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New to Nursing

Almost a heart nurse
July 13, 2014 1:40 PM by Lorenzo Ortega

Well it’s crazy to say, but now I have 5/6 first-day post-op open heart recovery orientation. After my next orientation shift I will be able to recover these patients from surgery on my own. It’s a thought that makes me quite nervous, but I feel as though I am ready. My last patient was an aortic valve replacement and I was able to work the patient towards extubation during the night. We successfully extubated in the morning on my shift, which was the second patient I was able to complete the weaning/extubating process with. I am pleased with the mix of patients I have had thus far. Two I received directly from surgery, which is an entirely different process all together. The process of initially getting them settled, figuring out the drips, covering the labs that need to be addressed, and getting the initial hemodynamic measurements, while being mindful to their blood pressure makes the first hour a complete hustle to stabilize them. The other three patients I took over from day shift, which is much easier, regardless of the patient’s acuity. Each one had different drips, some with a few and others with almost none. I have not had the dreaded bleeding patient yet. I was hoping to experience this while still on orientation, but unless my next patient has complications like this I will eventually have to deal with post-op bleeding on my own. I hope that won’t be until after I have several on my own, although I know I could handle the process if I had to.

It’s been a just over a year and four months since I started working. The knowledge and comfort of being a nurse exponentially increases at a certain point. For me I think the one year mark started to tie everything together. Once I became comfortable with the routine I was able to start noticing the similarities and differences with each patient situation. In many causes your past experiences help you predict or at least be prepared for what can happen to each person you are caring for. This intuition helps a great deal when caring for post-op open hearts. Predicting decreases in urine output based on cardiac output, knowing the possibility of covering lab values based on the patient’s trends, and being on alert for potential complications all play a vital role in caring for the sickest of patients.

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Intimidation Gives Way to Confident Care
June 30, 2014 5:01 PM by Frank Visco

While looking for a full-time job, I've been working for a home health care agency. I've been working an every-other-weekend case for about three months, and it's gone well enough that I'm readying to take on another case.  

I recently oriented on the new case, and I'd be lying if I said it wasn't intimidating. My case manager warned me it would seem that way. The nurse I trained with acknowledged she was overwhelmed with all the information when she first started on the case. Even the patient's mom joked about how it seemed like so much to do. 

It's a familiar situation. A few months ago, I was very nervous about starting my first case -- about being able to actually do this nursing thing, especially since I hadn't gotten all that much hands-on skill experience in my clinical rotations. But a few months later, I know I'm giving competent and confident care. For instance, I feel much more comfortable with tracheostomy care, transportation via Hoyer lift and G-tubes just to name a few things.  It's amazing how much of your book learning comes back and how easily you can take to the skills you've been taught to perform.

My new case won't be all that different-- it's another ventilated patient. I've got experience in my back pocket, which is comforting, but this patient has a lot more meds, advanced respiratory treatments, and unfamiliar equipment. In some ways, that can be pretty intimidating. But it's also pretty exciting to have that type of learning experience before me.  

Even though I'm intimidated now, I know I'll be confident in short order. History is proof.

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Back to Orientation
June 21, 2014 8:34 PM by Lorenzo Ortega

Recently on my unit we have been receiving a great deal of patients post MI and related interventions. We certainly are a cardiovascular ICU, but it was strange how almost every one of our beds was being taken by a traditional heart patient. All of these patients have provided our unit with a large census of CABGs and balloon pumps. I had my balloon pump orientation and took care of the patient independently. Luckily I had taken an educational class that was offered to our staff on the mechanics of the device, so I felt comfortable caring for the patient. I learned some interesting things along the way with this experience. Urine output is always important for all critical care patients, but for these patients its especially crucial. Although the balloon pump is helping with workload and perfusion, patients are still at high risk for cardiogenic shock due to the poor functional status of their heart. Once the urine output starts to decrease, cardiogenic shock could be creeping up. Urine output is also important because migration of the balloon downward can cause blockage of the renal arteries, obstructing a vital pathway of blood flow. I found this experience very interesting since you have to take care of the patient, but at the same time take care of the machine and pump to ensure all are safe.

At our hospital we require 6 orientation sessions of CABG day-one recovery in order to take them right from surgery independently as a 1:1. With our high census, I have had the opportunity to complete 3 of my 6 sessions in the last two weeks. I have another set up for Monday since we have an elective procedure that has been scheduled in advance. During the last few weeks I have learned much more about hemodynamics and their connection to physiology and drugs. It has been nice to have these experiences so close together since there has been consistency in my learning. I now have a better understanding of preload, afterload, and contractility in relation to PVR, SVR, CO, and CI. It has been informative and educational to see the direct effects of interventions based on specific measurements, then reassessing these measurements to find improvements. I'm not sure I can go as far to say that its "fun" yet, but I am enjoying the thinking that goes into caring for these individuals. In a few days I will have my 4/6 CABG recovery, and it will be one step closer to me being independent at another exciting skill. 

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Learning to Let Go
June 21, 2014 8:06 AM by Mia Ross
One of the most difficult aspects of my jobs has been learning how to let go.  It's easy when the day runs smoothly.  When I'm not accosted with the sorrow behind a tragic story or the euphoria accompanying an epic feat, it's easy to go home, unwind and sleep soundly.  However, as nurses, there are many days which don't end up perfunctory.  It is my challenge on those days to learn to let go:  let go of the sick child, the suffering homeless man, the family in denial of mother's illness.  The profundity of our days as nurses requires that we have skills to nourish ourselves, even during the hard times.  Time and experience have been my friends and allies in this department.  I have spent many fitful, sleepless nights tossing and turning reliving uncomfortable moments of my day, week, even month.  I have learned that it is so important to learn how to sit with discomfort without running or reacting.  I do recommend the new nurse find an outlet sooner rather than later.  It can be meditation, yoga, deep breathing, music.  Whatever you choose, make it a place that brings serenity, peace, acceptance and restoration.  Quiet work.  Do it often.  Eyes closed, heart open.  Especially on the bad days.  I know as your begin your first job the days are filled with learning clinical tools, medical knowledge, critical thinking.  Please leave some room for the inner work; make this a priority, too.  It has helped me grow more empathetic, allowed me to be more grounded.  And I guarantee it will help you be the best nurse you can be, regardless of the circumstance.
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Getting Used to Being That Nurse Guy
June 9, 2014 4:35 PM by Frank Visco

An interesting thing about being a nursing student, and you can double down on that when you're actually a licensed nurse, is that those around you expect you to know just about everything related to healthcare. If they are sick or something is wrong with them or a family member, they will come to you expecting answers.

This isn't something I'm all that surprised by. As a former editor, people often come to me to call on my "expertise," which basically means I've edited a lot of papers, resumes, and so forth. I'm ok with that, and, in fact, I think it's natural. If you have a friend who is a mechanic, you're going to ask him about the noise your car is making. If your sister's a lawyer, you're going to seek her out when you need legal advice. That's the way it works.

But, now that I'm actually a nurse, I feel more responsibility to know things, and sadly I'm still going to be stymied a great deal of the time. People often share test results, tell me symptoms or show me physical findings, and expect some great insight. It's kind of scary -- every time someone approaches me, I feel like my license is on the line, that my legitimacy as a nurse is being tested.  

Recently, a middle-aged man who works in my building sought me out because he wasn't feeling well. Someone had told him he should get his blood pressure checked, and my name came up, and then boom, I was taking his BP. He had a perfect reading, and his respirations and heart rate were in normal range, and yet he was feeling unnaturally lightheaded. No pain or any other symptoms. No history of cardiac issues personally or in his family. No medical issues at all really.

The man wanted to know if he was having a heart attack or a stroke or was at risk for either. What was I supposed to say?

I spoke in uncertain terms, saying he seemed healthy, but without access to EKG, blood results or a more experienced healthcare professional, I couldn't really say what the problem was (keep in mind, I still don't have a fulltime nursing job, so I work in an office building). 

I discovered he ate healthy, no frills meals and that he worked out often. In fact, he had just started a new intense exercise regimen, and the dizziness was only happening on the days following his classes. I suggested that perhaps he needed to rethink his diet -- that maybe he was just experiencing some hypoglycemic dizziness due to the increased workload and that eating more might help. But I didn't have a glucometer, and I really had no idea what was going on. I closed by telling him it might be best to talk to his doctor, which obviously wasn't what he wanted to hear -- avoiding that was why he had come to me in the first place. He wanted reassurances, and I didn't have much to offer. 

I think I handled this particular situation about as well as I could, and I believe that the more hands-on experience I get, the better equipped I'll be to provide useful and confident feedback to my family, friends and coworkers. I want to be able to field questions and be the super knowledgeable nurse guy, but I'm still very much a work in progress.  

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Taking Hold and Owning Your Nursing Practice
May 29, 2014 3:32 PM by Lorenzo Ortega

As a newer nurse it can be hard sometimes to look forward to going to work. There are uncertainties with the types of patients you will be getting, if you will be receiving a difficult admission, or even if there is an emergency situation that may come up relating to one of your patients. So many uncertainties arise from one day to the next in this profession. Recently I have started to relax a lot more about getting ready and going to work. I have had a few weeks of complicated patients that needed around the clock attention, as well as nighttime physician calls. In each situation I did what needed to be done, and with my close supervision, my patients were managed safely through my shift.

It may seem like an obvious statement, but experience and repetition make all of the difference. I have decided that the only way to become an advanced practitioner is to take every opportunity I can for improvement. This means attending all of the continuing education classes provided by my hospital as well as taking my own personal learning at home into account. My biggest down fall would be my knowledge in the specifics of all types of medications. I can genuinely say that I know a great deal about pharmacology, especially for my experience, but I want to be a master at the subject. I feel like one area that physicians think nurses are lacking is our understanding of pharmacology. Antibiotics and vasoactive medications especially. If I can learn these medications thoroughly, I can discuss certain clinical situations more competently and give appropriate recommendations.

As a new nurse if you are consistently weak in some areas (which we will always be as new nurses). The first assumption is to shy away from those tasks or duties, but I have noticed a change recently that I am trying not to do this anymore. It feels good to want to take on more responsibility. The weird thing is that I guess I am not so much of a "new" nurse anymore. Everyday I move further and further away from that, as all new nurses have done. My advice out there to other new nurses: take every opportunity you can to improve early on so you can avoid the feeling of anxiety that can come from being new. It really helps.   

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Doctors Are Not Nurses
May 23, 2014 11:47 AM by Mia Ross

Hey, New Grads, you’ve just finished nursing school!  This leads me to believe that you are a very intelligent, competent person.  And I’m sure you’ve learned so much!  You know about pharmacology, physiology, nursing theory and patient care.  Did anyone explain to you, though, that nurses are not doctors?  Luckily if you hadn’t realized this during your years of schooling, Dr. Jauhar’s recent op-ed in the New York Times is there to remind you:

http://www.nytimes.com/2014/04/30/opinion/nurses-are-not-doctors.html?_r=0

Dr. Jauhar graciously volunteered his time to write this thoughtful piece for anyone out there who thought nursing and medical school is synonymous.  Yikes.  There have already been plenty of rebuttals to his (weak) argument.  There are almost 900 comments on this piece, which leads me to believe that Dr. Jauhar's opinion was neither shared nor appreciated by the majority.  I don’t feel the need to showcase my own discord, but I did want to write a quick note to all new nurses out there.

It is so important you realize that doctors are not nurses (thank goodness!).  Your job is so important.  You will impact many patients’ lives no matter what nursing route you take.  This will always be your priority, so please don’t waste your time comparing yourself to other providers.  Instead, embrace the healthcare team atmosphere.  Appreciate other professional’s skills and expertise.  Appreciate your own contributions.  Encourage mutual respect.  And never, ever be afraid to stick up for your profession, your patients or yourself. 

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Proud to Be Among Nurses
May 12, 2014 8:52 AM by Frank Visco
It's National Nurses Week, and that means it's a time for celebration and appreciation for all nurses do as part of the patient care equation. As in past years when I was just a student nurse, I know I'll be receiving a decent amount of love and support from friends and family this week. I'll be grateful for it, and also embarrassed - I don't take praise easily, especially in a situation like this where I feel I haven't quite earned it. I may be a nurse now, but I'm not on the same level as the majority of my peers, many whom have saved lives, eased suffering, prevented complications and improved healthcare processes for years and years.

In this country, there are days, weeks and months that celebrate almost anything. Back when the ANA first decreed the week leading up to the birthday of Florence Nightingale as National Nurses Week, I imagine they never thought they'd be competing against the likes of No Socks Day, Root Canal Appreciation Day and Hamburger Month, but that's the world we live in.

Luckily, this is a week with actual substance to it, because it should and does go beyond mere celebration. This is also a time to reflect on the place of nurses in delivering quality care to patients, to remember what it is nurses are being appreciated for.

All people just want to be treated like they matter. Unfortunately, our society has a natural pull toward objectification, especially in customer service industries where we all basically become numbers. That may be infuriating if you're waiting in line at the DMV or calling IT support, but it can be downright demoralizing in the medical arena, which can often be a very confusing, depressing and overwhelming for patients and their families.

As nurses, we can ensure each person gets the treatment they deserve. We have the power to turn bad experiences into good ones, because we are presented with daily opportunities to offer kindness, assure understanding, restore dignity, and maintain humanity. Those opportunities are the reason I wanted to become a nurse, and the consistency with which those in our profession rise to such occasions are the reason this week exists.

I love nurses, and I'm proud to now number among them. I may feel weird being celebrated during a week like this, but I have no shame whatsoever in calling attention to my brothers and sisters in nursing. I can only hope to one day live up to the license I now possess, and the appreciation I steal from my association with such a wonderful profession.

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IVs and other skills... Adequate or inadequate
May 11, 2014 8:21 PM by Lorenzo Ortega

It is an interesting feeling to not be so much of “the new guy” anymore. After starting in the beginning of March 2013, those that were hired in my new grad cohort now have a year and two months of experience under our belts. It is a good feeling when even the more experienced nursing staff asks your opinion on something and you have to step back a few minutes later and realize how strange it is to be in that situation. I haven’t worked with students recently, but a few months ago answering their questions and being the “expert” was entertaining to say the least.

After one year working you definitely notice improvements in many areas. Decision-making improves in almost every situation, especially since you have many memorable nights that become engrained into your head. Sometimes they are hard to forget. One thing that I have made great strides recently is my IV skills. Although being proud about tasky things isn’t really the nature of modern-day nursing, something about being able to do your own IV sticks is extremely gratifying. It really is one thing that can make you feel adequate or inadequate as a nurse. When something needs to get done, it’s nice to know that you can feel confident enough to tackle that task one your own. It definitely didn’t come over night and I know I have a large amount of room for improvement.

Probably the more important area of improvement is the clinical decision-making. I have gotten this far by always bouncing all my ideas off of the charge or more experienced nurses on the unit and now that I have heard their opinions in many different situations I feel like I have a great understanding of what I should be worried about, what I should keep a close eye on, and what can be addressed at a later time.

Although I like the pace of nights, I feel as though some day I would enjoy day shift. I notice a lot of things during the night that don’t need to be immediately addressed. If I was on days then I could call the attending physician and inform them of any changes that should be made. However, I often feel as though my hands are tied at night when I come up with good non-urgent ideas at 3am.

It has been an interesting ride so far with many ups and downs. The difficulties of a new nurse are many, but each experience allows you to grow. I can see now why they say nursing is all about life-long learning.

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To All Who Nurse
May 7, 2014 8:54 AM by Lorenzo Ortega
After one year of working as an RN, being a nurse has a different meaning from what it had just over a year ago. I am fully able to understand the difficulty of the job, on both mental and physical capacities. There are difficult situations that present themselves on each shift, sometimes the same, but many times different. In nursing you never know what to expect. One day you may be busy with a crashing patient and another day you might have to deal with the psychosocial aspects of a family dealing with end of life emotions. It can be draining to say the least. Time management is always a difficult issue no matter how experienced you are. While some days will be easier than others, at the end of the day you feel like you worked out your body and critically thought about something important.

One thing that I have found after one year is that every person has a little bit of "nurse mentality" inside of their minds and their hearts. Although not all people may be able to work intensely at the bedside or handle the sights and smells of what we do, what I mean is that all people have the capacity to nurse in their daily lives. Parents are nurses every day, regulating the nutrition, exercise, and health promoting activities of their children.

Friends and family are nurses to one another when they ensure their loves ones are safe during travel and leisure activities. Providing encouragement and counsel is a large part of what nurses do. Family and friends do this too, spreading loving words to one another during difficult times of struggle. Being a nurse has a lot to do with caring about people and if you can do this on an unconditional level, you have the basic foundation of nursing in place.

With all this being said, to all the people out there who nurse mind, body, soul, and spirit, I wish you a happy nurses week. Whether you are a nurse by profession, or a mother, father, brother, sister, coach, teacher, counselor, religious figure, or the millions of other roles that could practice the act of "nursing," I hope you have a great week and continue doing things for others.

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Clinical Notes: Less is More
April 25, 2014 12:24 PM by Mia Ross

We had a department-wide meeting regarding clinical documentation last week.  As it turns out, no one was doing a really good job:  the senior nurses and newbies alike.  We all nodded our heads in agreement when our manager asked us to do better. 

A good clinical note has absolutely nothing to do with length.  In fact brevity is a virtue.  Our litigation-obsessed culture has created a feeling of fear and insecurity in healthcare facilities.  As nurses, we feel the need to write down every single action we performed:  washed hands, completed vitals, provided emotional support, brought water, assessed wound, smiled.  It’s not necessary.  In fact, it makes it difficult for ancillary providers to efficiently assess the status of the patient and the care delivered.  A good clinical note is a few sentences explaining pertinent medical interventions performed and the patient’s most up-to-date state of health.  No fancy language, excessive adjectives or adverbs required.

I’ll admit:  Nursing school did not prepare me to write good notes.  Plus, I love to write (surprise!) and my notes suffer because of it.  Experience has taught me that my eloquent sentences, sophisticated punctuation and satire are never, ever appreciated (I’ve made the mistake enough times to know).    No one wants to hear lengthy tales from my conversations with patients.  It’s not appropriate to write that my last patient owns his own engineering firm or is a renowned activist for HIV research.  No need to document that I admire him greatly, that he is absolutely lovely, or that I learned so much from caring for him.  That’s the beautiful part that I get to keep all to myself.

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Becoming a Working RN
April 23, 2014 12:59 PM by Frank Visco
It's been almost seven weeks since I passed the boards, and I'm still hard at work on the job trail. I've filled out quite a few applications, and have gotten a lot of rejections in response. There are a ton of jobs out there, but it seems everyone wants nurses with experience.

Still, I'm in good spirits. Keeping busy has certainly helped with that. I'm the best man in a wedding a few weeks from now, so I've been pretty occupied with bachelor party planning and speech writing. I'm currently training for the Broad Street Run, a 10-miler we do here in Philadelphia every May. And then, of course, there's my baby girl. She's already over three months old and readying to be baptized next weekend!

Besides, it hasn't been all bad news on the job front. I did get hired to do some part-time work for a home health care agency, and so far it's been a really rewarding experience. I'm functioning in a private duty role for a patient every other weekend, and even though I'm still new on the job, I've already gotten tangible experience maintaining a ventilator, a tracheostomy and a G-tube. I've even gotten an opportunity to do pulmonary vest therapy and use a manual Hoyer lift.

My home healthcare gig isn't a fulltime thing, but it is allowing me to care for a patient in need and gain real RN experience, so I am grateful for it. Taking on the second job isn't even that big of a problem for me. I attended clinical every other weekend for over two years, so this schedule just feels like getting back to the status quo.  

I'm still hopeful that I'll get full-time work in a hospital setting at some point in the near future, but in the meantime, I'm glad to be practicing in the field. Getting my degree was great, and passing the boards was even better. But actually logging hours as a working RN? That's been the best feeling so far.

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Streamlining patient care
April 15, 2014 4:17 AM by Lorenzo Ortega

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 earlier today.

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 EMR system.

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.

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Adjusting to Parenting as a New Nurse
April 9, 2014 11:42 AM by Frank Visco
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.  

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The Language of Nursing
April 7, 2014 8:08 AM by Mia Ross

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? 

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