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.

You’ve Come a Long Way Baby. Maybe.

Untitled. photo: jparadisi 2011

A friend of mine talks about aspects of one’s life occurring between bookends.  People use the cliché “things come around full circle” to mean the same thing, but I like my friend’s reference to bookends better. Coming full circle suggests ending back where one started, but the bookends metaphor implies a linear journey that includes revisiting one’s past, which is unavoidable if you live long enough. Personally, I prefer the bookends metaphor to the circle one, because I think moving forward is an important attribute of  happiness.

Today was my second shift using the new electronic medical record. Yesterday I practiced order entry, updating the home medication list, and documenting blood transfusions. Today, I focused on medication administration. The way the EMR works in our hospital, patients wear a bar code wristband and the medications are bar coded too. When giving a medication, the nurse deploys a laser scanner the size and shape of a pistol to scan both the patient and medications, verifying that the right patient receives the right medication, an important upgrade in patient safety. Scanning the bar codes exactly right so they register in the EMR is tricky. Most of the time I had to repeat the scan more than once before I got it right. I’m thinking it’s not very different from learning to start IVs: eventually my small motor coördination will develop muscle memory, and I will have a “feel” for getting it right the first time. It just takes practice.

Sometime during the course of the shift, however, I told a coworker that if my scanning ability doesn’t improve, my plans for a career at Whole Foods are doomed. We laughed. Then I remembered something from my nursing school days:

When I entered nursing school there was a nursing glut. Nursing shortages hadn’t occurred since before Salk invented the polio vaccine, and tuberculosis ran rampant. Around the same time, grocery store chains were investing in a new technology using lasers to scan bar codes on grocery items for prices at check out. After attaining my Registered Nurse license, I could look forward to eventually earning the same hourly wage as grocery clerks then. All through nursing school, both instructors and students joked about “scanning cans” for a living, if our careers in nursing didn’t pan out.

My very first nursing job paid an hourly wage of thirteen dollars and some change. Six months after graduation, the first wave of a nursing shortage hit where I lived, and my hourly rate nearly doubled in a single pay raise; a windfall. I never thought about scanning cans again, until today when I aimed a laser scanner at a patient’s wristband and medications, and I realized I have traveled a straight line punctuated by a bookend.

Advice for Transition From Nursing Student to Professional

Paper Dolls (First Communion diptych) by jparadisi

Last week RealityRN.com asked me to respond to a new nurse’s post about the difficult transition from student to professional nurse. Other nurses also contributed advice and insights. Here’s what I said:

My first six months as a new grad nurse were so painful, I almost quit. More than twenty years later, I can laugh about it enough to post them on my blog, https://jparadisirn.com/. I was lucky to find a great mentor, but don’t wait to see if that happens for you. Accelerate your knowledge base by looking up your patients’ diagnoses in textbooks at home to compare what happened on your shift, and look for information you may have missed in school. Trade work for work with your coworkers by offering to take vitals or other tasks to make up for the time they take to help you. And don’t forget your other non-nursing colleagues as resources: Pharmacists can provide medication administration advice and check your math. Respiratory therapists can offer advice on airway management and options. Buy coffee for the people who often help you and cover their patients when they need a break. Most of all, be patient with yourself. Becoming a nurse is a process, and it takes time. There are no short cuts.

I’ve documented my transition on this blog. The posts are published as The Roz Stories and you can find them in the right-hand column under Categories (Regular Features).

What would you tell new nurses experiencing reality shock?

Reconsidering Cherry Ames on Veteran’s Day

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photo: JParadisi (2009)

     This fall, I’m reading the first 4 books of the Cherry Ames series, by Helen Wells, for the first time. Cherry Ames, if you don’t know, is an 18 year-old student nurse, who’s intuitive style of patient care and indomitable spunk lead her through a spree of madcap adventures in the halls of fictional Spencer Hospital, eventually “winning” her cap and the coveted black stripe of a graduate nurse, during World War II.  

     Unlike Cherry, I did not want to be nurse as a young person, and I wasn’t particularly interested in books about nursing. From junior high on, I felt heroines like Cherry Ames were kid stuff.  In high school, I read Kurt Vonnegut, John Irving, Ray Bradbury, Robert A.  Heinlein, and James Thurber.  Characters such as Michael Valentine and Garp held more intrigue for me.

     I felt pretty much the same way as an adult reading Cherry Ames.  In a world of Nurse Jackies, Cherry’s declarations that,

The patient always comes first. Save the patient at any cost to yourself. That was the nurse’s creed.”

and,

“Nursing had always been Cherry’s dream. She knew it was the finest way a girl could serve people, and Cherry loved people and wanted to help them. Nursing was the way to put her idealism into practice.”

come across as cheesy cliques.  At least, that’s what I thought until last Thursday, November 5th, 2009, when the Fort Hood shootings occurred, and the stories of heroism during the crisis became publicly known.

     The first story of heroism I heard was that of civilian officer Sgt. Kimberly Munley, the first responder on the scene, who simultaneously shot the assailant as he fired upon her. She put herself  (as the clique goes) in the way danger to save the lives of others.

     On Tuesday morning, I watched The Today Show. Meredith Vieira’s guests were 19 year-old Pfc. Amber Baher, and her mother.  Amber is a soldier, credited with applying a tourniquet on the bleeding wound of one of her “battle buddies,” then carrying him to safety, while she herself was shot in the back. I don’t know if it was adrenaline, but my own personal safety wasn’t really what mattered to me,”  Bahr told Meredith. “Making sure that my battle buddies were safe was my No.1 priority.”

     Another soldier, US Army Reservist Dorothy “Dorrie” Carskadon (who has family here in Portland) was injured during the shooting, reportedly while assisting one of her comrades.

     I am deeply moved by each of these stories of individuals choosing to save the lives of others, at any cost to themselves.  By their actions, they put their idealism into practice. These women, these soldiers, exemplified, on American soil, the values and commitment of our past and present veterans overseas. This type of courage happens everyday, on battlefields far from home. “Their lives’ work is our security, and the freedom we all too often take for granted.”

     In healthcare, we borrow military language. We wage a war on cancer. We battle disease. Severely broken bodies in trauma units are FUBAR. Today, I went to work, hoping I would also borrow a small amount of the courage and idealism displayed by our soldiers.

I need to reconsider my opinion of Cherry Ames.