baby, and all of that has changed. Now that I'm living through these developmental milestones and immunizations, it's just a lot easier to remember them.
That's the positive part. The negative part is in being too informed on certain things. There's the saying that "knowledge is power" but then there's also "ignorance is bliss" and "a little learning is a dangerous thing." All of that can be applied to my parenting experience.
So far, I've been pretty easy going with most baby-related stuff. My nursing education has allowed me the comfort of not freaking out about every little thing, but it also has planted the seeds for worrisome issues I would've never even considered if I wasn't in the field.
For example, one day a few weeks back, Cassie was experiencing persistent hunger and progressive projectile vomiting. She had been refluxing some food after feedings, as is normal for most babies, but this day involved multiple instances of milk shooting across the room. Initially, I wasn't too worried about it, but then, after the second or third episode, my wife asked me what it could be. There were no palpable masses or peristaltic waves, but I suggested there was always the chance Cassie was developing pyloric stenosis and that we should probably monitor intake and output.
Wrong move. It freaked my wife out, and that made me more nervous as well. I felt like nothing was wrong with my daughter, but the knowledge of what could go wrong added a level of anxiety to the situation that was ultimately entirely unnecessary. The next day she was back to normal, and we've had few problems since.
Right now, I'm new to both parenting and nursing, and that can have both its positives and its negatives. I expect as time goes on, these issues will happen less and less as I become more confident in my knowledge and more trustful of my instincts on both fronts.
As a nurse, I’ve grown accustomed to asking the difficult questions. It wasn’t always easy. When I first began my career, I thought my well-honed social skills would be enough for me to connect with patients. I thought my charming smile and eloquent style would be the perfect combination to induce patient compliance and reverence. It didn’t take me long to realize that those beliefs were a fallacy and that I had (and have) much more work to do in the communication department.
In my early years, I struggled with delving out of my conversational comfort zone. I stammered when topics like abuse, illicit drug use, and sexuality arose. I would catch myself starring at the floor, hands shaking, afraid of exposing my ignorance. I knew that these reactions weren’t just and when I returned home after a shift I’d feel ashamed. Why did it hurt so badly?
It’s taken years for me to realize that this is, in fact, because the language of nursing is an integral part of the profession. Healing is impossible with a closed heart and narrow mind. I have found many, many times that illness has less to do with an isolated, acute incidence and more to do with a chronic build-up of some emotional or habitual burden. The inability to ask the difficult questions will never yield the root of the problem. In fact, it may only burrow it more deeply.
I have learned to be poised and confident when I ask a patient absolutely anything that may help us find a way to wellness. It’s a work in progress. The language of nursing may be a lifelong course. All I know is that if we don’t hold the ability to look past our own judgements and biases and dig deep, patients will suffer. We may be the only opportunity these people have to divulge the truth behind their ailments. If we can’t ask the difficult questions than who will?
After seeing patients with open heart surgery,
hemo/peritoneal dialysis, and multiple amputations during my last year of work,
it can be somewhat frustrating to work in a cardiovascular ICU. It is very sad
to think that the personal responsibility these patients needed to promote
their own health unraveled somewhere along the line. The notion that so much
irreversible damage can be done to one’s body over a lifetime is a scary
thought. It has made me consider the long-term effect of everything I put into
my body and my regiment of physical exercise.
Although education in nursing is key, it seems very
difficult to provide education to a patient who has end stage renal disease and
bilateral amputations. No matter how much education you give patients like these,
there is not a whole lot of information these patients can use to improve their
situation. I think that has been a tough idea to wrap my head around, the fact
that no matter how hard you try you can’t “save” someone. Even when they are
young and healthy, all a nurse can do is provide information to them in the
best way possible and then it is up to the individual to make the choices
throughout their lives.
One issue that I have been beginning to see as a potential
problem for the future is proper body mechanics. As an ICU nurse we all do so
much lifting and bedside procedures. Many times I personally forget to make the
bed at a comfortable working position because I am so rushed with time. After
only a year, I can feel the tension and pressure in my back from awkwardly hunching
over the bedside for dressing changes and other bedside tasks. I have become
more conscious of this problem recently and I am trying to take a few more
moments to set up a comfortable working environment. I don’t want to have any
issues later in life, so I need to start trying to promote my own health so I
can mitigate any complications before they start.
After years of schooling and weeks of intense study, I finally sat for my boards, and I’m happy to report I passed. I was scheduled to take the test over a month ago, but snowy conditions caused a cancelation that pushed everything back a few weeks. I suppose good things are worth waiting for.
For those unaware, the NCLEX is a computer adaptive test that uses anywhere between 75 and 260 questions to assess the test-taker’s nursing competency. I wound up needing 93 questions to pass, and it was a pretty grueling experience, but I give the people over at Kaplan credit – their program was a great preparatory tool.
So with that monkey off my back, I’m now fully in the thick of job hunting. Thus far, prospects haven’t been great – there are plenty of nursing jobs in the Philadelphia area, but not many opportunities for new graduates. Every job seems to require at least a year of prior RN experience.
Still, I’m plugging away with the applications. I think it helps that I’m not overly picky. I’m intrigued by any job opportunity, provided it offers the ability to care for patients and the chance to continue cultivating my nursing skills.
It’s interesting how one cause of anxiety (getting my nursing license) just got replaced by another (getting a nursing job). I guess that’s just the cost of living your life. There’s a saying about the building of Rome that seems appropriate, but I already used “good things are worth waiting for,” and I don’t want to double down on the cliché phrases in one blog entry.
As a result, I’ll close by affirming I know I’ll find something eventually. Until then, I’ll just keep at it while I continue enjoying the great feelings that come with newfound fatherhood and licensing.
Although the daylight has started to lengthen, you may still be suffering from The Winter Blues. Essentially, The Blues is an offset of seasonal affective disorder (or SAD, what an appropriate acronym!). If the lack of sunlight and frigid weather seem to impact you more than normal, you may be part of the 15% of the population who suffer from SAD. Do you lose interest in your normal activities? Feel hopeless or anxious? Are you having trouble concentrating? Have you withdrawal from family and friends? Are you fatigued (despite sleeping) and irritable? If you answered yes to most of these questions and have experienced these symptoms for two consecutive winter seasons, you may want to consider the following remedies:
1. Sunlight. Although the weather is cold, try to spend 10-15 minutes outside on sunny days. Pull up a chair next to that sliver of light coming through your kitchen window.
2. Light Therapy. Available at many medical supply stores, these boxes emit bright light that mimics the outdoors. It appears to affect brain chemicals and induce happier states in just a few days. Speak with your doctor before use.
3. Get moving. It’s probably the hardest time of the year to get exercise, but if you can muster up the energy to do it, you’ll release endorphins and adrenaline that will produce a sense of well-being. Sometimes starting is the hardest part. Invite a friend to join.
4. Mind-Body Therapies. Can’t imagine ever meditating? If you suffer from SAD, this may be the perfect time to try. Sign up for a class. Any deep-breathing or relaxing exercise such as meditation, yoga, massage can help re-energize the body. It may even help foster an environment where optimism can grow.
5. Smile! It’s okay if you have to fake it. The elevation of your cheeks has been shown to lower stress hormones, regardless of whether or not the movement is genuine.
If you suffer from SAD, the best thing you can do for yourself and your patients is to be prepared. Once fall rolls around, start implementing your strategies to combat The Blues. And even in your darkest moments remember: There’s always light at the end of the tunnel.
This next week marks my one year anniversary of my employment at Dameron Hospital in Stockton. It's really unbelievable that it has been a year already. The increments of time where somewhat segmented during the last twelve months, so I am not sure if it seems time has moved fast or slow. I started out as a part-time employee with a preceptor for several weeks, then went to nights, and then on my own. More recently I have been working full-time and am accustomed to the night RN life. I have good thoughts about the next year of my practice. I have learned so much over a short amount of time and I can tell that my knowledge has the potential to grow exponentially in the next year or two. This week will also mark the end of my critical care certification course that had been held weekly over the past eight weeks. I have had opportunities to apply the information directly in practice, which has proved to be a successful utilization of the concepts we learned.
Another interesting task on my horizon will be helping to implement the electronic medical record (EMR) system my hospital chose a few months ago. I will be among a group of people from my department who will be "super users". As our titles imply, we will have additional training to advise staff and answer questions during our shifts. I am excited to be at the forefront of this project and I'm sure I will be able to assist others while at the same time learn the system for my own clinical use.
Time has been somewhat hard to come by since the critical care course has given me one extra day during the week that I have a work related activity. As this duty ends, so will begin another. I am a little worried about my time commitments since the summer is arriving and I want to take full advantage of the wonderful outdoors. I have not used any vacation time yet, but I may just have to do so. Our census is still very high, but all of the more experienced staff say that summer slows down considerably. I hope this is true.
Lastly, I have experienced something rather odd. I have been taking care of some people that I know as my patients. Growing up in this town, most of these people remember me as a child or as a much younger adolescent. Now I am caring for them or their family member in a critical care setting. I'm almost sure the experience is just as strange in either role, not just from my perspective. One thing that is completely accurate is that this profession makes you grow up fast. There is no room for being immature or unprofessional, and neither of which I plan on being.
I just listened to a fascinating talk at Edge.org regarding social intuitions. The ultimate conclusion: our social reactions, especially in difficult situations, are not well constructed. As I always do, I tried to connect this idea with nursing and was surprised to find that, in fact, it seems to be extremely relevant. As we all know, healthcare is experiencing tumultuous times. People are frustrated. Unfortunately, there are many times when this frustration is transferred to nurses. In situations like these, it's important to remember the fault in our social intuitions.
When a patient appears mean or angry, I am apt to internalize and personalize harsh words. This, in fact, is an egregious error. My reaction presumes that the patient was intentionally trying to be hurtful towards me. This intentionality is natural, but not productive. This anger is really directed not towards any one person, but instead at our fragmented healthcare system. I have been working on suppressing that innate intentionality reaction.
Empathy is a great tool in situations like this: It is crucial that nurses learn to look past the words of an angry patient to the deeper sentiment beneath. This is much easier said than done. We all have different ways, different levels of expressing ourselves. It is the art of nursing to learn how to decipher the infinite number of communication codes that patients use. Learn to avoid internalizing. Use that saved energy to dig deeper into patient concerns, grow into a better listener and blossom as a nurse.
Visit http://www.edge.org and view David Pizzaro's talk on social intuitions for more information.
I’ve spent the last month in what I can only describe as a
dreamlike state. My daughter was born January 19, and in between the euphoria
and fatherly duties, I’ve basically been a nonstop study machine. Baby, notes,
baby, review questions, baby, more review questions – that’s been my life for
the last four weeks. Well, that and shoveling snow.
As far as the NCLEX was concerned, I had expected the end
game would already have come and gone. I was scheduled to take the test last
Thursday and was feeling more and more confident in the days leading up to the
test. And then we got hit with a Nor’easter.
When I woke up Thursday there was no indication from the
testing site that the test would be canceled. I had called looking for information
on Wednesday and was told I’d get an email if the test were canceled. I didn’t
have one in my inbox and there was nothing on the Web site. So I woke up early,
shoveled myself out and ventured out into the elements. It was only well after
I got to the center, 10 minutes before my report time that I got an email
saying the test was canceled.
I got that email while in the lobby of the building with
several other nurse graduates. It’s fair to say we were all pretty upset, and
also a bit angry. Why had this email come so late? Clearly, Pearson VUE (the
organization that administers the test) had made the decision well before that
– no employees were on site, so they must have been told to stay home.
But that’s the way the cookie crumbles, so now I have to
wait to take my NCLEX. None of the sites in the Philadelphia area have test
openings until March, which really stinks, because that means this whole
process of changing careers has been pushed back a few weeks. Instead of
applying for jobs and celebrating my licensure, I’ll be spending more time
taking practice tests and burying my nose in my notes.
It’s a bummer that things haven’t played out the way I
wanted, but good things are worth the wait. Hopefully, I’ll be celebrating
before I know it.
During the last two week I have felt like a student again. My hospital has offered a critical care certification course lasting several weeks to some of the newer employees. The class has connected a great deal of specific information with that of which we encounter during our shifts on the unit. Revisiting the information with a year of nursing experience has an immeasurable amount of value. It allows you to question and reflected on situations you recently encountered, as well as compare possible options to consider in the future. This class is just a beginning to the busy 2014 the my institution has planned. We will be encouraged to participate in a few simulation experiences using the SIM manikins and we will be undergoing a complete switch to electronic medical record documentation.
Lately I have been feeling the accumulation of the burden of more experience and more responsibility. Long nights, lack of staff, and flu season have made our hospital packed to capacity since November. With the increase in census, our nursing staff has had an increased responsibility to make things manage. Personally I can feel the stress and fatigue building up. When I first started, I was hired as part-time 3 days on one week and two days on the next. Even at that I was frequently getting low census calls and enjoying all my time off. It seemed almost too easy. Now since I accepted full-time our hospital has been extremely busy and not one of my low census requests have been honored. I'm getting used to seeing the "rejected" tab build up on my staffing request portal. It will be nice once we start to get closer to summer time. Typically we get slow in the summer and busy in the fall-winter time periods, so there may be some vacation time to take advantage of if predictions remain correct. I hope that time comes sooner rather than later since my stress is starting to affect the restful sleep that I would almost certainly get.
As for my decision in October to become full-time, I am happy I decided to take on the role of a full-time RN. The experience has made me more used to the hospital grind day in and day out. Everyday is a surprise, but it keeps you prepared and makes you ready for anything.
I've been getting all my "important 2013 tax information" documents the past few weeks. I had to laugh, as I filed them away, remembering my first year as a nurse and how I treated those documents as if they didn't matter, as if someone else was going to keep track of these things. I had absolutely no idea how to handle my finances and I felt like I was already too overwhelmed trying to handle being new to nursing to care.
I won’t make this a big deal because, really, it’s not. This may be one of those things you just storm through, look at the collateral damage, and learn for next time. Just a few friendly tips that I wish a colleague would have shared with me sooner than later:
- Please do keep track of all your financial statements from your work institution.
- Please be aware of what the terms and conditions on each statement mean. It was very helpful for me to meet with the paycheck coordinator and learn the different segments of a paycheck.
- Please do use the facility where you work to learn more about how you can submit your taxes this year. I didn’t realize my hospital had an account on staff just for employees (free of charge!) until two years after being there!
Please do not use an expensive tax-filing “expert”-- just download Turbo-Tax, sit down and give yourself a solid hour to complete your taxes.
- Please do start contributing something to your retirement savings. Schedule a meeting with the retirement advisor at human resources earlier than you think is necessary.
Unfortunately, most of us are coming into our first job with an amateur sense of how the financial system works. It is your employer’s responsibility to provide you with any education you may need. It is your imperative to utilize your resources and learn these oh, so necessary life skills. Your thirty-year-old self will thank you for it!
Checking in again for the first time in 2014. Every time I write this blog I reflect back on the first time it began. I was a first semester student in nursing school, afraid of touching a patient. And now, almost three years later I am working in an ICU, coming up on my one year anniversary with my hospital. So many things have happened during that time, both work and life related. Now at work they are discussing orienting me on fresh post-op open heart surgeries (CABG). Although I feel honored to take on such a responsibility, and knowing that they trust me, the thought of my limited experience has kept me from jumping at the opportunity. At my hospital you need a total of six orienting days before you can take them as a 1:1 on your own. If it was up to my unit I would probably already have one or two.
Taking care of these patients is another level of responsibility. Personally, I would like some additional time in my own practice to make the general nursing nuances sink in more. However, I am no stranger to the procedures required for these patients, and have done them before on second and third day post-op open heart patients. Management of mediastinal chest tubes, hemodynamic measurement via Swan catheters, wound care on chest dressing and donor leg sites, and the other generalities are in working order in my brain.
I was talking with my charge nurse the other day and our conversation really put me into perspective. She was asking why I hadn't recovered any hearts yet. I told her my concerns and she stated that fact that she has asked me for advice in the past and that with my experience I am no longer “new”.
Another interesting thing I have seen recently is the intra-aortic balloon pump. This is another type of patient that requires six orienting experiences and a 1:1 status. The technology is pretty amazing. A balloon more or less helps perfuse the coronary arteries and improve cardiac output. The balloon is inflated and deflated using helium since its safer than any other gas at preventing an embolism.
It really was true when people told me about all the opportunities nursing offered. We’ll see what I take on in the not-so-distant future.
There was an article in my inbox this week regarding “The Noncompliance Epidemic.” It was no surprise to me to read that the vast majority of patients do not take their medications as prescribed (>75% is one survey of 1000 patients). Although over 3.8 billion drugs were dispensed last year, most of them were taken improperly, if at all. Even after a multitude of studies, surveys and meta-analysis’, there is still no conclusive remedy for the issue of non-adherence of medical regiments.
The answer to the problem is an individualized one. It’s been proven that more information doesn’t work. In fact, it seems to lessen adherence even further. If people aren’t feeling symptoms (i.e. diabetes, hypertension, high lipids), they’re less likely to stick with a medication regime. If patients are depressed, forgetful, in denial, or lack social or financial support, you might as well put that prescription pad down.
I believe this is a wonderful opportunity for nurses to step-up to the plate. If physicians do not have time to explain the function of the medications they prescribe, they certainly are not able to delve into the patient’s head to understand why medication adherence is so difficult. Each patient holds their own barriers to healing. This is what the nurse must discover.
Imagine this scenario: The patient enters the exam room to be assessed by the doctor. After the doctor’s diagnosis/treatment plan is decided, the doctor leaves and the nurse arrives. The nurse sits with the patient, actively listens and meets the patient where they are. The nurse evaluates: What is the patient’s understanding of this medication? How can I explain it in a way the patient will understand? What are the barriers for adherence? What resources can I provide to make things easier? Do we need to readjust treatment goals to better our chances for healing?
The physician and nurse reconvene. All third-party support systems are notified. The patient’s pharmacist is flagged to provide another round of education at pick-up time. The nurse checks-in the next day and provides support for the continuation of the treatment.
New nurses: start now!
Reference: Chesanow, Neil. Why Are So Many Patients Noncompliant? Medscape. January 16th, 2014.
http://www.medscape.com/viewarticle/818850_2 Acessed January 22, 2014.
As I continue my march toward NCLEX, I've begun to delve into the preparatory work provided in the Kaplan course I'm taking. It's mostly the type of stuff you'd expect - key content focused on the areas the NCLEX covers and tons of practice questions - but there is one thing about Kaplan I thought was worth sharing here in this space.
Kaplan pushes The Decision Tree as the key to passing the NCLEX exam. The Decision Tree is a five-step critical thinking framework meant to guide test-takers through NCLEX questions. As outlined on the Kaplan Web site, it suggests doing the following five things in order when answering any question:
- Uncover the topic
- Determine if the questions asks for assessment or implementation
- Go with the lowest Maslow level that makes sense
- Apply ABCs
- Determine the outcome of the answers
A great deal of Kaplan's content and questions are filtered through this structure, and so far, I've found it to be a good tool. It has required me to sort of rewire the way I approach questions, but I can see the benefit, so I wanted to call everyone's attention to it.
I imagine other prep programs have similar critical thinking approaches, and my suggestion for anyone looking for suggestions is to find one and go with it.
I must be honest: I’m not too fond of New Year’s resolutions. They’re too heavy to carry for 365 days. There is too much pressure to resolve the many things that we all could do better. Instead, I like to think of the New Year as a time to go inward, to reflect and re-charge. I like to take this time to remind myself that I prefer to wake up with this mantra: What can I do today to be healthier, happier, kinder person? I don’t always keep to it, but no matter how much pizza I eat or how many times my patience is tested, I relentlessly come back to this daily question. You can do absolutely anything for just twenty-four short hours. You could be the nicest person on earth for twenty-four hours. You could eat absolutely nothing but nutritional foods for twenty-four hours. Today, you could allow someone else to take the prime parking spot you’ve been eyeing. You get the picture.
Below is a list of daily mantras for the new nurse:
What can I do today..
· To listen more actively with my patients?
· To take better care of myself in order to help others?
· To educate people on the importance of their health?
· To be an example of the healthy, happy person I wish my patient to be?
· To be the best employee and colleague I can be?
Another exercise I find helpful is to set daily intentions. Yesterday, my focus was gratitude. I was delayed in heavy traffic last night due to an accident. We sat for hours on the highway. I remembered my intention and changed my perspective. Instead of feeling anxious and annoyed for the delay, I thought of my good fortune to not be one of the injured parties. I literally felt my shoulders relax.
Some great intentions:
In order to do this New Year’s right; you must pay attention to yourself, your thoughts and your actions one day at a time. Make that your resolution! Cheers to 2014!