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!
Now December, I am seeing many nursing school friends post pictures of pinning and graduation online... Boy does the time fly. As they continue to post inspiring statements about their completion of nursing school and their aspirations for the journey ahead, I have become understandably nostalgic about my time one year ago in the exact same situation. I really can't believe it has been one year since graduating. I came to the realization that one year had passed last week in the funniest of ways. I was attending a Sacramento Kings basketball game with my girlfriend, who also graduated with me at Sacramento State School of Nursing. The Kings play their games in Sleep Train Arena, which happens to be the same location in which Sac State holds graduation. Interestingly enough the game was on Saturday December 14th, the exact day we finished one year prior. It just so happened that an event had brought us back one year later. Honestly, it was kind of weird when we realized it standing in line to be let inside the arena, this time minus the cap and gown!
I have noticed the passing of time in my nursing practice as well. My anxiety level at work has decreased significantly, although I am convinced it will never completely go away. I have learned that some days are tough and some are easier, but regardless, the day always ends and new one begins. There is no use in dwelling in the past on rough days and simple mistakes, just move on.
On my unit for the last few weeks we have had nursing students from a nearby university. During the last two weeks I have been paired up with a student for one night each week. It really blew my mind to be in the preceptor role. I did my best to take my time, share knowledge, and answer questions. I still recall many of the challenges I had in my school days, so I did my best to encourage as much participation from the students as possible. They did a great job being positive and helpful whenever they could. Looking at their skill level and knowing the progress that can be made in one year was something interesting. It is a true testament to the power of knowledge gained through repetition and practice.
This new role has made me consider the possibility of nursing instruction later in my career, something I know I'll look forward to when the time comes. As for now, my continued immersion in critical care is giving me new experiences every day. I can't wait for what comes next.
I’m done. Done clinicals. Done classes. Done finals.
And right now, I’m happy, super-de-duper happy, but mostly I
feel like I do right after Thanksgiving dinner – way to full and ready for a
As such, I’ve been floating in a sea of relaxation since
taking my last final a week ago. It’s not smart – even though I’m done with
school, I still have boards to prepare for – but I guess at this point I
deserve a break.
I may give myself a few more days, but after that I really
need to get myself motivated. The goal is to take the boards after my daughter
has arrived, which means sometime in early February. Thus, I have about 7 weeks
My school requires we take a preparation class for boards,
and I’ve elected for the online Kaplan course. I feel pretty good about where I’m
at now, but I’m determined to do all the modules. I’m just hoping I can keep my
resolve and not wait until too late in the game.
I’m hoping to set aside at least two hours every day doing
something productive – questions, modules, studying notes, whatever. It’s going
to be tough – especially since the structure provided by school is no longer in
For anyone who’s been in a similar situation, feel free to
share how you went about preparing in the final march toward boards in the comments
section. I appreciate any feedback, and, I assume, any readers in a similar
situation will as well.
I can remember one of the first pieces of advice I was ever given as a nurse: A good nurse must be a fantastic multi-tasker. At the time, it made sense. Once I was thrown into clinical rotation, I felt constant, head-spinning pressures and demands. At every junction, I was thrown in three directions. And, as promised by my predecessors, I did grow quite adept at juggling multiple balls in the air simultaneously. Initially, I felt proud. I've done it! I've become a grade-A multi-tasking nurse. I can administer meds while thinking about the patient next door who needs his Foley removed while talking to the physician about discharge instructions all while advising my co-worker what to get me for lunch! The good feelings wore off fast when I realized that although I was completing all my tasks on time, I wasn't doing any of them very well.
It was here that my issue with multi-tasking started. I hated the feeling that I was rushing and preoccupied all the time. I hated that I couldn't give my total attention to the task at hand because my brain space was always filled with impending responsibilities. I knew I needed to change the way my days were spent. I read a wonderful book titled "Your Brain at Work" by David Rock. It was here that I found pertinent advice on how to get through the work day most effectively without compromising quality. My assumption was right: Muliti-tasking does not translate with superior performance. In fact, it harms productivity and quality of work.
As nurses, we don't work with deadlines or projects or reports. We work with human beings. I suddenly felt a sense of regret for treating my work days like to-do lists. I started triaging my tasks more efficiently. I removed things from my short-term memory and instead wrote them down on paper which left space for the present moment. I instantly became a better listener. I became more assertive. If a physician was interrupting my time with a patient or co-worker, I would politely say that I was preoccupied and that in order for me to give her/him my full attention, we'd have to talk later. I learned how to say no. When an aggressive family member demanded water for their brother/sister/mother/father, instead of running to grab it, I'd bring the person with me to the kitchen and say, "consider this your kitchen, too".
If you asked me today to glorify multitasking, I'd have to decline. I hate multitasking at work. I hate multitasking at home. I like living in the present moment. I like being aware of the now. I like being attentive. And I'll never go back.
In a recent shift I was astounded at the spectrum of what is considered to be an ICU patient. This astonishment was a much needed reality check for me, as I had been needing something uplifting in my work routine. In the last few weeks I worked a good amount during my birthday and on the night before and the night of Thanksgiving. This was something new to me, working my first holiday season since I got the job. I was missing my friends and family, and all my patients seemed to be confused or sedated and critically ill. During this shift however, I had one patient who I had cared for previously and who was very critically ill, but my other patient was someone who had been admitted recently for an MI. Since our unit is a cardiovascular ICU we get many patients post MI, so this was nothing new. Usually these patients are alert and oriented, but have drips that are of the most importance so they require a different level of maintenance. This patient was extremely cheerful. We experienced several memorable moments, both of which we agreed we would remember for quite some time, and shared a number of good laughs. I don't think I can recall a patient that I laughed with more.
Going back and forth between the two rooms made me think about what constitutes an ICU patient. There is a very wide spectrum of what is considered critical. At face value they look like two very different things. On one side my MI patient looked fine. Aside from the IV medications (Heparin and Integrilin) a person not familiar with medical care would have wondered why this patient was even in the hospital. As for my other patient, clearly there was a reason for them to be there. That night made me think more deeply about disparities in our country. The two major ones that exist are health disparities and economic disparities. Sometimes they go hand-in-hand, but many times they don't have to be linked together. The great equalizer in society in the 21st century is health. Rich, middle class, and poor all seem to end up in the ICU. Although they could be for different reasons, their general levels of health have suffered equally.
Nights like this one I had will give me the motivation to continue through nursing. That one patient that you connect with and who shows true gratitude for you giving them your time is a treasure. It felt good to experience something so genuine. I look forward to more experiences like these and even if they are few and far between I hope one instance propels me forward to the next so i can continue giving the level of nursing care that I pride myself upon. I see people who are burned out and I don't ever want to be one of them.
Until next time, Lorenzo Ortega, RN, signing off.
Here comes the cold! And rain. And snow. As the days shorten, don't let the darkness get you down. As nurses, we have an obligation to keep our spirits high. After all, cheerfulness is good for healing! Your patients will thank you. Here are some tips to avoid the winter blues:
- Defy those blustering winds! When we walk outside, the frigid weather causes us to look down with our shoulders hunched. Keep your shoulders upright and face that cold head on. Don’t be afraid to take a wintertime stroll! It will help keep both your spine and your vitality aligned.
- Enjoy seasonal cuisines. Wintertime offers us an opportunity to eat wholesome, hearty warm soups, stews and roasts. Brush up on those kitchen skills so that you can share with your patients your favorite heart-healthy recipes.
- Read! Without the distraction of endless summer barbeques, you’ll be able to expand your knowledge base and read all the books you haven’t had a chance to throughout the year. Looking to expand your nutrition knowledge? Try What To Eat by Marion Nestle.
- Sip and Sweat. The summertime offers us a valuable de-tox tool: sweating. Go the gym and get that heart rate up and those toxins out! Or visit a local spa with a steam room/sauna. Always re-hydrate with water. The winter time should not be sustained on lattes and hot cider.
- Relax. This is a beautiful time of year where we have more opportunities to go inwards. Take some time to reflect, to meditate. Enjoy some solitude. Ponder your priorities. What are the things that really matter as the year closes? What things can you let go off?
And, as always, keep smiling.
Last Saturday, I had my last day of clinical. Yesterday, I
handed in my capstone project. In three weeks, I’ll take my last final.
And then I’m done.
It’s amazing how quickly time goes. It’s been two years and
three months since I started the nursing program at La Salle and almost four
years since I started going back to school to pursue a career in nursing.
A lot has happened in that time. I got married in August of
2010. I bought a house in July of 2012. And, by the time I sit for the boards,
I’ll have a newborn daughter.
Through all of that, I somehow managed to transition from
being a guy who knew as little as a grown adult could know about the human body
without hurting himself into a nursing school graduate.
Overall, I’d say it’s been a fruitful and rewarding experience.
During most of my time in school, I’ve often felt quite lost, but I was assured
that, at some point, it would all come together. I still think that day – the day
where it all comes together – is somewhere in my future. But I know I’m closing
in on it. People in the know tell me that day comes once you’re actually in a
job and doing it every day.
I can’t lie – I’m nervous. Nervous about the boards. Nervous
about finding a job. Nervous about being a nurse. But I think being nervous can
be a good thing for me. If I’m nervous, I can’t coast. If I can’t coast, I’ll
have to work for it, and that means I’ll have to continue to grow.
Last year around this time, I was about halfway through
school, and I thought to myself “Geez, I know nothing. I’m not even close to
ready to be a nurse.” But, I thought, “Well, I certainly know a great deal more
than when I started, and if I have a similar jump in knowledge by the time I’m
done, I’ll feel pretty comfortable with where I’m at.”’
Well, that jump in knowledge happened, and the results have
started to show. Certain things have gone beyond knowledge and become
instinctive. I’ve exceed the national average on my last few Hesi exams. I’m
even able to answer medical questions in a somewhat intelligent way when my
family and friends ask them.
That being said, I’m still nervous. But I’m also encouraged.
And encouragement is probably an even greater motivator than nervousness.
2014 Is going to be a big year. The year I become a father.
The year I become a nurse.
I’m nervous for it. I’m excited for it. I’m ready for it.
Now that I have become more deeply immersed in the hospital lifestyle I am beginning to see the situations in which many different patients are stereotyped. For the last month and a half I have been working as a full-time RN in my hospital's CVICU. Previously it was just part-time, about twice a week on average. This more consistent scheduling has allowed me to witness some situations where I have seen patient's behavior stereotyped, at times causing a disruption in medical and nursing treatment. This was no surprise to me as I had seen this behavior before as a student and a new nurse, but recently I had been thinking more introspectively about the topic.
In one case I had a patient who had chronic anxiety. The patient's physical condition and diagnosis would provide anxiety to anyone in a similar situation, but according to the physicians this was an extreme case. There was data that was being ignored about the patient because the medical and nursing staff were referencing the fact that it was all due to his chronic anxiety. During a night that I care for this individual there didn't seem to be any signs of anxiety, and the patient was even asleep, but the vitals didn't sit right with me. A call was made to touch bases with the night physician, but again, few interventions were given and things stayed how they were. It was frustrating to see nothing happen.
Another night I can recently remember had to do with a patient being "needy". In many instances I can see this as being a true statement. Some patients need more and ask for more from the nursing staff. This can be due to various reasons, but what I have always noticed is the underlying nature of this "needy" behavior. All of these patients have had an extreme loss of control in their lives. Whether is be a sudden change, or a very drastic change happening over a longer period of time, people struggle to adjust. Human being's lives are struggles to begin with, but adding a life threatening or serious disabling illness into the mix and I'm sure I would become "needy" too.
One thing that I have also found interesting is that being aware of patient norms can be helpful is finding slight changes in patient condition. Since I have been working more hours I have a lot more shifts in a row or close together than I had before. This allows me to identify what is normal for each patient and identify subtle changes that I may not have noticed in the past. Although consecutive shifts can be physically demanding, they allow for more easy mental processing of data, especially during day two and three.