Nurses: Keeping Your New Job From Feeling Like The Titanic

Complaining about being overwhelmed by a job in this economy is a little like complaining about too much sunshine. It’s a complaint of the fortunate, particularly when the work involves caring for cancer patients: Certainly the grass is not greener on their side of the infusion chair.

by jparadisi

by jparadisi

Nevertheless, the reality for those of us fortunate enough to have jobs is that everyone works harder, for longer hours compared to when the economy was robust.

I’ve thought about this a lot during my job transition to a new employer. Learning new expectations is overwhelming for everyone involved, not only for my previous coworkers and myself, but for the new coworkers too. For instance, it takes a lot of trust to cosign chemotherapy administration with a nurse you’ve never met before. Both new and previous colleagues are confronted with this. Physicians I’ve never met have been welcoming, and willing to learn that I know what I’m doing. I am a new face for the patients too, earning their trust as well.

I’m relearning skills I’m already good at using new equipment. An example of this occurred when a new colleague asked me to start an IV. “I got this,” I thought, until opening the IV catheter package. In it, I found an over-the-needle system I’d never seen before. I asked my coworker how the safety gizmo worked, feeling a bit dull-witted. I practiced with it once on a tissue box, all the while thinking of that scene from the movie Titanic, where Jack makes Rose practice swinging the axe a couple of times before letting her take a swing at the handcuffs binding his wrists to a pole while the ocean water rapidly rises. Like Rose, I was successful on the first attempt. Whew!

For those of you making a job change in the clinical setting, here are some tips for managing new job-related stress:

  • Allow extra time. Something as simple as changing a PICC line dressing can take twice the expected time if you can’t find the special wrap the patient wants to secure his PICC in an unfamiliar storeroom.
  • Bring a water bottle, and keep hydrated. Have a packaged protein snack handy for low blood sugar.
  • Go to bed early. Stress often interrupts sleep in the form of processing thoughts during the night. Allow for extra rest.
  • Minimize outside obligations. Spend leisure time with your family or significant others. They benefit from your job, and will support you when the going is tough.
  • Remind yourself that you know how to be a nurse. You may not know where to find gauze or tape, but you know how to keep patients safe. Rely on those skills.

What other suggestions are helpful when starting a new job?

Nurses Work in Tight Spaces Under Intense Circumstances

I’m standing in the patient nutrition nook, eating a mid-morning snack of yogurt with a plastic fork, because I can’t find the plastic spoons. Twelve feet away, a patient can see me from her infusion chair. She smiles and waves at me.

At the same time, another nurse joins me in the nook, which is so tiny we stand nearly shoulder-to-shoulder as she responds to a text from her kids. This doesn’t bother me; she’s just looking for a private moment, same as me.

Under Oregon law, farmers selling eggs are required to make changes in how their chickens are raised by 2026.

watercolor painting by jparadisi

watercolor painting by jparadisi

According to the article, egg farmers must increase the personal space of each chicken from 67 square inches to 116.3 square inches. I’m trying to visualize what this would translate to proportionately in private space for nurses.

I don’t know very much about chickens, but I do know a little about nurses. We work in tight spaces under intense circumstances.

Finding a private spot from which to make a phone call or even to enjoy a quiet half hour during a lunch break is nearly impossible for nurses. A staff lounge for breaks provides respite from direct contact with patients, but since it’s a common area, not only nurses you work with, but people from ancillary departments, usually share it too.

Here’s the thing about people — we’re all different. For some, a break means eating a lunch brought from home, catching up with friends’ updates on Facebook, or reading a book or magazine. Other nurses, however, are re-energized by using their breaks for socializing. There’s not a right way or wrong way to take a break from patient care; it’s a matter of personal diversity.

Regardless of either style, it’s not likely that hospital units or clinics will increase private space for nurses. While it’s acceptable for hens to be less productive when privacy needs are not met, it is not acceptable for nurses to be less productive or deliver unsafe care because of a lack of personal space.

How can nurses support each other’s privacy needs?

  • Respect each other’s different break styles by moderating the volume of conversation in the break room.
  • Exercise patience with coworkers who re-energize through socialization.
  • Text rather than talk on the phone whenever possible.
  • Be sensitive to signals the person you’re on break with may not want to talk, such as reading a book or magazine.

What is your personal privacy style at work? Does your institution provide a quiet space for nurses? What are your tips for finding moments of private time at work?

You’re Going to be Alright

Years ago, following an art reception, my husband and I were enjoying dinner at a restaurant. As the server set our food on the table, we watched through a window as a car hit a bicyclist who had run a red light.

Go Team Oncology by jparadisi

Go Team Oncology by jparadisi

Immediately, we left our table and went to the woman’s aid. She wasn’t wearing a helmet, and her face was bleeding. She was unconscious, but breathing. Besides a possible neck injury, my concern was that she would stop breathing before the paramedics arrived. Despite my fears, I told her over and over, “You’re going to be alright. Help is on the way.” I don’t know if this mantra helped the woman, but it calmed me.

Nurses tell patients, “You’re going to be alright” all the time, whether or not the situation is as dire as the scenario above.

We tell them they will be alright while we are learning a new EHR documentation system at the same time we are administering their treatment. We tell them they will be alright while we struggle to enter lab orders correctly in the new EHR. Fortunately, EHR experts are readily available to answer questions and help us through this transition. They show us the step we missed, which is the reason the order did not go through.

I slap myself on the forehead, and the EHR specialist kindly reassures me, “You’re going to be alright.”

I think this is one of the most special qualities of nurses: Despite our fears and misgivings about a patient’s condition, or our ability to handle a situation, we tell our patients, “You’re going to be alright.” For the most part they believe us, probably because what other choice do they have? What choice do we have? It is what it is. We must move forward, together.

In Human Resource department lingo, focusing either a patient’s or coworker’s attention on the positive is called “managing up.” For instance, instead of telling a patient you are precepting a nurse who’s giving chemotherapy for the first time, you might introduce yourself by telling them they won the jackpot today — two nurses caring for them instead of one! — and that you are helping Nurse B, who is new to the unit. By doing so, you tell both the patient and Nurse B, “You’re going to be alright.”

In what ways do you manage up at work? What techniques have you adopted to promote a patient’s or coworker’s sense of security during a change of condition or a work-related transition?

A Blue Mason Jar Full of Post-It Notes Goals for The New Year

Note from JParadisiRN: This post was originally published on this blog in 2011. As it remains one of my most popular, I dusted it off for you to read today. Happy New Year 2014!

Every year I write my New Year’s resolutions on Post-It notes, filling a blue, vintageMason jar with them after reviewing the ones from the year before. I write the date on each Post-It note.  If a previous year’s resolution wasn’t met, and still holds merit, it remains in the Mason jar with the new ones.

Blue Mason Jar of Dreams photo: jparadisi 2011

Blue Mason Jar of Dreams photo: jparadisi 2011

Previous years’ resolutions in the jar:

  • “My health: that I may remain cancer-free” (1999)
  • “The continued good health of our families” (1999) I updated this one to “our families” in 2004, the year David and I married.
  • “David’s and my continued good health and happy marriage” (2008)
  • “To show a financial profit as an artist.” (2008)
  • “Gallery representation”(2008)
  • “Publish more stories in 2011″ (2010)
  • “A book deal for my manuscript” (2010)
  • “The blog will have more than 1,000 visitors/month (2010)
  • “Lose ten pounds” (2011)

Most striking about the hopes and dreams on this list is that none of them are actually resolvable. They are ongoing. Sure, publishing The Adventures of Nurse Niki into a book, (or better yet, a TV series) would be great, however, knowing me, the next year I would resolve to write another book, one that won an award or topped the charts, or something like that. Artists are rarely satisfied with any level of achievement. We are always looking up the ladder at the next rung:

  • Gallery representation leads to the desire for critical recognition, increased sales, collectors, fame.
  • Publishing stories leads to writing more stories, longer ones, for larger audiences.

In general, human nature is much the same:

  • Health and happiness leads to the expectation for more of the same.
  • I lost ten pounds last year. For 2012 I expect to keep them off.

Resolution is the wrong choice of word. For me, setting New Year’s Goals is better phraseology. Most of the improvements I wish for in life take time and perseverance to achieve, and more hard work to maintain. To my way of thinking, New Year’s is a time to review the larger goals of my life, and see if they are still worth steering towards. If so, then I ask myself what small adjustments can I make this year to further them? These adjustments are written as goals on the Post-It notes, dated, and placed in the jar.

The most important part of opening the Mason jar each year is reading the hand written Post-It notes, and saying a small prayer of thanks or another expression of gratitude for the advances, which occurred over the past year towards each goal. There is no lasting joy in achievement without gratitude. This year, I am thankful for:

  • A clean bill of health when we were afraid my cancer had returned.
  • Editors who published my paintingsessays, and blog posts.
  • David and I lost weight. He avoided a prescription for blood pressure medication.
  • I was represented by Anka Gallery. I met wonderful people there and made lasting friendships.
  • I sold some paintings.
  • JParadisi RN blog has grown beyond my previous goals.

So what’s on Post-It notes this year? What goals am I steering my life towards in 2012?

  •  Remain cancer free
  • The continued good health of our families
  • David’s and my continued good health and happy marriage
  •  A financial profit as an artist
  • Finish the series of paintings and drawings begun in 2013
  • Gallery representation
  • Write and publish more stories in 2014
  • Increased writing income
  • The blogs, especially The Adventures of Nurse Niki will grow increased readership
  • Keep off those ten pounds

Here’s the cool thing about writing down goals: The Examined Life (Socrates). Today I see  each goal I’ve written down is focused on an unknown future. I haven’t written a single one, which applies to my present reality. So, until my dreams come true:

  • I will continue to develop my skills as a nurse so my patients remain safe in my care.
  • I will strive to be a better team player at work.
  • I will phrase criticism in a constructive manner.
  • I will remember that everyone has a difficult job. That’s why they call it work.
  • I will say Thank You at least once daily. It’s wrong to wait an entire year to give thanks for everything that is good in my life.

I wish to thank my family and friends (new and old) for your support of JParadisi RN blog. May your New Year be filled with Health, Love, Happiness, and Prosperity.

Nurses and Holiday Stress

Painting by jparadisi

Painting by jparadisi

Nursing potentiates normal holiday stressors. For many nurses, the beauty of the winter holidays is diminished by feelings of stress.

Staffing woes contribute: Who knows why every year during the holidays, patient census randomly explodes abundantly or trickles down to near nothing, resulting in too much overtime or hours-deficient paychecks?

We go home to enjoy the glow of Christmas tree lights knowing our patients spend their holidays in a hospital or hospice bed, their rooms lit by overhead fluorescent lights, and this knowledge dampens a nurse’s ability to fully enjoy celebrations of bounty. We may experience feelings of guilt that our income is dependent on the misfortune of others, in this case, illness or trauma.

Mismatched schedules, especially those of night-shift nurses, complicate holiday arrangements with family. Gift giving weighs heavily on sensitive souls: Instead of buying gifts, shouldn’t the money be given to those in need? Or are our expressions of love for family and friends, the creation of memories and traditions left after our own health fails, equally important? Someday, we will become the ones missing from the family dinner table of Christmas’s future.

Here are suggestions for handling holiday stress:

  • Reduce expectations. Holiday preparations and gifts are expressions of love, not declarations of wealth. Stay within your physical and fiscal boundaries.
  • Plan quick, easy, and low-calorie meals in between holiday parties. You’ll feel better.
  • Enlist the help of children with holiday baking and food preparation. This is an opportunity to teach them to cook while spending time together.
  • Lighten your housework load by asking children to help with age-appropriate tasks like dusting, folding clothes, drying dishes, etc. Work out a payment incentive with them. Encourage them to use the money for Christmas shopping, to buy a toy for a less fortunate child, or donate to a food bank.
  • Plan downtime and use it for activities with personal meaning. Don’t skip yoga class or your morning run. Take a break from wrapping gifts for a cup of fragrant hot tea or cocoa with marshmallows. Spend an hour at church, take a long walk, or meditate to regain your sense of grounding.
  • Remember the gifts you give. Nurses give to their patients throughout the year gifts that cannot be remunerated on a paycheck. Although we do not have magic wands to cure disease, taking time to listen and help patients with their needs goes a long way. The best way to feel better is to help someone else feel better. This is the gift of nursing.

Does your nursing job ever affect your ability to enjoy the holidays? What steps do you take to reduce holiday stress?

For The Nurse on Your Holiday List: A “Shift From Hell” Emergency Kit

As if the onslaught of commercials isn’t enough to remind us, the winter holiday season has begun. For nurses, whose patients always seem to worsen, or expire, around the holidays, jumbled feelings of anxiety and guilt may arise.

‘Tis the season to practice extra strength self-care and creative gift giving!

If you need an idea for an inexpensive holiday gift for a preceptor, mentor, student, or that special nurse buddy who always has your back, here’s an idea: Give him or her a Shift From Hell emergency kit for their locker or fanny pack. The contents will vary with your own creative ideas, but here are some suggestions gleaned from my 25 + years of bedside nursing:

  • Nail clippers: for fixing a broken or snagged nail
  • An emery board: see above
  • A pair of tweezers — for wayward eyebrow or nasal hairs
  • A package of toothpicks: Does anyone share my irrational fear of food stuck in my teeth?
  • A small package of antacids: They can mean the difference between leaving a shift early or staying to finish it
  • A travel-size package of ibuprofen or acetaminophen for unexpected headaches and minor pain
  • A laundry detergent pen or wipes to remove betadine, coffee, or blood stains from scrubs and lab coats before they set.
  • Lip balm — For those shifts when you don’t have time to drink enough fluids
  • Change for the vending machine — particularly useful on the night shift
  • Gum or breath mints
  • A hair tie as back-up for the one you wore to work that broke
  • A cheap pair of reading glasses: because who can read that tiny print on single dose medication vials?
  • Packages of fancy instant coffee, a fragrant tea, or cocoa — for when you finally get a moment to sit down
  • Chocolate

Remember to keep the supplies miniature. Collect them into a cloth drawstring bag, coffee mug, or Mason jar. Those cosmetic bags you get as a “gift with purchase” from department stores work, too. Add a bow and gift tag: voilà!

If you prefer a gift for your unit while maintaining a budget, consider buying larger amounts of the supplies, and place them in a basket lined with tissue paper or gift straw, as a group gift available in the staff lounge.

What items do you consider essential items for a nurse’s Shift From Hell?

Rolling Out Changes So Nurses Aren’t Under a Rock

I was about to administer a chemotherapy infusion. The carboplatin dose was double-checked by a co-worker. First, she calculated the patient’s GFR and then the AUC (area under the curve). 

Area Under the Curve by jparadisirn

Area Under the Curve by jparadisirn

Independently, I calculated the GFR and then calculated the AUC using the carboplatin dose calculator I found on the hospital’s online resource. Following those directions, I plugged in the patient’s GFR, serum creatinine, weight, height, etc. My coworker and I came up with the same answer. Whew.

When the IV bag of carboplatin arrived from pharmacy, we reviewed the bag’s label against our calculations, completing the double check. Holy moley! The dose in the IV bag was different from our calculation. The process stopped while I made a phone call to the pharmacist. Here’s what I learned:

“We cap the serum creatinine value at 0.8 and the GFR at 125. Your patient’s creatinine is 0.6, which increases the GFR above the cap. The dose is based on the capped values.”

“Oh,” I replied.

This is what the FDA says about carboplatin dosing:

Based on preliminary communications with the National Cancer Institute/Cancer Therapy Evaluation Program, a potential safety issue with carboplatin dosing has been identified. By the end of 2010, all clinical laboratories in the US will use the new standardized Isotope Dilution Mass Spectrometry (IDMS) method to measure serum creatinine. The IDMS method appears to underestimate serum creatinine values compared to older methods when the serum creatinine values are relatively low (e.g., ~0.7 mg/dL). Measurement of serum creatinine by the IDMS-method could result in an overestimation of the Glomerular Filtration Rate (GFR) in some patients with normal renal function. If the total carboplatin dose is calculated based on IDMS-measured serum creatinine using the Calvert formula, carboplatin dosing couldbe higher than desired and could result in increased drug-related toxicity.

I must have been under a rock when this happened. Using the capped values, we recalculated the same dose as in the IV bag. I administered the carboplatin. Problem solved — or is it?

Afterward, I vaguely recalled an email from pharmacy sometime last year (or maybe it was a few months ago?) explaining the change in carboplatin dosing. That was the entire rollout of this information. Did in-patient nurses receive more information or an in-service? I don’t know.

I applaud pharmacy for initiating a best-practice in medication dosing. I also feel that a significant change such as this requires more than an informal email, and I suspect this happens often to nurses working in hospitals.

Nurses are expected to assess a patient’s understanding of the education we provide. Likewise, significant changes in clinical practice should be coordinated across departments, using nurse educators and managers to assess their nurses’ awareness and understanding.

Have you had similar experiences missing crucial information that was informally communicated?

Nurses: Do You Carry Liability Insurance?

When I was fresh out of nursing school, all bright and shiny, I bought a personal liability insurance policy, because I saw right away how easy it is to make a serious nursing mistake. As years passed, however, I let the policy lapse. At various new employee orientations throughout my career, hospital administrators told us forthrightly,

Umbrella of Safety by jparadisi

Umbrella of Safety by jparadisi

Nurses do not need liability insurance. Nurses are covered under the umbrella of this hospital’s insurance policy. The hospital is the financial deep pocket. No one sues individual nurses.

For years, this made sense. Lately, however, I’ve been rethinking this stance, for multiple reasons:

Stories of hospitals firing a nurse after he or she made a serious (often fatal) mistake are more frequent in the news. Perhaps this occurs because of the terms of the settlement. Perhaps the hospital promises a patient’s family that it will no longer employ the nurse. Or perhaps the nurse violated a hospital policy or protocol, and the hospital agrees not to disclose against the nurse in exchange for laying him or her off. Either way, the public never knows why. Does the umbrella of a hospital’s insurance cover a nurse they fired?

Commercially, the argument for purchasing personal liability insurance, even if the nurse is not fired, is this:

When a serious event occurs, the hospital’s legal department works on behalf of the hospital, not the nurses involved. A nurse’s legal rights and reputation are not the legal department’s priority. In such a scenario, an attorney hired by the nurse, working on her behalf and covered by her liability insurance, is a good investment.

Some insurance policies cover the costs incurred when a nurse is called to stand before their state board of nursing for complaints or misunderstandings filed against them.

Those who feel liability insurance is unnecessary argue that it cuts individual nurses “out of the group,” implying that being sued collectively offers more security.

Patient acuity is increasing, as are patient care loads. Many medications bear similar names, but cause very different results. As technology advances, nurses are required to maintain higher levels of vigilance. In the meantime, I’m getting older and acutely of how easy it is to make a serious nursing mistake.

Do you carry nurse liability insurance? Why or why not?

Hand

 “All nurses are different. Some just jab the needle into you, and it hurts.”

-A patient

White Gloves by jparadisi

White Gloves by jparadisi

Few things make me feel more successful as a nurse than when a patient says, “That was the most painless port access, (IV start, or injection) I’ve ever had.” I can never promise a patient I won’t hurt them, but when I don’t, it makes my day. I strive for a gentle hand. 

In art the term “hand” describes the workmanship of an artist, and nurses often tell patients going to surgery, “You’re in good hands,” referring to a surgeon’s skill with a scalpel. But “hand” refers to the way we treat people too.

Whether educating patients about chemotherapy and radiation regimens, explaining home medication administration, or simply discussing current events, it’s important to remember that even the most optimistic patient is emotionally fragile. Tone of voice, the abruptness of an encounter, and our choice of words all contribute to the “hand” we touch them with emotionally. Too heavy of a conversational hand can pierce a patient’s soul as painfully as any needle or scalpel.

I forgot this during a shift memorable for both the number and acuity of its patients. Everyone had complex questions about their care. I enjoy patient education; however, this shift I was doing so much that I began pulling information from my knowledge base as if it were files from a computer. By this, I mean remotely. I wasn’t paying attention to hand, my personal touch.

During the course of an assessment, a patient revealed she wasn’t taking a prescribed home medication because of its side effects. The patient also reported a symptom, which I recognized was caused by the discontinuation of the home medication she’d just mentioned, and I just sort of blurted out my observation. Immediately, I regretted my heavy-handedness as I saw this otherwise optimistic patient crumble nearly to the point of tears. I had carelessly broken a tender reed.

Needing to make amends, I sat on the rolly stool, and I apologized. I complimented her involvement in her care, and her ability to sense changes in her body. I also apologized for abruptly responding to the discontinuation of her medication. I regained my gently touch, she forgave me, and we devised with a care plan.

I hope I made up careless hand. I had hurt her as if I’d jabbed her with a needle.

Nine Fictional Clinicians I’d Like to Meet (Yeah 9 Not 10. I’m Picky)

In nursing, where years of working long hours can leave us feeling at times as if the tumor always wins, finding meaning is essential to happiness. People find meaning in different ways — some through spiritual practices such as meditation, others at a church, temple, or faith center.

photo by jparadisi

photo by jparadisi

When I can’t make sense of life by other means, I find meaning within inspirational themes of literature and art. Sometimes that meaning surfaces by way of humor. It’s been said that laughter is the best medicine. Maybe, at its finest, humor becomes a place where science, humanity, and art converge.

With humor in mind, last year, Scrubs magazine posted a list of “Top fictional nurses and docs YOU want to get trapped in an elevator with.” Getting stuck in an elevator would cause me the same escape anxiety that makes a wolf chew off its paw to escape a metal trap. However, the article did make me think about my favorite fictional nurses and doctors, and what I would say to them if I ever met them.

Here’s my list of clinicians and what I would say to each:

  • Dr. Frankenstein: In light of your previous laboratory experiments, what is your position on stem cell research?
  • Major Margaret “Hot Lips” Houlihan, RN ( M*A*S*H, TV version ): Thank you for evolving from a rule- and sex-obsessed stereotype into a nurse comfortable with being compassionate, smart, and sexy. TV audiences would have been satisfied with just sexy.
  • Alex Price, RN ( An American Werewolf in London ): Exercise caution if you’re going to date your patients.
  • Phil Parma, RN ( Magnolia )You are an unsung hero, the home health nurse. You take on the pathos of the dying and their families alone. Without judgment, and through unorthodox means, you found a way to fulfill your dying patient’s last wish.  And when no one is looking, you grieve.
  • Hana, RN ( The English Patient ): Make more time for self-care and fun, instead of dating guys who are as self-destructive as you.
  • Gaylord Focker, RN ( Meet The Fockers ): Dude, if you were my coworker, we’d be BFFs.
  • Dr. Hawkeye Pierce ( M*A*S*H ): What time is happy hour?
  • Catherine Barkley, RN ( A Farewell to Arms ): Have you ever felt, like I do, that your dialogue is written in a way that sounds as if Hemingway never spoke to an actual woman?
  • Jenny Fields ( The World According to Garp ): You are the fictional nurse I’d most like to meet, despite your shortcomings. Your fierce independence is both a blessing and a curse. Despite this, you are a true healer, demonstrating profound love of humanity in all its diversity, weaknesses, and beauty. You inspired me before I knew I would be a nurse. I pray to have a heart as open and generous as yours someday. I think of you often.

Which favorite fictional doctors or nurses would top your list?