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?

Shift Observations: When It Feels Like Work

Our fatigue is often caused not by work, but by worry, frustration and resentment.

Dale Carnegie

Derail photo by jparadisi 2012

I had one of those patient assignments I couldn’t get control of. The care plan refused to move forward in its time frame, despite fervent pushing. There were unexpected variables: The patient possessed few usable veins; those she had were challenging, and time was lost starting her IV. The infusion wasn’t available when expected. Once it started, the vein blew. No harm occurred to the patient, but another vein had to be found, another IV had to be started, all at the cost of more lost time. It became clear the patient was not going to be on time for a scheduled procedure in another office. This happens once in a while in the ambulatory setting, mostly because the parties doing the scheduling are unaware or overly ambitious about what can be done in a limited amount of time.

I called the RN at the office scheduling the procedure, explaining our patient would be late. Then I returned to my post, watching her IV, willing it to stay open and unobstructed. The expression on my face must have been intense: I didn’t notice our nursing student enter the unit until he came to me and asked, “Tough day?”

This student returned to school to pursue a career in nursing. His commitment, work ethic and accountability are rare. Despite raising a family, and going to school full-time, he finds things to do above and beyond expectations. He’s smart and funny too, with a natural ability to get along with our crusty, all female staff. He’s going to be a great nurse.

“Yeah, it’s a tough day,” I replied. Remembering how hard this nursing student works I realized, instead of whining, I had the opportunity, a choice, to show some professionalism. I explained some of the factors making the assignment difficult. Without thinking, out of my mouth came the words, “Solving the problems is what I do as an RN. This is what I’m paid to do. When things go wrong, that’s when my education kicks in full throttle. I’m here when the work is slow, for the times when things get tough.”

The student smiled and said, “Yeah, that’s what makes it a profession. It’s like when I had my company, the job was easy until there was a problem. That’s when it felt like work.”

He’s going to make a great nurse.

Diplomacy, Apologies and Boneheads

Bone Head watercolor and charcoal 2012 by jparadisi

Diplomacy is as necessary to successful nursing as IV skills, medication administration accuracy, and critical thinking. In fact, diplomacy is a subheading of critical thinking. Further, apology is a subcategory of diplomacy. During a recent shift at the infusion clinic, I had plenty of opportunity to practice both.

Nurses are well familiar with these shifts: They start looking like a doable workload. Then nothing goes as planned and you and your coworkers spend the entire shift chasing after it like a pack of grey hounds trailing behind a rabbit on a track. Unexpectedly, the rabbit jumps the track: Medications are not delivered on time from pharmacy. The patient needing a nurse inserted PICC is vein-less, requiring radiology placement and transport to their department; this delays the patient’s antibiotic treatment. The home infusion company is late delivering the continuous chemotherapy infusion for another patient left twiddling his thumbs waiting. IV pump alarms ring longer than anyone can bear, and nothing is on time per the electronic medical record. Meanwhile, the phones never stop ringing! 

These factors cost patients lengthy waits. During such shifts, I say, “I’m sorry” to patients all day long. For the sake of diplomacy, I can’t explain the bonehead roadblocks I’ve endured while trying to move their day forward as efficiently as possible. Diplomacy also prevents me from telling the bonehead roadblock he or she is a bonehead roadblock. I remind myself everyone, including me, makes mistakes, and to show a little love to the bonehead on the other end of the phone, because my turn will come.

My last patient of this shift doesn’t understand my explanation of why her care is delayed. Her sister eyes me suspiciously from a chair. I know she thinks I’m the bonehead. I stay the course, however, and it all works out. The patient eventually received safe treatment.

At the end of these shifts, it’s the outcome that matters. No one really cares who’s the bonehead.

Nurses’ Week: Sometimes The Best Recognition is None at All

The Broken Elevator photo: jparadisi 2011

Saturday morning, David and I woke to a noisy buzzing alarm coming from the elevator in the hallway of our building. It was stuck on our floor with its doors half open. Because it’s the weekend, I’m not hopeful of it getting fixed promptly. Next, as if we are under attack from a conspiracy of machines, our normally silent dryer started making a loud thumping noise, like tumbling canvas shoes, but all that’s in the drum is a small load of delicates. David is on his computer, looking for a repairperson as I write this post. The coincidental mechanical malfunctions remind me that as long as things meet my expectations, I often take them for granted.

At a social event, I was surprised to see an ex-patient and his wife also in attendance. I remembered them vividly, because of the longer than expected amount of time spent admitting him to our unit. The husband had the misfortune of being discharged from the hospital on a Saturday evening. Commonly, hospitals have a minimum of discharge planners on weekends, and the discharge planner’s job is frustrated by the fact that most of the outpatient services he or she needs to coordinate are closed. Also, he did not have a primary care provider, meaning no physician or nurse practitioner was in charge of his outpatient follow-up. To fix this problem, he was given a physician referral, and a phone number to call on Monday.

He arrived in our ambulatory clinic on a Sunday morning for daily treatment in pain, after a difficult night at home.  His wife and son accompanied him. The son was concerned about the eschar on his father’s wound, and I agreed with his assessment. Eschar is a dark, leather-like tissue formed on the surface of a wound. In the worst- case scenarios, it creates a tight band around an extremity, cutting off the blood flow to the body part below it. It increases the patient’s pain by preventing oxygen-rich blood from reaching the affected area. Fortunately, the body part below the eschar of this patient was warm to touch, with strong pulses, and a brisk capillary refill, so he wasn’t in imminent danger. He didn’t have a fever, and his vitals signs were normal, so pain control and obtaining a surgical consult became our priorities. We needed a doctor to write orders.

Luckily, the resident who treated my patient in the hospital was still there. I paged him, and told him what was happening. He agreed to see the patient in the clinic. This was generous of him, because once a patient is discharged from the hospital, technically, he is no longer responsible for his care. He wrote a script for breakthrough pain medication, and made a phone call for a surgical consult to address the eschar. In this way, the patient avoided a trip to the ER, the only other option on a Sunday. On Monday morning, a surgeon removed the eschar. I was pleased with myself for mobilizing the necessary resources on a weekend. The rest of the patient’s course flowed uneventfully until discharge.

The Dryer: Things That Go Thump photo: jparadisi 2011

At the social event, I approached the former patient and his wife to say hello. Looking at me blankly, they reciprocated, then awkward silence. Realizing I’d made a mistake, I said, “I didn’t mean to bother you. We’ve met before. I just wanted to say hello.” “Really?” said the wife. “Where would that have been?” Uh, oh. I mumbled the name of the hospital, but not the unit. Even the name did not prompt a recollection. They continued to stare blankly.  I desired to end the interaction, unsure if I was circling the drain of a possible HIPPA violation. Complementing the wife on her earrings, I retreated to another part of the room.

Later, it occurred to me that their discharge ordeal wasn’t an ordeal to them, because by means of coöperation and teamwork, I fixed it. They expected a smooth discharge with seamless follow-up care, and they got it. They took it for granted, because they didn’t experience the frustration of falling through the cracks. They didn’t recognize me, because I hadn’t stood out. They did not experience poor care versus quality care. In their mind, I did my job, and that did not merit recognition. They are right.

I appreciate the effort hospital administrators make each year during Nurses Week to thank nurses. Recognition for a job well done is one way of saying, “Thank you.” However, a lack of recognition, because the person served is unaware of the effort made on their behalf, is a form of reward too. The best recognition of a job well done comes from within.

If I Could Save Time in a Bottle

Oregon agates in their natural state. photo: jparadisi 2011

It’s late Sunday evening as I write this post. Usually I’ve already written one and clicked the “publish” tab by now, but what the hey, I’m not a trained seal, you know?

Anyway, David and I went to the Oregon Coast for a brief trip to celebrate a family birthday. Surprisingly, it was sunny there, and sunny days are as rare as agates on the beach this spring. Now we’re back in Portland, and the clouds darken the sky as if someone put a gigantic hat over the city. However, my day was brightened to find that Dr. Dean Burke mentioned my post from last week among those of other talented nurse bloggers in The Millionaire Nurse Twitter Chat edition. Thank you!

Normally, when I know I’ll be out of town, I plan a post in advance so it’s ready to publish on Sunday evening, but this week time flowed away faster than a spilled latte at the nurses’ desk. First, work was crazy busy: the kind of shifts that make you come home and go bibbety-bibbety-bibbety, while drooling. Despite this, I felt strangely fulfilled. My colleagues and I worked well as a team, and we made some significant improvements in the lives of our patients. Being busy is not the same thing as being frustrated. Hard work resulting in good outcomes is its own reward.

Speaking of which, I was accepted into a juried art exhibition this week. I really wanted to make it into this show, but now the work begins. There’s an artist statement to write, a résumé to update, and framing to do before the show. Achievement comes with a to do list. Being an artist requires a level of professionalism similar to any other career. It’s not all crayons and finger paint.

Added to this week’s frenzy, my favorite 11 year-old had a band concert. He plays trombone, and shows promising talent. I wouldn’t have missed it for anything. In fact, I showed up late for a gallery reception I promised I’d attend months before rather than miss it.

On the drive home from the Coast, David asked me how I was doing after such a busy week. I told him I am tired, but content. If I could save time in a bottle, this is how I would spend it: in meaningful relationships, and doing meaningful work. David said, “What else is there to spend it on?”

The Fragrance of Caring

Cupcakes! photo: jparadisi

Hospitals are not known for their fragrance, and recent shifts in particular have lacked delicate bouquet. It comes with the territory, and if I wanted a perfumed environment, I should have chosen a profession that doesn’t include the collection and measurement of body fluids. People with sensitive stomachs should think twice before becoming nurses. Whining about poop and vomit belongs in the “Well What Were You Thinking It Would be Like?” file.

If you require regular and predictable hours for happiness, nursing is not the career for you either. Shifts are unexpectedly extended because of late admissions, acute changes in patient conditions (read EMERGENCIES!!!), short staffing, etc.  In the past weeks, I have left work late for these reasons. Poop, vomit, EMERGENCY! I’m not complaining. This is what I am educated to do. I am proud to be a nurse with the necessary skills to lead patients through their dark moments.

Recently, I came home from a particularly long, smelly shift to find a UPS slip stuck to my door, informing me that a package required my signature IN-PERSON for delivery. The package was my birthday gift from David. I worked the following few days, so I called the UPS customer service number and arranged package pick-up. There was enough time left to pick up the package that evening. Since the gift was from David, he wanted to go get it, even though he’d also worked a longer than expected shift that day. We changed out of our smelly work clothes, and hopped into the car to get the package.

Traffic was horrendous. It was raining, and getting dark. I told David it wasn’t important; we could pick up the package the next day, but he was on a mission. When we finally arrived, it was twenty minutes past the office’s closing time. Surprisingly, the light was on, and the door unlocked. A smiling woman stood at the counter, holding my package. “Are you Paradisi?” she asked. “Yes, I am. Are you waiting for me?” “Yes,” the woman said. “I didn’t want you to drive all this way and find us closed, not in the traffic and weather.”  She extended her shift to take care of me, as I had done during my shift to take care of someone else. It is the essence of excellent customer service: the fragrance of caring, and the gift of time.

How I Became a Nurse Part III: It’s An Ongoing Process

The Christening Gown (From Cradle to Grave: The Color White) by jparadisi

One shift, Roz and I worked alone. That night, there were only two patients in the pediatric intensive care unit. Roz was charge nurse. I sat at the console charting, with the hypnotic QRS tracings of sinus rhythm in the background. Roz charted at another desk by the door. The door opened and a man I’d never seen before entered. He walked past Roz, to me. He identified himself as the pediatrician for Roz’s patient, and asked who was the charge nurse.

“Roz is in charge. She’s taking care of your patient.”

He continued addressing his questions to me. “How’s my patient? What’s his blood pressure?” “I don’t know,” I reinforced, “Roz is your patient’s nurse, and she has his chart. She can answer your questions.” I looked quizzically to Roz, who briefly looked up, then put her head down, intent on charting. The doctor continued. “I want to know the I and O. Is the patient getting enough pain medication? Are his parents around?” I didn’t get it. I remained confused until Roz walked over and handed me the chart. Suddenly, I understood. My anger flared then turned into a cold lump in my stomach. I had to control my voice as I answered his questions from the chart.

Roz nursed circles around me. I owed it to her that I was in the PICU and this physician wouldn’t talk to her because of the color of her skin. I only spoke to him because of his patient, a child. He scribbled some orders, gave me the chart, and left. I felt traumatized by his overt racism, and because he directed it towards Roz, my friend. The cold lump in my belly morphed into nausea.

“Roz, I’m so sorry. He’s an ass.” Her eyes betrayed her feelings, but her words were calm.  “Jules, I don’t blame white people for this. That fool is an ornery, nasty soul no matter what color his skin is.”

Decades later, Dr. Racist remains a painful memory. Dr. Racist was never seen again in the PICU. He was a blip on our screen, nothing more. His disappearance prevented Roz and I from doing more than complain to management.

Becoming a nurse is an ongoing process. Certainly, a nurse’s expertise grows through attainment of knowledge and skills, but it is more than that. Becoming a nurse also includes learning when to speak up and when to let something roll off your shoulders. Like everything else she taught me, Roz was better skilled at this than I. I am not a qualified authority on racism in nursing, but the National Black Nurses Association, and minoritynurse.com are two educational resources by people who are.

My treatment by Sister Sebastian was workplace bullying. What happened to Roz is workplace bullying taken to its sinister extreme. It is so universal that the successful TV comedy series The Office uses it for its premise. However, when nurses experience workplace bullying, we are usually in the midst of work requiring responsibility for the safety of others. It’s hard to stand up to rude or disruptive comments when your patient’s condition is rapidly deteriorating or you are in a patient care area. Bullies know this, and use it to their advantage. I think this is what makes workplace bullying particularly demoralizing for nurses:  often, we must choose between defending ourselves and protecting our patients.

I have one strategy, developed over the years, which I find effective. When I overhear a coworker berated by another in either language or tone of voice, I go stand next to that person. Usually my quiet presence is enough to cause the offending person to stop. Occasionally it is not, and the offender asks, “What do you want? Why are you here?” I reply, “I’m just wondering if everything is okay over here. Do you realize everyone can hear you?” So far, this has always stopped the abuse. It’s particularly effective if more than one nurse stands by.

Becoming a nurse is an ongoing process. I am still learning.

Of Med Errors and Brain Farts

I read the physician’s order carefully, looked up the medication in the nurses’ drug book, and consulted with our pharmacist before I gave it.  While signing the medication administration record (MAR), I read the order again, and I did not see the same dose I had read the first time.

Immediately the blood in my feet rushed up to my ears and I was lost in pounding waves of white noise. Fuck, fuck, fuck, I made a med error, and it’s a serious one. Of course, I didn’t say these words out loud. Instead, I carried the patient’s chart and the empty, pre-filled syringe to the nurses’ station. Putting them in front of the charge nurse I said, “I think I just made a med error, a bad one. Look at the order and the syringe label. Tell me what I’ve done.” She stopped what she was doing. She read the order and examined the syringe. “You gave the right dose. You didn’t make a med error. Now breathe.” The pounding breakers of white noise in my ears subsided into the gentle lapping of my breathing. Another nurse came to my side saying, “I know exactly what you’re feeling.”

I felt relief. My patient was safe. It was a medication I am not very familiar with. That’s why I read the order carefully, looked it up, and consulted with our pharmacist. All I can determine about my confusion after giving the dose is that I had a brain fart. Somehow my eyes and my brain disconnected after I gave the medication, and the order unexplainably failed to make sense. That’s the best I can come up with: a brain fart.

Later, my coworkers told me their stories of making med errors. We all make them. I didn’t know that when I was a new grad.

It is unbelievable to me as I type this, but it is true: in nursing school  I had an instructor who told our class that she had never in her thirty year career, ever made a medication error. Never. And I was young, and shiny, and idealistic enough to believe her. Seriously, I did. So when I made a medication error during the first couple months of my new-grad job, I was sure that I was not cut out for nursing. At that time, my coworkers didn’t gather around offering support like they did recently. No, I was written up, and had to call the pediatrician and tell him that I had forgotten to hang a dose of ampicillin. He was more sympathetic than the day shift charge nurse back then. I made other medication errors too, nothing serious, but enough to consider quitting nursing during my first six months of practice.

Then I met one of the best nurses I have had the pleasure to work with. For some reason, she decided to mentor me. I confided to her that I considered quitting nursing, because I made med errors, and that my instructor never had.  She laughed.”If that instructor of yours never made a med error, then I’m thinking she’s too dumb to catch them. You are so crazy. Let me tell you about med errors…” She was a great nurse, not a perfect one.

She showed me how to string nursing tasks together like a pearl necklace, and eventually I gained the confidence needed to stay in nursing these past twenty-four years. I still make mistakes from time to time. I take responsibility for them. I learn from them. I am compassionate towards my coworkers when it happens to them. Nursing is not a risk-free profession.

And sometimes I have brain farts.

Consensus and Majority Rule are Siblings not Twins

     Just because you are not in charge, it doesn’t mean you are not a leader.

Anonymous

         I’ve thought a lot about working in groups and leadership lately. I think it’s important for nurses to respect the skills necessary to do either. In a perfect world, all nurses, or at least all the ones I work with would.  In my dream team-nursing unit, every nurse communicates his or her needs and patient care concerns clearly and concisely. Every nurse stays focused on the present situation, without bringing past history or personal issues to work. My first-rank draft pick teammates respect each other and never say anything hurtful about a coworker. In my dream team unit, passive aggressive behavior doesn’t exist, because nurses speak openly about their feelings and concerns. My dream team colleagues and I would never have a lapse in judgment or make a mistake.

     Anyone out there know where I can find a job like that? Anybody? Bueller?

     I was speaking with someone about leadership in the workplace. She says she goes along with the majority’s decisions, even if it’s not what she believes in, because that’s consensus.  That feels wrong to me. While I admire this person’s willingness to put her own beliefs aside to move her department’s work forward, I have concerns. First, what if the majority is wrong? Second, why would a group lack concern for the feelings of one of its members, if the goal were to develop a team working effectively together? Lastly, what are the effects on a team member’s performance and psyche that regularly has their needs and concerns ignored? At what point will habitual sacrifice transform a willing team player into a nurse whining, “No one ever listens to me”?    

     News Flash: No one will ever listen to you if you don’t speak up. You have to speak your mind. I know it isn’t easy for everyone, but like learning to start IV’s, it gets easier with each attempt. It’s tempting to go to your “nice” coworkers for help with uncomfortable staff dynamics instead, but eventually you will wear out these people too.

      As for leaders, if you say things like, “The problem with you…” or “This is your problem, not mine…”, you are promoting passive-aggressive behavior. Eventually, this coworker who appears weak, will consciously or unconsciously create a situation that may sabotage positive clinical outcomes. No one wants that.

    Majority rule says, “This is how we’re going to do it, and you will do it this way or else we will __________ (fill in the blank). Common nursing punishments for peers who don’t comply are shunning, refusing to help them (leaving patients at risk), rudeness, and belittling them to other coworkers.

         In comparison, consensus is the voice of reconciliation achieved through sincerity. Consensus says, to the minority, “This is how most of us want to do it, but we don’t want to alienate anyone on our team. What can we do to make the way we are going to do things easier for you? What concessions can we give you to make the work flow well for you too?” 

     I do not work with my dream team, and neither do my colleagues. Our patients depend on us, so we work together as a team to move each shift forward. Some shifts move easier than others do. Each morning we start the clock over, leaving the past where it belongs, and play a new game.