Our ninth installment of this series talks to Lorry Schoenly, a nurse who has earned her PhD whose bio states: “Dr. Schoenly has been a nurse for 25 years and is currently specializing in correctional healthcare. She is a clinical education specialist and author actively advocating for excellence in this practice setting. Her site CorrectionalNurse.Net provides a forum to interpret correctional healthcare to the public and healthcare community. Lorry is a strong advocate for development of the specialty practice of correctional nursing, speaking and writing frequently on correctional nursing practice issues.”

Very few children say something like “I want to be a nurse and take care of prisoners when I grow up”. Yet 1 in 100 Americans is behind bars today, making the need for correctional nurses ever present.

Many nurses I know who now work in corrections came upon their career accidentally. Most nursing schools do not have clinical experiences in a jail or prison, and we don’t generally think about that as a clinical setting. I have helped nursing schools begin community rotations in correctional settings. Nursing students end up enjoying the experience. You see some interesting and unusual conditions in our specialty.

You have spoken of misconceptions about correctional nursing. How important to you personally is it to change the misconceptions?

Generally, doctors and nurses working in jails and prisons struggle with a poor professional image. I’m not sure all the reasons, but one is likely that inmate-patients are not always easy to work with. Some may paint the practitioner with the same brush as the patient population. However, this patient group is vulnerable and marginalized. They are typically an under-served group and in need of a lot of care. Some nurses see their work in corrections as much a professional calling as a job.

One of the reasons I started my blog two years ago was to make visible the nursing specialty and to improve the image of the correctional nurse. There are so many wonderful people working every day to provide needed health care to our citizens behind bars. I want to do my part to applaud them and also help them through the information I share.

You can go back in time, and give yourself some helpful advice as a nursing student in her first year. What do you tell yourself as a way to avoid something or improve something about how it all comes together for you later?

I graduated from nursing school in the early 80’s. Nursing school is such a busy and stressful time. I learned more in my few years in nursing school than I think I have ever learned prior or since. I think I would recommend that any nursing student take advantage of every clinical opportunity they can during school. All the basics apply in any clinical situation, including corrections. I would also recommend for nursing students to really see the patient in the care they are giving. There is so much to remember to do when you are first passing medications or changing a dressing. It can be easy to miss the human connection.

Once a student decides to be a specialist, such as correctional nursing, what should they expect?

Choosing a specialization can both increase and decrease career options. Although I said earlier that most correctional nurses come to the specialty accidentally, I don’t advocate that method for career management. Carefully consider the kinds of nursing care that bring the most pleasure and satisfaction, then strive for more of it through specialization. Once you are skillful in the basics of nursing, moving into a specialty is a matter of developing expertise in the common conditions and procedures of the field. For example, correctional nursing is all about the security setting and the patient population. By understanding those two variables, you understand the key components of correctional nursing care.

—————————

Thanks for the insight and first-hand knowledge, Lorry! Be sure to visit Lorry’s blog Correctional Nurse.Net where you will find MANY excellent posts regarding the challenges, benefits and details surrounding the subject of correctional/specialty nursing.

For the eighth section of this series, we reached out to Terri Polick, well-known for her online contributions as MotherJonesRN. Her bio states: “Terri Polick, RN is a psychiatric nurse and freelance writer living in Maryland.  She is the author of numerous nursing articles and the proprietor of Nurse Ratched’s Place, which gives readers an insider’s look at the mental health system.  Terri graduated from Lake View Medical Center School of Nursing.”

The bold statements are taken directly from her posted works, followed by our questions and her responses.

Sometimes, I think nurses get a little crazy about collecting letters behind their name. I’ve met nurses who wear credentials like kids wear designer jeans. It’s all about the label. When I graduated from nursing school a bizillion years ago, you got an RN, period! Do you feel that an ability to perform in working environments, regardless of the letters in your title, is enough to compete, given how hospitals and care centers are changing? Meaning: it may have been easier in the past to be “only” an RN, but are you limiting yourself today by approaching it with only licensure?

Does a degree give you a competitive edge?   It depends on what you want to do.  For example, you must have a formal degree to teach or go into research, however you do not need a degree to give excellent bedside nursing care.  Nurses were doing that way before anyone had heard the term “BSN.” Much to the chagrin of the ANA, many nurses reject the notion that you must have an advance degree to be a professional nurse. Knowledge is a tool that allows an individual to complete a task or achieve a goal.  Individuals can obtain knowledge through different pathways.  Attending inservices and reading nursing trade papers are a great way to add to your knowledge base, and let’s not forget good old fashion life experience. I am not anti-education, but college is not the only path to a successful career.    I am a three-year diploma nurse and I have never felt limited in my career.  Employers have always judged me based on the quality of my work, not the letters behind my name.

I told a group of medical interns that I graduated from a three-year diploma nursing program. One of the interns innocently asked me, “What’s that?” I felt so old when he asked me that question that I expected a museum curator to come out of the woodwork and cordon me off with a velvet rope. In the new breed of nurses coming-up today, what do you see as the one greatest challenge they will need to overcome more today than nurses did in the past?

Every generation of nurses have faced the same challenges throughout the years.  For instance, we have always worked short handed and long hours since the days of Florence Nightingale.   I think the impending nursing shortage will be the greatest challenge for the next generation of nurses.  Hospitals will be critically under staffed when older nurses finally retire from the profession.  It will be interesting to see how new generations of nurses deal with the crisis.

(referring to Millie, a nurse who worked with her “country” doctor growing up) When I graduated from high school, I decided to become a nurse. I never thought of nursing as a subservient profession because of Dr. Estes’ relationship with Millie. Do you feel that in your years of nursing, the nurse has been seen as a subservient role in most situations? How do newer nurses work specifically to combat this perception? Do you see change happening?

Has nursing been viewed as a subservient role in the past?   Yes, but not because it was nursing per say, but because women, which made up most of the nursing profession, were viewed as subservient to men. It was truly a man’s world back then and society’s view on women greatly influenced the balance of power between doctors and nurses, and how nurses were viewed as a profession.  When I was going up in the 1950’s I was surrounded by messages that told me that women were not equal to men, but I didn’t get that message when I went to the doctor’s office.  Dr. Estes and his nursing staff truly had a collegial relationship, which was unusual for the times.  As time passed, societal norms changed, which had a major impact on the working relationship between doctors and nurses.  Young people today have a hard time wrapping their heads around what nurses had to put up with before the Women’s Movement.

Part of my job as a psychiatric nurse is to help people learn to communicate more effectively with others. What skills that are not taught in nursing school apply here? How would a nursing student improve on these necessary skills before they are called-on?

I’m appalled that most nursing schools these days just skim over specialties like psych.   I learned my best communication skills during my psych rotation. My rotation was three months long and I worked 8 hour shifts on an inpatient psych unit three days a week.  My classmates and I worked with seasoned psych nurses.  We modeled our nursing practice on what we observed on the unit and I honestly learned more by watching the nursing staff talk to patients than I ever learned out of a book.  The staff gave me excellent feedback on how to improve my communication skills, which serve me well to this day.  Today’s students can improve their communication skills by turning off their cell phone, sitting down in a chair, and having a conversation with their patient.  Too many nurses don’t take the time to find out what’s on their patient’s mind.

I urge all health care professions to join the cause to promote health care reform. Whatever you believe, get involved. How has getting involved affected you professionally – both pro and con – or has it?

My zest for political action has enhanced my life.  I’ve met nurses serving in Congress, in state and federal offices, and in private industry that have passed on valuable life lessons.  These individuals all have one thing in common; they had a vision and worked hard to improve the lives of the American people.   These nurses taught me that one person could truly have a positive impact on others.   I’ve incorporated this core value into all aspects of my life, including my professional career.

Standing up for your beliefs sometimes comes with a cost.  My outspoken stance on issues cost some writing jobs, and I was taken off of a masterhead of a prominent nursing magazine because I locked horns with a certain nursing organization.  I don’t let things like this get under my skin.  I know I’m doing the right thing.

I’ve noticed that different types of talk therapy fall in and out of favor over the years, and I’ve seen a lot of changes throughout my nursing career. What are the constants, if there are any? What causes change, in your opinion?

The need to be heard and understood is a constant in any human relationship.  Theories about how to make this happen are based on new research, popular belief, and financial constraints.   Freud and his theories surrounding psychoanalyses were very influential when I graduated from nursing school.  Later on, in the 1980’s, Dr. David D. Burns popularized cognitive behavioral therapy in his book, Feeling Good: The New Mood Therapy.  Each theory has something to offer, but I believe that the push for cost containment is playing a big roll in which modality is chosen for patients.  For example, psychotherapy is time consuming and very expensive while cognitive therapy can be conducted more quickly with less cost.  HMOs influence the options we use for our patients.

As a nurse, I’ve watched HMOs grow into mutated monsters. It makes me mad as hell when my patients can’t get access to care, even with insurance. Today, I’m very careful about embedding key words into a patient’s chart so their claim will not be denied, and even then, the hospital has to fight in order to get paid. Believe me, HMOs are all about making money and they won’t stop until your bank account is stripped clean. How much control does a nurse have in insurance situations? How does a newer nurse understand how to protect the patient’s needs, even if they are not articulated?

Nurses can greatly impact insurance situations.  Hospitals hire nurse care managers to deal with insurance companies.  Their primary goal is to make sure that insurance claims are not denied and that the hospital gets paid.  These managers are in daily contact with insurance companies, and they must constantly justify why patients are still in the hospital.  Nurse care managers use information found in patient charts when talk to insurance companies. The information must validate why the patient still needs to be in the hospital.  I’ve asked case managers to tell me exactly what needs to be in my nurses notes so they can do their job more effectively.   All nurses need to team up with their nurse case manager and learn how to chart for insurance companies.

I was also taught that anyone willing to work long, hard hours could obtain the American Dream. …  I’m a nurse for life, which means I’m not going to retire. In other words, I’m going to die with my Nurse Mates on. At this point in your career, it is safe to say you’ve worked long, hard hours as a compassionate caregiver. In retrospect, is that American Dream now your story? What would provide the happy ending? What were the necessary steps, unavoidable, to get there?

Yes, I am living the American Dream thanks to my parents and to my nursing instructors.  I learned my work ethic through their example.  My parents worked hard and made sacrifices so I could have a better life, and my teachers passed on their knowledge and wisdom when I was under their tutelage.  With their support I was able to work weekends as a nursing assistant which allowed me to gain extra bedside nursing experience and graduated as one of the top students in my class.  My life is blessed thanks to those who came before me and prepared the path that I followed.

People who want to be a nurse must understand that the profession is demanding.  I have worked countless weekends, night shifts, and holidays, and I have trudged through blinding snowstorms, hurricanes, and floods to get into work.  Personal issues must be set aside.  Patient care always comes first.  Nursing also has its rewards. Nurses bear witness to the most intimate moments in a patient’s life. I’ve held newborn babies in my arms, and I’ve held the hand of the dying.  I’m honored that I’ve been a part of so many lives.  What would provide my happy ending? I hope that I can keep just one nurse from throwing in the towel by passing on what I’ve learned. I am going to die with my Nurse Mates on because it’s who I am.  Once you are a nurse, you are a nurse forever.

Was there a specific point in your career where you started looking at nursing as a whole, rather than being more focused on your own part in nursing? Not saying you’re altruistic or neglecting your personal growth, but more if there was a point when you started seeing it from a larger perspective, or if you have always done so. Not every nurse travels to Washington for what they believe in about healthcare – so what makes you different?

I come from a politically active family, so I’ve been immersed in politics all my life.  Nurses have immense collective power and my nursing instructors always encouraged my classmates and me to get involved in the legislative process by joining our professional organizations. I quickly became disillusioned with nursing organizations because they don’t represent the best interests of my patients. In 2005, I teamed up with like-minded nurses and became a founding member of the National Nursing Network Organization.  We are a 501(c)4 non-profit legislative advocacy organization that is dedicated to insuring that the same quality of health care afforded to past generations of Americans is available to future generations. Our mission is to promote, encourage, and support a National Nurse for Public Health and other projects that promote wellness and disease prevention. We also support the creation of opportunities for licensed practical and registered nurses to work together to solve our country’s health care crisis and improve the health of all Americans.  Thanks to our supporters, H.R.1119 — National Nurse Act of 2011 was introduced in the 112^th Congress. I will continue to work with NNNO team members to promote the nursing profession and health care in America.

———————

Thanks for sharing your insight and experiences, Terri! Be sure to visit Nurse Ratched’s Place to read the work Terri has been regularly offering there since 2006.

Tune-in tomorrow, and in part nine of this series we will be talking to Lorry Schoenly about some of the challenges and misconceptions often held in becoming a correctional/specialty nurse.

For our seventh installment of this series, we talked with Kim McAllister of Emergiblog.  An RN, BSN and CEN, her bio states: “My name is Kim McAllister, and I’m a registered nurse in the San Francisco Bay area. I graduated in 1978 with my ADN and have been a nurse for 33 years. My experience is predominately Emergency and Critical Care, but I have also worked in Telemetry, Psychiatry and pediatric telephone triage.” In addition to the work she has done on Emergiblog since 2005, in the summer of 2011 she was invited to become the blogger for Masters in Nursing.com, and she contributes a bi-monthly post to AllHealthcareJobs.com.

The bold statements are taken directly from her posted works, followed by our questions and her responses.

I made the decision to be a nurse in 1966, on my ninth birthday, after receiving “Cherry Ames, Student Nurse” from my great-grandmother. Are there ever lingering moments where you question the path you have chosen, or has nursing provided you a relatively unfailing foundation with lots of room to interpret it personally? How much of your path would be considered “by-the-book” for a nursing student (study, practice, advance, study, specialize, new credentials/training, etc…) and how much of it was you making it up as you went along?

Oh, I have totally questioned it a million times. Every time I feel overwhelmed at work; every time I roll out of bed, exhausted, before a night shift; every time I have to engage with a surgeon who thinks the sun rises and sets on his rear end. LOL! But the operative word in you question was “lingering”. These moments don’t linger at all. And every time I entertain “escape” fantasies and imagine myself doing something else, I realize I am where I am supposed to be.

My path was totally by-the-book. Nursing school virtually out of high school, right into med surg for a brief period followed by critical care followed by ER, all within eight years or so. Maybe it was a bit unusual in that I veered in to psych nursing for about 2 ½ years, which is something not everyone does, and it did take me 32 years to earn a BSN, which may be a little unusual. I can pretty much guarantee that  I will be the oldest MSN graduate on record, so perhaps, now, I AM making it up as I go!

I spent the last three decades working in CCU, ICU, and ER with a side of psychiatry and pediatrics. When you left nursing school, did you have loose plans to try different areas of care or did specific  professional/personal situations tend to be the ones to open doors for you or lead you somewhere?

Well, first of all, I was NEVER going to go into critical care, EVER! And within six months of graduation, that is exactly where I ended up! I was nurtured by a wonderful group of nurses in a small community hospital who took the time to bring along a young nurse who didn’t know her head from a hole in the ground. Seriously, I was twenty years old when I graduated.  It didn’t take me long to realize that in critical care you could give the sort of nursing care that you were educated to give.  You could focus on one or two patients fully. It was intense in a different way than floor nursing. I fell into ER by accident, the census was very low one summer and instead of making us stay home, they offered us the chance to orient to ER so we could help out if we wanted to. It was a very small ER, only 3 beds.  And I was NEVER going to work ER, EVER (are you detecting a pattern here?), but I figured there could be no harm in orienting. I fell in love the FIRST HOUR! LOL! It was fast, the turn over was amazing, never the same thing twice (same complaints, but every patient was different), the time just flew by – this was my next step!  The job in psychiatry came along because of an interest in working with patients with eating disorders. There was actually a unit in a local hospital and I applied. The director kept my application in her desk, and long after the unit had changed to an open general psych unit, she called and asked if I was still interested. I had always been interested in psych, loved it in school, and was rather burned out with critical care and ER. It was the right call at the right time.

But I got bored after 2 ½ years and returned to ER. Twenty years later, the same thing happened. I was burnt beyond belief and got a job 9-5 as a pediatric telephone advice RN. LOVED IT! First, I love talking to parents – it was a wonderful facility with great coworkers.  They placed no quotas, no time limits on us at all, so we could talk as long as we needed to and answer as many questions as the parent needed to ask.  Sounds wonderful – day shift, 9-5, very few weekends, no holidays….and then…I got bored! I was back in ER in 9 months (are you detecting another pattern here? LOL)

So, sorry I’m rambling, after school I expected to work in med surg for my entire career and then retire after my husband settled a ginormous case (he’s a lawyer).  Instead, I would up working in the area that scared the hell out of me in school, entering areas I never would have tried and always trying to escape to what I thought I wanted only to find the grass really isn’t greener and coming back to ER.

Earning my BSN in 2010 through the online University of Wisconsin – Green Bay BSN/LINC program was the best decision I ever made for my career. Do you feel you reached this decision because of your rich and varied field experience, or is additional education something you would now, in retrospect, suggest someone already a student simply stay with – taking educational opportunities further while they are already entrenched in the routine of school?

I went back for my BSN because I read blogs by nursing students who were excited by what they were learning, who had a passion for nursing that I wasn’t exactly feeling anymore. I thought “these people are sacrificing soooo much for a profession that I am taking for granted.  I will tell you up front that I would not have appreciated the education without the clinical experience to back it up.  And face it, after nursing school the last thing you want to see is another textbook. My thoughts would be to get out, get a job, work in the real, honest, gritty world of the real day to day nurse for at least a year or two and then get back into it. At that point you are no longer a sponge, but you are actually bringing wisdom and experience to the classroom and the difference is enormous. Plus, with online classes and programs, you can actually go for your BSN part time, my program at UWGB did not even have a time limit. There were semesters I took only one class. Anyone can do one class. Trust me, you can!

From 2008: When I started back for my BSN, my goal was to take my time and enjoy the process. … I am enjoying the process, but sometimes I have to remind myself to keep my eye on the prize. Spending a week immersed in Margaret Newman’s Health as Expanding Consciousness theory has made me glassy eyed and wondering if I should just spend the rest of my days crocheting doilies and baby blankets for the grandkids I don’t have yet. Baby blankets aside, have any of the theory-type of classes that you drudged-through actually surprised you by being more relevant than you had believed possible?

Yes, but that is because I am a geek by nature. I love that stuff. I will take nursing theory and I will see it in daily practice. Some of my colleagues in and around the interwebs disagree with me.  I found EVERY class relevant – but this is what having clinical experience does to you when you go back to school. You will relate EVERY SINGLE THING  you are learning to something you have experienced. Now, you may say, “Well, there is no room for that in MY practice!” but at least you were exposed to it and you had the opportunity to apply it or not apply it! And you are a better, more well rounded nurse for knowing it.

And for the record, I didn’t drudge through a single class! Ms. Newman may have had me wondering what on EARTH she was thinking, but that class on theory was one of the best. School for me is exciting, a constant state of “what’s next?” There is a quote in Doctor Who that sums up my philosophy of education “all of time and space, everything that ever happened or ever will… Where do you want to start?”

Like I said, I’m a total geek 😀

Nurse manager. Clinical Coordinator. Head Nurse. Whatever the title, it’s a rough job. They must balance the needs of the nurses and the unit with the orders that come down from Administration. Is there anything you’d suggest to a current student as far as classes to take, internships or other potential ways to get better exposure to this balance to understand if management is a smart trajectory?

Now this is where I am waaaay out of my league.  I wouldn’t be a manager if you paid me a million bucks. First of all, I’d be on the side of my nurses and my attitude would be one of trying to protect my staff from administration. NOT a good attitude for a manager. LOL! Seriously, I don’t know how managers do it, but I could never be one of them. I see the job as one long exercise in conflict management, and definitely not my thing. So I would not be the person to go to for management advice at all. Now given what I’ve said previously, I’ll probably be a manager by the end of the year : )

Let’s just say God help the manager who has to deal with a nurse going through severe, depressive burnout. The life of a nurse is often going to be high-stress, low pay, and demanding physically…so what are the best strategies you have learned to overcome your own professional burnout? What are some early warning signs that suggest a potential problem is on the way?

The best way to deal with burn out is not to let it happen at all. So, do NOT work yourself to the bone with overtime no matter how attractive the money looks or how badly your unit needs you or how badly your manager pleads or lays on the guilt trip.  Learn to say “no” early and often.  You need your days off to process and to refuel.  The occasional extra shift is fine, especially if it is scheduled ahead, but doing double after double or double after double-back (doing a double and then coming in 8 hours later for your regular shift) will kill your spirit no matter how old you are or how much you love your job. Have interests outside of nursing. I have so many outside interests it has become a standing joke in the family, but when you are off your mind needs to be as far away from nursing as possible.

Burn out starts insidiously. You start worrying about work outside of working hours. You start dreading your shift hours before you go in and then days before you go in. You sleep too much or you have insomnia. You overeat or don’t feel like eating at all. You feel very sad or you feel nothing at all and all you want to do on your days off is sit on the couch. You either start being unable to detach from patients and situations or you are totally detached. It is very similar to what depression feels like, and you need to be careful about decisions you make during this time.  You feel trapped and like you suffocating. You are just going through the motions. You may blame it on the job and make a job change on impulse. Conversely, don’t be afraid to make a change if that is what you need.  This is where you need to talk to someone, because you need someone with a fresh perspective. Being in the throes of full on burnout is unbelievably painful, so better to not get there at all. The word “no” and the ability to realize when you need a change and act on it are to major ways of heading it off.

Been there, done that, wiped up body fluids with the T-shirt. How long does it take a nurse to say this with confidence? After the decades you have spent as a caregiver, are there surprises still waiting for you in many shifts – or does there come a time when professionally, you really have seen it all (in a relative sense, of course)? What shocks you now, if anything – and is it ever difficult to put on your game face?

I think each nurse is unique in terms of when they feel like they “have it”.  The first year, no way! LOL! That was a year of just getting used to the role and functioning as a nurse. I would say by year 3 I was hitting a stride, but it was when I moved on from my initial hospital and realized that I could make it “out there”  that I knew I was a seasoned pro.

There are always surprises because you never know what is going to walk in the door or more importantly WHO is going to walk in the door. Each patient is different. So while the diseases and symptoms may similar, the way they manifest in the individual patient can always present you with something new. It’s never routine.  The only thing that still shocks me is the rudeness of  the public, the lack of manners and general civility, particularly concerning new technology – just when I think I HAVE seen it all, someone reaches a new plateau of  audacity with a cell phone. I can put on my game face for ANYTHING  but that!

It’s a catch-22. You are supposed to move faster because there are more people to see, but every year more information is required from each patient at the point of intake. Is there any way for an aspiring nurse to better prepare for this inequity, or do you see it as part and parcel with the changing times? How does one improve at triage if experience is not an option (say for a new nurse)?

I wrote that specifically with the emergency department in mind – and the only way to prepare for it is to adapt emerging technologies to make it (triage) a more efficient process. I’m sure that would translate to other nursing disciplines, too, but that particular quote was in reference to ER.

We’re nurses. And we should be proud of our accomplishments. Every department. Every day. Every shift. How have you found it easier to maintain this necessary sense of pride in your work? How has that changed for you as your professional experiences grow?

I’ve always had pride in my work and in nursing, but it does get easier as I gain experience because I am am able to put my experiences, and nursing in general, into a greater perspective, to see areas of growth and to marvel at the changes in both myself and the profession. Nurses, as a whole, don’t value themselves or their contribution, in my opinion. We tend to say, “Well, it’s just what we do.” Yes, it’s just what we do and thank goodness we are here to do it!

I’m saying that all entry level programs whether ADN or BSN have one thing in common: they all must teach with an eye on passing the NCLEX. That makes the programs very inflexible as to what can be taught, and neither program can provide what you really need to appreciate nursing education at the baccalaureate level: Experience. When do you think are the logical transitional periods for a nurse – when they should move from academic pursuits into practice and then back again?

I really do feel that there needs to be a period of real world experience either before or concurrent with  obtaining a BSN if you have your ADN, as I explained in a question above.  I believe that even moreso from a BSN to MSN if only that the MSN requires even more specialization – you have to know what you want to do with the degree at that point. At least this has been my personal experience. Everybody’s mileage may vary.

You refer to having an “inner-hippie” so how has the hippie within you found its expression through nursing?

LOL – freedom is NOT just another word for nothing left to lose, freedom is having the ability to be open and share and accept and appreciate the world around you and I think nursing has opened me up to be able to do that. Or maybe I chose nursing because I wanted the space to be able to do that. Oh sure, there are rules and regulations,  but they have yet to legislate how you connect with people and that is the best part of nursing. I can actually be me and more to the point, I can appreciate people for who they are and what they bring to the table of life. Life and death and illness tend to strip away facades and you see the real side of humanity on a daily basis. It isn’t always pretty, but we are privileged to be with people at the most intimate moments of their lives, often the most frightening moments.  What other profession can you think of that just being there, just being, is therapeutic?

————–

Thanks for sharing your insights and depth of experiences, Kim! Be sure to check out Kim’s work on Emergiblog and Masters in Nursing.com.

Return tomorrow, and enjoy our eighth part of this series where we talk to Terri Polick about the way she has successfully blended nursing into life, and back again.

For our sixth installment, we reached out to a nurse pursuing her Master’s degree. “Nurse Teeny” is a community health nurse who currently works supporting seniors and people with disabilities. She will be earning her Master’s degree in Clinical Nurse Leadership in May, 2012. She has been blogging at “The Makings of a Nurse” for four years.

The bold statements are taken directly from her posted works, followed by our questions and her responses.

Age 17 … decided to be a nurse. Promptly told I had “too much potential” – why not go to med school? Given your perspective now, what would be your advice to someone who is hearing that from their own family members or advisors?

I would say wouldn’t you want to have a smart nurse looking out for you?!?!? Demeaning nursing as a career that is “beneath” women and men with potential only reinforces traditional hierarchies and stereotypes. Nursing is a profession that has undergone a lot of transformation, and health care organizations are beginning to realize that having smart, autonomous nurses is a huge benefit to patients.

I would also say to keep an open mind about your future. There are a lot of pluses and minuses to going back to school for nursing, rather than choosing this profession from the beginning. I’m very thankful for the experiences I had pre-nursing and I think I’m better at my job thanks to those experiences. So by being discouraged at first, people ironically did me a favor.  The point is, you don’t have to make up your mind at age 17.

(re: July posts of struggling with hospital in BSN)[I was] putting my foot down and demanding they make it possible for me to get my BSN so that I have a degree to back up my RN license. How much does having the degree behind the license affect professional opportunities in a working/hospital environment (opposed to teaching)?

The Institute of Medicine has set benchmarks to further the profession of nursing, and one of these benchmarks is increasing the number of nurses with BSNs. Hospitals and health care organizations (especially magnet hospitals, which are great places to work) have made BSNs “preferable” in their job descriptions and many hospitals are moving toward requiring BSNs in the near future. Having a degree behind a license is becoming indispensable. Even though I have a previous Bachelor’s degree and the equivalent of a BSN (in my opinion), not having those three little letters definitely presented a barrier in my job search. Especially in the era of online applications and impersonal screening processes, meeting those “minimum recommendations” by having a degree is pretty much a necessity.

One of the things I love most about my job is that it feeds my inner nerd. Whereas I was lucky if I had time to look up an unfamiliar medication in acute care, I have the luxury of conducting my own research in order to encourage evidence-based practice among my colleagues and by other health care providers. If a student wanted to professionally cater more specifically to their inner-nerd, what would you suggest as ways to help focus their efforts, or specific areas in nursing where this has been more common?

I think it is possible to cater to your inner nerd wherever you practice, but the time constraints and everyday demands of nursing can present a challenge. I have found community health to be wonderful for me because I have time to grow my own practice. On the other hand, it’s been difficult because we have fewer resources and less impetus to foster evidence-based practice because there is no financial or professional pressure to do so. You have to be internally motivated.

I would definitely encourage nurses with intellectual interests to further their education, but I think we also have a responsibility to take this academic learning and find ways to translate it into professional practice. Whether it’s through teaching or leadership opportunities, what is the point of learning in the Nursing Ivory Tower if isn’t used to improve care. It’s ultimately about the patients.

One way to advance learning in practice is to see if your hospital has a Clinical Ladder program, which gives you opportunities for promotion (and higher pay) based on practice improvement projects, research and/or leadership opportunities that you get involved with at your workplace.

in 2007 wrote: Though I feel confident about where I am headed, part of me whispers, “How can you know what you will do with your nursing degree until you’re an actual nurse?” You write about being attracted to Pediatric Hematology/Oncology Nursing – but this is not where you arrived. How confident now are you in your professional direction, and how accurate was that statement for you in retrospect – were you qualified to know what you wanted, even in a general sense?

Not confident at all, actually.  One of the particular challenges of becoming a nurse in this economy is that my choices have been limited. I thought I would be a peds nurse, but I’m working in geriatrics instead (the irony!). I’ve taken the jobs I can get, rather than the jobs that I want. I’ve learned that I can be happy in unexpected settings and I’ve learned the virtues of flexibility (a key nursing skill!), but I can’t say that I’m “thrilled” with my current path.

Of course given our aging population, I’m probably setting myself up for a pretty secure future. But I still find myself drawn to my clients dealing with cancer. So I still think oncology is where I ultimately belong (whether with kiddos or adults is less important).

In a way, I still think my previous goals were pretty accurate and that I had made those statements based on (limited) experience. I knew what brought me joy and interested me, even back then. (I knew that cancer fascinated me looooooong before I stepped foot in nursing school). However, I also think that by not “getting my way”, I actually benefited by learning the value of an open mind and realizing that I had unexpected skills and gifts to offer.

I’m still not sure where I’ll end up but I guess I’ll know when I get there. And that is part of the adventure!

Almost 18 months into life as an RN and I’ve been struggling. Struggling to find my place. Asking myself “Was it all worth it?” Usually the answer is a resounding “Hell yes!” but I have my moments of doubt. … The future is out of my hands and the best I can do is take care of myself today. What has changed the most in the time since you wrote this? Does time in the field help to dispel some of these internal struggles, or how do you take better care of yourself today in this regard?

I wish I could say I’ve moved past this sentiment. For the most part I’m okay with the struggle and have gotten better about accepting what I can’t change and focusing on self-care (which is harder than it sounds when you’re a full-time grad student and you’re also planning a wedding). I’ve learned that self-care includes being thankful for the fact that I can go home to my family and even on my worst days, I’ve got it pretty damn good.

When I send clients away in ambulances for two weeks in a row, when I have clients who play mind games (even if I know intellectually that mental illness is to blame), when I know that the counseling and advice and therapeutic relationships I bust my rear end to establish won’t make a lick of difference for 95% of my clients, that gets to me. And makes me occasionally question the choices I have made.

But then a small victory happens. And that’s all it takes to sustain me through multiple setbacks.

Even when you set boundaries between yourself as nurse and your patient as consumer/client/call them what you will, community health nursing  often calls for an emotional investment beyond what I ever experienced in the hospital. They tell you in nursing school that you should ideally be looking ahead toward termination of the relationship from Day 1. That’s easier said than done. If a future nurse has a leaning toward more involved and personalized care, where would you suggest they seek opportunities? Have you seen great disparities where this is concerned between different units in a hospital?

I think the reality is that acute care nursing discourages personalized care. Nurses can do their best to provide person-centered care, but in 12 hours, chances are you will never see your patient again. Chances are that psychosocial concerns you express will be deferred to social workers. As patient acuity gets higher and higher, it’s just physically impossible to “get to know your patient” in the hospital, at least at the level I wanted. It doesn’t mean that you should dismiss hospital nursing altogether, because there are a lot of skills you can learn (assessment, critical thinking and TIME MANAGEMENT). There are also certain specialties that lend themselves more to a high level of personalized care (long-term care, oncology, rehab, even ICU at times). I think that’s one of the reasons I loved my peds oncology capstone so much – the staff really knew the patients and their families. Some nurses shudder at the thought of getting so close. To me, it was a non-negotiable.

Health is political. As much as we would like to pretend that we can talk about health without discussing issues of policy, equity, access, and disparities, we are dead wrong. The system is a mess and it’s going to take a lot more than direct care providers to fix it. How would you suggest that a nursing student might better equip themselves – educationally, politically, etc. –  to be able to become part of the solution?

This is one of the most frustrating parts of being a nurse. Many of our leadership classes discuss issues of policy, financing, etc. – and yet I continue to hear from colleagues that they don’t care about that “stuff” and they just want to learn how to be nurses. To me, learning about “that stuff” is part of learning how to be a nurse. And yet nursing school is already so exhausting and demanding that I can at least understand the sentiment. Working as a nurse also places demands on your heart and mind and a lot of people just don’t have the energy to give more. There is also a perception that administrators don’t understand what it’s like in the trenches and are disconnected in their policies and practices. I don’t have an answer to this larger problem. I can say I think we have a responsibility to equip ourselves to learn about the bigger picture. I just can’t say that everyone agrees with me. I think it will require a culture change at a macro level.

Give yourself permission to try jobs and clinical rotations that you never imagined you might like. Despite the multiple headaches and challenges, I continue to find that community health nursing offers a wonderful fit for me. Despite the barriers, I still feel that I am part of the solution. My job is absolutely insane. And I wouldn’t have it any other way. How many different types of care have you personally explored in your career, and do you still open yourself up to changes like this – or does time tend to tame the professional wanderlust?

I have been a nurse for almost two years now and I have practiced in critical care and community health. Neither of them were where I expected to be. I think my career trajectory is due less to “wanderlust” than necessity (see above). I needed to work as an RN. I found jobs that were willing to give me a chance. I think I have learned important lessons about being more open-minded and less myopic and I’m much more willing to try jobs that might not have appealed to me at first glance. On the other hand, I think that if I loved the work I did through and through, I’d be less likely to wander and more likely to seek opportunities for growth in the area I loved. At this point, I have changed jobs because I had to and I still feel restless. Hopefully I will find my place.

All three of the [MSN] programs to which I applied encourage you to work part-time as an RN once you pass your boards and begin the graduate-level work. So it’s not like I’ll only be in school without working too. I’ll be learning in the classroom and on the floor. If a current nursing student has interest in pursuing a Master’s, would you suggest they stay in school and keep at it (so perhaps only working part-time through it all), or would you suggest more full-time work in the field first, so they are more seasoned with real-world experiences?

I think it depends on 1) whether you can balance work and school and 2) where you are in your professional journey. I think there is a misconception that people in second-degree MSN programs are ill-equipped because they don’t have “real-world experience” as nurses. But I think that belief discounts other real-world experiences that lead us to be well-rounded people (nurses are people too!). The development of particular nursing skills and instincts can only occur in nursing, it’s true. But I think the life skills and instincts that make us human and help us relate to patients are minimized to the detriment of the profession.

If you are finishing up your nursing education and looking at Master’s programs for afterward, whether you go straight on depends on how burned out you are (and whether you think you’ll go back to school after years of being away). It also depends on what you want to accomplish with your Master’s degree. Do your homework and make sure the investment is worth the exhaustion!

[from 2007] From what I’ve read, doctorate-level nurses will be where it’s at in a few years. I am 27 and have been in school forever. The thought of getting my nursing degree, practicing and then having to go back to school to get my Master’s is daunting. Medical students have to go to school for one year more than I would, and they get to be called doctors. Do I need more patient contact before I can claim that I am advanced in my profession? In the three years since you wrote this, you have completed your degree and enrolled in a Master’s program. Have you found this is coming true, that you are seeing more doctorate-level nurses in daily working environments?

I have yet to meet a doctoral-level nurse in my practice (except for Ph.Ds as professors and nursing reseasrchers). All of the nurse practitioners I have met are Master’s-prepared and they all have different opinions about the move to the DNP. However, the DNP is still extremely new and I don’t think there are that many doctorally-prepared NPs in clinical practice yet. I am intrigued to see whether there will any professional tension once “Dr. Nurses” start becoming more prevalent.

You are about to be married (congratulations!) – so how has nursing played directly into your thoughts of stability and long-term commitments? To be clear, were there professional aspects (where to work, when to go to school, which shifts to take, etc.) that directly affected decisions made in your personal life – and if so, how has nursing helped? Has being a nurse ever felt limiting?

I made the decision to become a nurse during my first marriage (a long story!) and the decision had little to do with my personal life. I was intellectually and personally drawn to nursing and I honestly didn’t give much thought to the interplay between my professional and personal life. I just knew I wanted to move forward.

That disconnect from my personal life has certainly changed as I have “grown up” and have realized that the professional and personal are intertwined for me. I don’t feel personally fulfilled if I am not professionally fulfilled, and vice versa. I met my husband-to-be just as I was about to start my nursing education and I am fortunate enough to be marrying a man who understands how integral my work and my studies are to my identity. He has patiently stood by (and moved with me more than once) as things have gotten off to a somewhat bumpy start for me. And he has put some of his own goals on hold. The beauty of nursing is that I know I can take it with me, so to speak. When I graduate in May, I’m giving myself a break and also tipping my cap to his patience. I know that if we move for his education or for him to pursue a professional opportunity, that it doesn’t limit me (especially with my MSN…I hope).

———————————-

Thanks for sharing your experiences and wisdom, Nurse Teeny! Be sure to check out more of Nurse Teeny’s writing on her blog The Makings of a Nurse (this links to her new, self-hosted site, too!)

Tomorrow, our seventh installment of the series will talk with Kim McAllister about her experiences in nursing, and how and why they have changed through the years.

Our midpoint of this series brings us to talk a bit with Gina Rybolt – a nurse for over 14 years with her BSN and over 13 years direct experience in the ICU. Gina has been regularly blogging since 2002 at Code Blog, where in addition to many wonderful posts, you can find many interviews Gina has conducted with different nursing specialists.

The bold statements are taken directly from her posted works, followed by our questions and her responses.

After over a decade of being an ICU nurse, I had never before been the one to make The Call to the family. Are there many aspects of the job that are like this call – necessary and happening every day, but things you may never actually do yourself? Is it possible to intentionally avoid certain “unpleasant” aspects of the job, or do most things eventually find you?

I don’t think there are many, actually.  I thought and thought but the only other thing I came up with is that I have also never had to disimpact anyone 🙂  I haven’t actively avoided patients that might have to be disimpacted or anything.  I’ve just never taken care of one!  Seriously, though, we are usually given the choice of what patient assignment to take on my unit.  I tend to avoid patients that are withdrawing from alcohol if I can help it; I’m just not good with those patients.  I think eventually most things find you, however infrequently.

There are also things that simply just don’t occur often enough for everyone to get a crack at it… It’s more likely that a patient’s family is going to be there if the patient codes.  That was an unexpected code blue and with all the technology we have these days, unexpected code blues are rare.  I believe it’s more likely that a nurse will be able to ascertain when a patient isn’t doing well and will alert the family, who then usually comes to the bedside.  Although my unit does open heart surgeries, and we have had patients code where the surgeon comes in and cracks open the patient’s chest at the bedside, in over 13 years of working in a unit that cares for open heart patients, I have never once seen this thoracotomy procedure at the bedside.  It’s just so rare.

So being a highly trained RN is a bit of a double-edged sword when healthcare becomes personal. Other than treating family members, have there been any other instances where your personal feelings made it difficult to be objective/effective as a nurse?

I think it was difficult to be an objective nurse when I was inexperienced.  It’s only until you’ve seen a situation time and time and time again that you can become truly objective.  The first few times I withdrew life support from a patient, I was a mess inside.  I kept it together for the patient and the families, but it took some practice to become an effective nurse in those situations.  It can still be heartbreaking to remove someone from life support; but now I have the benefit of having done it many times and have a better handle on my feelings and know what to expect from myself, the patient, and the family.

My boss informed me that I am to start training to be charge nurse. She didn’t ask if I wanted to, just told me. Then said that I was already on the schedule to start next week. Have you found that in professional situations, this example (being moved into a supervisory position as needed) has remained the norm, or was it more of an exception? Is there generally any professional risk in refusing to take-on additional responsibilities, or can nurses generally set their own professional pace?

I honestly can’t tell you what that was.  That particular boss also “told me” that I would be precepting new nurses after only having been in that hospital for about 6 months.  I think at the time I thought, “Well, if she thinks I can do it….” but I was scared to be responsible for someone else’s training!  On the other hand, it turns out that I do well at precepting and charge and probably just needed to be pushed.  Other skills were different – I had to practically beg to be trained on CVVH (continuous hemodialysis) before getting to do so.  On the other hand, I adamantly refused to train to take care of post-op open hearts and patients on balloon pumps at my current hospital and was not forced to do so.   When I worked in CVICU in Illinois, every nurse in the unit was expected to learn how to take care of post-op open hearts, balloon pump patients, pulling femoral lines out post-angioplasty.  At my current position, there are enough people that want to do a wide range of skills, so not everyone needs to learn every skill.  I think that’s as it should be.  We are all competent enough to take care of critically ill patients of any kind.  I am completely proficient to help during an emergency with a patient who has a balloon pump, even if I don’t know exactly how to work the balloon pump – the nurse who knows how to work the balloon pump focuses on that and the rest of us focus on everything else that needs to be done.   So it may depend on the unit.  I believe I have been able to set my own professional pace with some encouragement to learn skills I may not have had the confidence to sign up for myself, so to speak.

When I first began nursing in an ICU, I was very naive. I remember as a young naive new ICU RN that VADs scared me but were also very exciting. Are there any specific lessons you learned that might help a newer nurse get past their own naiveté a bit more quickly? Tips to avoid a rude awakening?

I don’t know why this is, but when I was training, I felt as though I was supposed to already know everything.  That’s very counter-intuitive, but I felt that if I didn’t have the right answer all the time I was going to look stupid.  Turns out, that’s an unbelievable amount of stress to put on yourself.  I realized when I started training other nurses that I didn’t expect them to know anything!  I specifically remember wishing that I hadn’t been so hard on myself when I was new.  When you’re new, that’s the absolute perfect time to ask stupid questions.  I wish I hadn’t been so afraid to just be inexperienced.  One of the things that scares a preceptor the most is a nurse who doesn’t know what she doesn’t know.

I can’t really say I felt great about “saving” her. Does that sound a bit callous? I’m just not sure what I saved her for. More bedrest? An amputation of her foot? More infection? More dialysis? You talk a lot about patient rights and dignity in decision-making. How do you tend to convey difficult information to help them understand the gravity of their situation – ideas not made clear on a chart? Is it usually the patient or the family that has the hardest time making difficult decisions, and what is a nurse’s role in this situation?

Actually, the doctor conveys the gravity of the situation more often than not.  I do get asked this a lot: “Have you ever seen someone this sick recover?”  And depending on how sick the person is, I usually have to say no and watch the heartbreak on their faces.  The patient is often obtunded or minimally conscious, if conscious at all, so the difficult decisions fall to the family.  Every once in awhile I’ll get a patient who’s had The Discussion with their doctor and all the ducks are in a row, forms filled out.   As for how I convey difficult information, I try the most direct route possible.  I try very hard not to sugar-coat or make it sound better than it is.  I’m not shockingly blunt, but beating around the bush is counterproductive.  I’ll say, ‘You know, her blood pressure is really awful, and I already have her on several medications to support it, so this isn’t looking good at all.”  As for the chart – the gravity of the situation is spelled out very clearly most of the time.  “Prognosis: poor” or “guarded” is something I see often.

The nurse’s role in the situation is to be there when the doctor is talking with the patient and/or family about the situation.  A lot of information is being thrown at them, very unfamiliar words are being said, and although they appear to understand at the time there are ALWAYS questions later that they didn’t think to ask when the doctor was there.  So if the nurse is there for the conversation, they can help to clarify or answer questions about what the doctor said, or reiterate if necessary.

The patient stated that he no longer wished to be a burden on his family and was ready to go. At which point I thought Uh oh… now we’re going to establish depression and an inability for the patient to make decisions in his own best interest. When a patient reaches this state of mind, how does a nurse offer proper guidance and information to help them make the best decision? How “clinical”  (opposed to emotional) do situations like this remain from a nurse’s perspective?

Unless the patient in question is literally (sorry) rotting in the bed on maximum life support (and then some), I have no personal feelings about whether they should fight to live or decide to throw in the towel.  So my personal feelings almost never differ from what the patient is going to think, if I understand your question correctly.  I more often deal with families struggling with these sorts of decisions rather than the patients.  The patients are typically barely conscious, if at all.   That particular patient was a rarity.  As for helping them understand fear, I have little experience with this as well.  I can help reassure a family that they are making the right decision to continue with or withdraw life support, but I don’t deal with the patient’s actual fear of death very often at all.

I think there’s a balance between clinical and emotional for these situations.  I tried to present him with as much information as he could handle in his condition, answer his questions as thoroughly as possible and offer reassurance that if he started having pain at all, we’d address it and treat it.  There’s a way to deliver this information in a sensitive way – making lots of eye contact, not doing anything else while talking to the patient (eg, not straightening the bedsheets, charting on the computer, playing around with the monitor), holding the patient’s hand if he or she seems to want that.  You have to read body language and pay attention to nonverbal cues.  You don’t want to get overly emotional and have the patient think that YOU are the one who needs comforting.  There are ways to show concern and care without getting all teary and crying.

I realize this may sound bizarre to laypeople, but we ARE critical care nurses for a reason. We thrive on stress and excitement and chaos and mayhem. You made that statement when you were less than one year into marriage and no kids. Seven years later, you have a lovely family of your own. Did having children temper your natural attraction to chaos, and is it affecting your professional direction?

Yes!  Having children absolutely tempered my attraction to chaos.  I have enough chaos in my life here at home (good chaos!).  But sometimes I wonder if I wouldn’t be tired of the adrenaline whether I’d had children or not.  I’m definitely looking into changing my profession direction within the next few years to something less … exciting 🙂   On the other hand, experience has made many situations less stressful than they were in the past, simply because I know better how to handle them now.

I had no idea, as a young impressionable eager nursing student, that I would eventually be SO inundated with paperwork once I became a nurse. For the love of God and cotton candy, this has all gone WAY out of control. Is there anything a nursing student can do to better prepare for the profession’s inherent bureaucracy?

No.  It’s only once you are actually 100% responsible for the patient that you get a real idea of the amount of paperwork involved.  It’s mostly on computer now, so I’m not even sure I can call it “paperwork.”  We call them “flow sheets,” but everything that was on paper is now on the computer and it still needs to be done – we just type it out now instead of write it.  Actually, now that it’s all on the computer, they’ve managed to integrate a lot of it.  We don’t have to keep coagulation or blood gas flowsheets anymore – the physician can just look at the labs on the computer to see the progression.  But we still have to keep blood glucose flow sheets, wound management sheets, intake/output, restraints, etc etc etc.

You have collected years worth of stories and interviews from nurses all over the nursing field. Has any specific story or interview inspired you personally to look into a new direction?

Not that I can think of.  I did an interview I haven’t posted yet with a nurse volunteer organization, and that sounded really neat but not for this time in my life with small children.  I have incredible flexibility with my job for now that would be hard to match anywhere else, so I’m going to stick with where I’m at for now.  I think I’d like to eventually get into hospice or palliative care, but I’m finding it’s difficult to switch to another area of nursing.

What have been the real game changers for you as a nurse, professionally?

I wouldn’t call it a “game changer,” but attending conferences such as NTI (National Teaching Institute – they organize a conference for ICU nurses every year with classes and expos) can be very inspiring.  There’s lots of camaraderie, networking, and education opportunities at this conference.  I have been to a couple of them and they can really ignite a passion for your job.  I’d recommend any nurse to attend such a conference in their specialty every few years.

I feel that nursing school barely touches the tip of the iceberg in preparing someone to be a nurse.  I think the best preparation you can do to be a nurse is to work as a nurse’s aide or tech in the hospital.  And if the nurses you work with find out you are going to nursing school, many of them will go out of their way to seek you out and show you different things.  I’ve learned more in one CNA shift than a week’s worth of school clinicals.  Also, if you are an aide/tech and work with patients, you are that much ahead of the game when you do start clinicals in school – you already know how to relate to patients.  And that can be quite a hurdle to overcome.  (I think I went on a rambling tangent there!)

I think my exposure to patients who are being subjected to futile care has shaped my own personal nursing philosophy over the years and has made me more interested in palliative care and educating patients and families about their choices and the possible outcomes of those choices.  And letting them know that it’s okay to use some treatments and refuse others.

——————

Thanks for your personal insights and observations, Gina! Be sure to visit Code Blog to see more of Gina’s work, and spend time reviewing her interviews to see if there is a nursing specialty that answers to your own needs.

Come back tomorrow for part six of our series, where we will be talking with Nurse Teeny, a popular blogger at Makings of a Nurse, as she talks with us about her experiences in nursing , family, and more.

Our fourth installment of this ten-part series talks to Lovlei McKinnie, a popular nursing blogger who has been expressing her ideas at The Dog Ate My Care Plan for more than two years. Her bio states: “I’m a 30-yr-old mother of three and wife to one. I am a senior nursing student in an evening/weekend BSN program (still working FT) and will graduate December 2011. Be nice to me…I may be your nurse some day!” As a participant who is also currently a senior nursing student, Lovlei offers a unique perspective.

The bold statements are taken directly from her posted works, followed by our questions and her responses.

The Kaplan review course that many people like to take before they take their boards (it’s actually required for my program) is actually less about content review and more about how to be a better test taker. It’s all about strategies for breaking down the questions and recognizing traps. In testing your way up to becoming a practicing caregiver, do you find that the book tests or the practical skill tests are the most challenging and why? In addition to becoming a better test taker, are there any other lessons you have picked-up that might help a nursing student know what to expect?

I would definitely have to say that book tests are more challenging. Practical skill tests (or “check-offs” as we like to call them) are simpler because they are pretty much just memorization of sequential tasks—after A comes B, then you do C. But quizzes and exams involve application and critical thinking. You will never see questions on a nursing school exam like “What is pneumonia?” or “What is normal blood pressure?” You just don’t get simple, black or white, definition-type questions on nursing school exams. And there usually aren’t true or false questions either because in health care there’s always usually an exception to the rule. What you will see is something along the lines of: “While assessing her 70-year-old patient admitted with pneumonia, Nurse Flo auscultates his blood pressure to be 165/72. Which of the following does she consider to be an age-related change contributed to this finding?” followed by a list of conditions/symptoms. This type of question requires that I realize first off that the patient being admitted for pneumonia is extraneous information I don’t need to answer the question; that I already know the normal range for blood pressure so that I notice that Flo’s patient’s systolic blood pressure (top number) is elevated; as well as being aware that a change frequently seen in older adults (such as a 70-year-old) that would increase the risk of systolic hypertension is a loss of elasticity in the arterial walls (which was the answer). To arrive at that point I had to pull from knowledge of pathophysiology (specifically age-related physiologic changes) and etiology, know normal ranges for vital signs, all while weeding out distracters—from the stem as well as the answer options. There’s definitely nothing “wham bam thank you ma’am” about nursing school exam questions at all.

That’s not to say that skills check-offs are exactly cake. Whereas in an exam situation even though you’re in a room full of people you’re sort of by yourself—alone in your concentrative bubble, hovering over your Scan-tron. But when you do check-offs, oftentimes all eyes are on you so there’s a certain pressure to perform well or risk looking stupid or being corrected in front of a crowd. Sometimes the nerves alone will have you stuck on stupid. But I look at it like this: we’re students; we’re not supposed to know it all. That’s what we’re here (paying good money) for—to learn and to practice. Your professors and clinical instructors are resources—use them. Besides, better to get it right now than to go out into the world experimenting on patients…

And not to sound cliché but “practice makes perfect”—in and out of the classroom. Doing NCLEX practice questions will help you get used to the complexity of nursing school questions. It’s an adjustment from the straight-forward or simple recall type of questions most students are used to. And take advantage of any “open lab” hours your school offers to brush up on your clinical skills—it can really help build your confidence.

Part of the problem is I feel like we do a lot of stuffing and dumping every semester—we focus on and study what we need to know for that particular class and then that knowledge gets neatly tucked away in some obscure corner (hopefully of the mind and not of a bookshelf). As more time passes and your hands-on experiences in the hospital increase, are you finding more of this information does come into play – or were you right, it is a case of stuffing and dumping a lot of “book” learning that does not get applied in an obviously practical manner?

Surprisingly, you remember a lot more than you think you do—especially when it’s put into use. Nursing school is sort of like baking a cake—you get a bowl, add butter and sugar (stir), beat in the eggs (stir), dump in the flour (stir), lastly some milk (stir), then pop it in the oven and out comes a cake. In nursing school you start out with raw, scared out of their wits students and little by little you build them up—start out with a little history and theory, introduce the components of the nursing process (good ol’ ADPIE), slip in disease processes and management, add in some clinical skills…and out comes a nurse (well just about). I’m oversimplifying, there’s a little more to it than that, but you get my drift. All the while during this process new learning builds upon what has been previously learned and over time increases in difficulty and complexity. These “layers” of the nursing school cake are what help seal in the flavor so to speak—the remembrance. Now you have all of this knowledge, all of these concepts and theories and skills, but it really doesn’t “click” until you put it to work. When you are able to take what has been learned in the classroom and actually apply it in the clinical setting—that—is the icing on the cake. Now I don’t know about you but I always remember the icing on a cake—that’s what I’m licking off each finger. So while you may not remember that the American Nurses Association was previously known as the Nurses Associated Alumnae or that it was started in 1898, most the of truly important stuff, sticks.

Nursing is one of those fields where you truly never stop learning. There are always new meds, new equipment, new best practices… To all of those that have come before me—how the hell do you retain it all?!? You mention using mnemonics to help remember things, so are there some specifics that you devised personally that might help others? Are there any other tricks or techniques you have developed to help you stay on top of it all, and not be overwhelmed?

As I’ve said before—mnemonics are your friend! Not only are they fun, but they work! I haven’t created any personally but there are plenty to go around. One of my all-time favorites (and one I will never forget) is one describing the side effects of anticholinergics—”Can’t see (blurred vision), can’t pee (urinary retention), can’t spit (dry mouth), can’t sh!t (I think you can figure that one out…).” I talk about a few others in my post VEAL CHOP.

Once you figure out what type of learner you are you can really hone in on what will help reinforce what you are learning in class and clinical. Visual learners may find outlines (and most professors do use powerpoints), diagrams or pictures of complex concepts such as the renin-angiotensin-aldosterone system, or color-coded pharmacology flashcards helpful. On the other hand, recording lectures for playback later may work for more auditory learners. I like to record lectures on my iPhone and then listen to them during my “downtime” (imagine a nursing student having any of that!)—in the car, while I’m washing dishes, etc. Trust me you’ll hear things you didn’t the first time around during lecture—you may have been taking notes, digging through your bag for a pen, texting (as if!), or whatever. And then there are tactile learners who learn best by doing. These students can benefit by spending extra time in the lab (or meeting up with other students) practicing their skills or volunteering for additional hands-on experiences at clinicals.

And then there are some people (myself included) who don’t just fit into one category so you may need to mix and match–whatever works. Different strokes for different folks as I like to say.

Just remember to be patient with yourself—it may take a little while to find out what works best for you. And be prepared to tweak your routine—what works for one class may not work for another and you may need to adjust your efforts from semester to semester.

We finally had orientation which gave me a little taste of what I should expect for the next two and a half years—total and complete information overload. If a would-be nursing student wanted to do a little prep work, is there anything you could suggest to try to reduce the impact this information overload? How do you tend to handle it now, and does it remain as daunting as it first appeared?

Some aspects of nursing—such as the critical thinking piece—are a little harder to prepare for. It’s a new way of processing information for most people and it takes time and practice to master.

But one thing that an incoming nursing student could probably benefit from reviewing that many people usually do not think of is math. No fancy calculus or trigonometry, just a few of the basics—fractions, decimals, and systems of measurement (metric, apothecary, and household). This is in preparation for a very important element of nursing school that freaks most students out—med math. Med math will have you sweating like a menopausal diabetic with a blood glucose of 45. It’s not so much that the math itself is that hard because it isn’t—especially if you use dimensional analysis—once you know your conversions it’s pretty much impossible for you to fudge it up. But it’s the fact that a mistake—something as simple as erroneously moving the decimal one time to the right overdosing a patient with ten times too much medication—could potentially cost them their life. The seriousness of pharmacology and drug calculations is why most nursing programs administer periodic med math tests. Students are required to pass these exams with at least a 90% (some programs demand a perfect score) or face not being allowed to administer medications in the clinical setting, failing the class and/or clinical, or even being removed from the nursing program altogether.

As far as dealing with information overload, for the most part you’re always going to feel like you’re in it up to your eyeballs—that’s just what nursing school is. But when you get to “that” point, you have to learn to take a step back. Sometimes I’ll push myself so hard, up late studying until the wee hours of the morning telling myself “just one more hour.” But I’m at the point where my eyes are just glazing over the words but my brain is not registering any of it. I have learned to tell myself, I say, “Self. Enough is enough. Time to close the book and go to bed.” And that’s what I do. Being driven and persistent are both good qualities, but too much of a good thing can be a bad thing (wu ji bi fan). And so I have learned to set limits with myself into order to avoid driving myself into the ground.

One of the most basic things nurses and nurses-to-be need to recognize is that in order for you to be able to take care of others, you must first take care of yourself. Get adequate sleep—or at least take naps. Eat breakfast. And lunch. And dinner. Take study breaks. Go for a walk. Get a mani/pedi—or do your own if that’s not in the budget. And for goodness sake—learn how to say NO! I cannot tell you how important that is. Most nursing students—especially those with jobs and families—already have plates that runneth over, don’t make it worse by biting off more than you can chew.

With 4 more semesters to go, it kind of makes you wonder if that person sitting next to you now will walk with you at commencement.  Nursing school really is survival of the fittest. Doing well in class is a given, but what else have you seen that helps to make a nurse one of the survivors? How does one “toughen-up” to prepare for what is coming?

First things first—you need to be sure that nursing is really what you want to do. A lot of people get sucked into the nursing media hype—the ginormous advertisements with nurses smiling ear to ear…the so-called abundance of job opportunities due to the nursing shortage…talk of how the pay is so great… But the not-so-shiny parts of nursing don’t seem to get broadcasted—the difficult patients (or families), the stress, the physical demands, the long shifts and rotating schedules, the sometimes having to watch people die. Often people drop out because they discover a few months into class and clinicals that they hate it. Nursing is definitely not for everyone. But sometimes people are so mesmerized by the nursing castle in the sky that they truly don’t understand what nursing really is until they’re in the thick of it.

Sometimes you have to change your mind set. With nursing school admissions being as competitive as they are, you get a lot of the cream of the crop—many of the students come in the door with GPAs at or close to 4.0’s and plan to keep them that way. But in nursing school perfectionism can be a double-edged sword that can either motivate you to succeed or chop off your legs bringing you to your knees. You have to come into this based in reality—know that it’s going to be hard work, know that you’re going to have bad days (and good ones too!). These are not the prerequisites anymore–this is a whole different animal. You may have to let go of that I-gotta-get-an-A (every time) mindset. I was one of those people. My first B+ hurt me to my soul. After the initial shock wore off I had to regroup and jump back in. You have to keep it moving. I’m not saying not to set high standards for yourself, just do your best—that’s all anyone (including yourself) can ask of you. But with that said, I do not subscribe to the whole “C = RN” mentality…

And lastly, you have to be organized. Organization is crucial. Whether it’s a planner, iPhone app, stickies—whatever works. Find a system that works for you. With so much to read, care plans/case studies/projects to do, clinical work to keep track of, and quizzes and exams to take, it’s easy to fall off the bandwagon. And it’s even easier to stay there if you’re not careful. But if you do happen to find yourself behind, first, take a breath. If you let frustration set in, it’ll be even harder to get your rhythm back. Next, assess the situation. Are you behind because you just had to go to that party last night and then came home too tired to study or is it because you keep being distracted by the kids, the dog, or the dirty dishes in the sink? Figure out what you can do differently to try and alleviate the problem and then do it. Did it work? If not, reexamine the situation and try something different.

Hey, and by the way–we just walked through the nursing process—assessment, diagnosis, planning, intervention, evaluation. Go nursing!

There’s more than one way to skin a cat—or give a Z-track injection, insert a Foley catheter, or just about any other clinical skill. And the way it’s taught in the textbook may or may not differ from the way the clinical instructor will show you that they do it “in the real world.” Have you found that there is a great variance in the way people perform these types of tasks or does efficiency kind of trump everything – so generally speaking, there is going to be a “right” way to do it? How much of this is personal, compared to how much is answering to a superior or hospital rule?

I think this can be attributed to a number of things—efficiency, personal preference, even “old school” vs. “new school.” And practices and policies are constantly changing. As well they should—nursing is all about evidence-based practice these days.

I also wouldn’t say there’s a great variance in the way things are done, but just think about think about if it were a drug calculation—a small variation could have a big impact on the patient. Sometimes it’s an education thing—nurses need to be educated as well.

For instance, recently it was asked if nurses needed to alcohol swab single-use vials after popping off the tops. Some argue no—that the vials are sterile under the cap so swabbing is unnecessary. Others argue yes—that the cap is just there to protect the top of the vial, but does not ensure sterility. And still there are others who are from the “swab everything” camp, who figure why not—it can’t hurt. I am still not sure what the “official” answer is on this one…

And once in clinical it was asked if we do indeed need to wipe off the first drop of blood when doing an Accu-Chek. According to Accu-Chek themselves discarding the first drop of blood is unnecessary, but the policy of the hospital where we were assigned dictated to do so and that trumps the “FAQs” of the meter’s manufacturer—so we wiped off the first drop of blood when we did our Accu-Cheks. When in doubt always check the hospital’s policy, which to make things even more confusing, often differs from place to place.

If you can’t take the heat, nursing school is definitely one kitchen you want to stay out of. Nursing school is NO JOKE. Add kids, jobs, and LIFE to that—and you’d better be prepared for some blood, sweat, and tears. With three children and a husband, you certainly have a lot to juggle while attending nursing school. Looking back, is there anything you would have done differently as far as your family is concerned, or perhaps asked them to help you with a little better, knowing what you do now?  How would a nursing student in a similar situation be able to reduce the amount of tears shed?

I don’t think I fully comprehended the magnitude of the time commitment my nursing program was going to require of me—especially since it’s technically a part-time program. Though we only take two courses a semester, there’s so much work to be done outside of class—case studies, care plans, NCLEX practice questions…not to mention having to read as many as 10 chapters in one week! Add a full-time job (and a night-shift job at that—which I’m told guarantees me an early demise anyway), three kids—one with special needs, and a husband…. So not only do I have schoolwork to manage, there are work meetings or trainings, IEP meetings and report card conferences, doctor/dentist appointments, and regular everyday stuff—food shopping, laundry… It’s definitely a lot.

You can try to prepare your family ahead of time, and planning is very helpful, but talking about it is very different from actually living it. My family misses me, and I them. My son once said: “Mom, I haven’t seen you for three days!” And it was true. I had clinical all day Saturday and Sunday so I was out of the house before dawn, worked day shift Monday, and had class Monday night. My husband will occasionally have a tantrum because I’ve zoned out so far it was the only way to get my attention. Realize that in all of this it is not only you that is making sacrifices.

My advice would be to go in with a clear head a plan. And know that depending on how things evolve you may need a Plan B (or even a Plan C)—and that’s okay. It’s not easy. If it were easy, everyone would do it. You have to be organized. Think ahead. Who does the cooking, the laundry, the shopping? See if those tasks be redistributed or look at how can you re-work them into a new routine. Would it be helpful to cook several meals ahead of time so that your family can “heat and eat” them later themselves? Another thing, your house does not need to be immaculate. As long as everyone’s clean, fed, and safe, who cares if you haven’t ironed your curtains in a couple months?

Identify your support system—is it your husband, your parent(s), other family and friends? Talk to them about the journey you’re about to embark on and more than likely, they’ll want to help. You may need someone else to take the kids to ballet/soccer practice on occasion. You’re going to need a quiet place to study. I remember once it got so chaotic in my house that I had to take my textbook and prop it up on the steering wheel in my Suburban. And in all the madness, don’t forget to set time aside for your family and for yourself. My husband and I have “date nights” at least once a month—we go out to dinner, maybe catch a movie or a play. My five-year-old is on a cookie-making mission right now so I buy the ready-to-bake sugar cookies and we add our own pretty sprinkles/toppings. Just little things, but they mean a lot. And sometimes you’ll just need time alone, and that’s okay too.

I’m really starting to rethink my desire to be a NICU nurse. Not because of the less than stellar experience I had (because the nurses in the NICU where I volunteer are great), but because I’m starting to think it’s just not enough excitement (patient care/interaction) for me. Having a specific idea of where you want to go as a nurse is what brings many people into nursing school. How has this changed for you, now that you are transitioning more from the academic side of it to the practical side of it? Do you have a crystal clear direction now for what you want to do with nursing, or is it a more general one at this point? What seems to affect this direction?

I’ve always wanted to do pediatrics. I like babies (though with three kids/strikes I am retired from that line of business) so I initially thought NICU would be a good fit for me. A couple years ago I began volunteering as a “cuddler” in the NICU to get a better glimpse at life as a NICU nurse (and the ability to do a little undercover networking while I was there also didn’t hurt). Volunteering or shadowing in an area of nursing you may be interested in is a great way to get the inside scoop. Clinicals are another. Many students who initially thought they wouldn’t be caught dead working on a maternity floor loved it after our maternal/newborn rotation. So just go into things with an open mind.

I lost a grandmother to cancer and worked in a cancer treatment facility a few years back. I was so amazed and inspired by the strength of the patients there—their will to beats the odds. I have since fallen in love with pediatric oncology/hematology nursing. It combines something I love (peds) with something I hate (cancer)—all the more reason why I feel drawn to join the fight. I began volunteering with Alex’s Lemonade Stand Foundation. I follow a lot of oncology (nursing and non-nursing) orgs on Twitter—as well as some of the pediatric cancer “child warriors.” I subscribe to CaringBridge pages and blogs of oncology patients and families. I love following their journeys and cannot wait to be able to truly contribute to the cause. I’ve begun networking with some of the nurses and nurse managers in pediatric oncology in my area and even shadowed an oncology nurse for a day and they almost had to kick me out because I absolutely loved it!

For anyone planning/needing to take the HESI, what I found to be really helpful were the case studies and practice quizzes/tests on Evolve. I also liked that they gave you the rationales for the correct and incorrect answers—it really helps you learn to critically think through the scenarios. Were there other specific sites or helpful techniques that allowed you to improve the depth of your learning?

I’m a hands-on, visual learner. So for me, learning (skills especially) is doing. And although SimMan, SimWoman, or SimBaby may be okay initially—there’s nothing like the real thing. Most students get so caught up in the “work” of clinicals that they don’t realize they’re one of your best resources! You’re not going to get closer to the real thing than that because it is the real thing. Don’t spend your day just looking up meds or pathophys for your care plans, get involved—volunteer to assist your primary nurse with tests or procedures, or if you can’t help ask if you can at least observe. If there are opportunities to go to specialty floors—such as the perioperative suite or the ICU—by all means, go. Every little bit helps reinforce what you’re learning.

As far as your general knowledge base, I think it’s a good idea to review with resources other than your own textbooks. Depending on your professors’ teaching style, they may be working from your textbooks’ chapter outlines and/or test question bank.s Sometimes professors may unconsciously “teach the tests.” They know what’s important (or even what they think is important) and may focus their lectures and exams solely on those areas (because there is so much to learn).  But the NCLEX-RN will not be based on your lectures and textbooks—it’s a national exam. So I like to cover my bases and make sure I have a broad understanding of the subject matter. I do that by testing myself against alternate resources. It’s kind of like in research when they repeat a study to see if they come up with the same results. What has been working well for me is doing case studies as well as NCLEX-style review questions in the Davis Success Series (see Resources at TDAMCP) books—both of which are broken down into specialties (med-surg, psych, peds, etc.) allowing you to focus on the area(s) you need to work on. And since they are not based on your textbook, if you are also able to do well on those exams you can be relatively confident that you have a solid knowledge base in those areas.

This semester I got to do a lot more “real” nursing stuff and not just vital signs, AM care, and changing sheets (though I can miter like nobody’s business). Can you talk a little about how the idea of becoming a nurse changes for you as you actually start to do it? What was something you did or someone said, that made you feel: “OK, I truly deserve to be here: I am going to be a good nurse”?

The more clinical experience you get, the more comfortable you will feel. At first most students (particularly the ones that come into the program without any health care experience) are terrified to even step foot in a patient’s room alone— huddling around the nursing station or staying close to their clinical instructor.  Then you begin to slowly venture from the nest. You start off slow, getting vital signs and helping with AM care. Then you might progress to administering medications, usually PO (by mouth) at first, then maybe you’ll give a newborn their hep B shot in maternity, or hang your first IV. Over time you’ll continue to add new skills—and number of patients. You’ll begin to switch from thinking reactively to proactively—anticipating your patient’s needs instead of intervening once a problem develops. By the end of the program you’ll be running around like a chicken with its head cut off like the rest of them—trust me, you’ll feel like a real nurse. But what really seals the deal for me are the patients. To have a fun-filled (read: crazy, hectic) day filled with more ups and downs than a roller coaster end with a patient pulling you to the side and genuinely thanking you for the care that you provided to them (Me?!? Little ol’ student nurse me?) makes it all worth it. I’ve even had nurses tell me “you were more his nurse today than I was.” Now I’m ready to make it official—bring on the NCLEX-RN!

——————————

Thanks for the wonderful insights, Lovlei, and good luck on completing your degree! Be sure to visit The Dog Ate My Care Plan for more of Lovlei’s work.

Tune in tomorrow, for our fifth part of this series, where we will be talking with Gina Rybolt about some of her thoughts after more than 14 years spent as a practicing RN.

Part three of our series connects with Keith Carlson, an outspoken and popular nurse blogger who has been adding ideas to his personal blog Digital Doorway since 2005. His bio states: “I am a nurse, writer, Laughter Yoga Leader, and Certified Professional Coach. Originally interested in pursuing a career in the arts, my disposition has led me to a life in healthcare and service. One of my life goals is to live a simple, community-oriented existence in a Spanish-speaking country with my lovely wife, some dogs, good friends, good wine, an organic garden, and a pile of books (and a laptop with a fast Internet connection, of course!).”

The bold statements are taken directly from his posted works, followed by our questions and his responses.

I have dedicated most of my nursing career to working with vulnerable and under-served populations, and have used my Spanish-language skills to work extensively with the Latino community. If a student wanted to expand their potential here, other than being bilingual, what do you suggest?

If a nurse wants to work with so-called vulnerable populations, there is nothing better than hands-on experience in that particular clinical and cultural arena. I recommend urban community health centers, homeless outreach programs, under-served rural areas, Indian reservations under the Bureau of Indian Affairs (BIA), and venues where those most in need are served. You cannot serve your patients’ needs in a vacuum, thus the importance of understanding the historical and socioeconomic circumstances that caused a particular population’s present-day situation. You also cannot step into this sort of situation out of pity or some erroneous notion of self-sacrifice. Embracing and understanding the challenges that others face is paramount, as well as understanding your own motivations for choosing to serve them as a health provider.

I am not meaning to say that my work as a nurse is thankless, pointless and unrewarding. Far from it. But the Sisyphean aspect of nursing resides in the notion that whatever we do, however we do it, it never seems to be enough. How does a single force in this storm determine what they are doing “helps” and is part of the solution rather than more of the same old, same old? How do we get past the rock?

As an individual serving within a larger health care system, one can only exercise a modicum of control over your circumstance, as well as the circumstances of others. While it is also true that there are many variables at play vis-à-vis patients’ health as well as their relative chances of recovery, we can bring our skills, compassion and intelligence to bear through the exercise of critical thinking, simple kindness, and intuition (an important yet often overlooked skill in nursing and medicine). As nurses, we can also question the system, stand up for the things that we believe to be right, and speak truth to power when we feel that things are not as they should be. Whether it is safe staffing levels, questionable working conditions, a corrupt administration, or sloppy sterile technique in the OR, our voices are important and need to be heard. Additionally, the media often propagates a false image of nurses that we nurses can choose to undermine and change when given the opportunity to do so.

When it comes to patient care itself, at times it is the quality of our interpersonal interactions with our patients—rather than our actual nursing skills—that are remembered most by those under our care. Anyone can be a skilled technician since those skills can be learned and practiced. However, being a skilled listener with an intuitive and compassionate ear is another thing altogether, and this is where we can sometimes have the most memorable and significant impact on the trajectory of another person’s life.

I inherited a multifaceted position that was poorly explained and passed on in a manner that created the steepest possible learning curve as I dipped my toes in the waters of local public health. In your experience, do most positions nurses will fill fit this description? How do you fend against being unprepared, or can you?

Many nursing positions are inherited complete with a manual, job description, as well as supportive colleagues who will assist the nurse in fulfilling his or her duties. However, certain positions are sometimes passed on with poor documentation, minimal training, and a sense that one is being “thrown to the wolves.” Your best defense against being poorly prepared for a new position is interviewing the person you are replacing, if possible, having frank conversations with your new supervisors and colleagues prior to your first day, and gaining as much of an understanding of your new responsibilities as you can manage before you punch the clock for the first time. Requesting a preceptor or mentor can sometimes be helpful, and many workplaces have programs whose aim is to make sure nurses succeed in their newly acquired positions. At other times, you simply dive in feet first, cross your fingers, and hope for the best as you apply your best skills and knowledge.

[from 2008] Nursing is certainly the career track upon which I have been treading since 1996, and it is indeed a viable, flexible and (sometimes) attractive way to earn a living. Of course, when push comes to shove and money needs to be made, a job as a nurse will certainly pay the bills, but only time will tell if there is indeed a nursing job out there that can truly feed my soul, for that is what I have decided work should really do. In the three years following this statement and reflecting on your past experiences again today, are you finding that nursing does answer to your hungry soul – or are you still longing for this today? If still hungry, how would you advise students to quench their own hungers?

Nursing intermittently feeds my soul, however, to be honest, it is also sometimes simply a means to a financial end. At this point in my life, I have found that work cannot provide me with the spiritual and emotional fulfillment that I seek, thus I’m endeavoring to find that elsewhere. While I do indeed put my heart and soul into my work as a nurse, I also pour my heart and soul into my daily life, and I have found that relationships, my marriage, family, and the pursuit of optimal physical, spiritual and emotional health are what truly feed me. I advise other nurses to seek the fulfillment of their spiritual hunger through whatever healthy means are necessary, but certainly seek it outside of the workplace. We all need a place to rest, a place where we feel safe, healthy and whole, and it’s very important to not expect our work (nor our colleagues) to fulfill our multifaceted needs.

I feel that we overvalue the importance of work and career in our culture, and this is underscored by the fact that, when meeting someone for the first time, we tend to ask the question, “So, what do you do?” This question obviously seeks to define the individual not by their personality or predilections, but by their choice of career. Sometimes when I am asked this very question, I refuse to reveal my profession for as long as possible, focusing instead on other things I “do”, thus forcing the questioner to judge me not by my work, but by my hobbies, likes, and interests. I feel that this is a truer indication of who a person truly is.

I have enjoyed many positions in the outpatient world, namely hospice, community health centers, home care, case management, and public health. Was it easy to start in these fields, or was there a specific prerequisite of education or experience that seemed to open doors for you?

Whether it was hospice, an urban community health center, case management, or public health, none of these positions required specialized training other than my nursing experience and my desire and willingness to learn while applying myself. Each of these positions provided varying amounts of on-the-job training, and some involved a steeper learning curve than others. However, as a bilingual (Spanish-English) nurse with strong references, good computer skills, and a solid resume, these factors have all contributed to the general ease with which I usually find employment.

While nurses do indeed carry out many orders originated from doctors, nurses use their own brand of critical thinking and autonomous action in order to perform specialized patient care. Nurses are not just “the caring eyes and ears of doctors”—nurses are skilled professionals fully involved in patient care—and patient cures. Do you find in home/hospice-types of care scenarios, that a nurse’s role is significantly different than it would be in community or hospital settings?

In home care, the nurse is generally on his or her own to some extent, acting relatively autonomously in the absence of a doctor or other colleagues. The hospice nurse is charged with a much larger degree of autonomy, with standing orders allowing for individualized actions within the parameters of those orders. Home care and hospice call for autonomy, initiative, and the ability and willingness to act independently as needed. The thing that most home care and hospice nurses must adjust to is the lack of nearby colleagues to assist in assessments or decision-making. While a supervisor may be available by phone, there is no one at the nurse’s side to give their opinion on a wound’s status, for instance, so you have to be willing to make those judgment calls on your own. Hospital nurses have the luxury of colleagues upon whom they can lean, while home care nurses ostensibly fly solo.

[New Year, 2011] The nursing profession has been kind to me, and I relish being able to pick and choose the positions that are most suitable for me. What do you feel makes this a field with opportunity for you – is it your own skill set and years of service, the market demands, or a combination?

Nursing in general provides a large breadth of varied positions and specialties from which to pick and choose, and this allows the motivated nurse a fair amount of mobility and career flexibility. Having specific skills does give nurses some additional power when it comes to picking and choosing the best positions, but the nursing profession offers all nurses the ability to change their careers, pursue specialized training, and seek personal and professional fulfillment within the industry. My varied experience and resume definitely help, and I’ve been careful to build a resume and references that speak to my career goals and strengths.

While not being self-congratulatory, nurses can count themselves as members of a profession which holds compassion, caring, and healing as three of its central ideals. Saying that one is a nurse is something I encourage the graduates to do with pride, as well as with humility. Has there been times in your career when carrying the mantle, title and responsibilities of a nurse felt less rewarding?

As a nurse, one can sometimes feel obligated to provide care for neighbors, family and others despite your lack of willingness or ability to do so. Having strong personal boundaries is important so that you do not feel taken advantage of. Providing care for others on a “casual” basis can also raise interesting and worrisome liability issues. Interestingly, I have noticed that doctors who I know rarely give opinions or assistance for free, whereas nurses are quick to jump in and offer help or advice to neighbors and friends. This is a double-edged sword and one to use judiciously.

Nurses are highly trusted in our culture, and while establishing one’s identity as a nurse generally elicits a positive response, many individuals often have a misguided image of what nurses are and what they do, and this erroneous image can be a difficult thing to overcome. Television, movies and print media portray nurses as sex objects, doctors’ handmaidens, or as angels of mercy. This can be frustrating and maddening to those of us who take nurses’ public image seriously.

More and more, the management of information has become part and parcel of my job, something they never really mentioned in nursing school. How would you instruct a student to be best prepared for this?

Having a good facility with information technology is important for any nurse since most systems are now digitized. More than ever, managing information is an enormous part of most every nursing position, so understanding various computer systems and being willing to learn to use unfamiliar systems is simply crucial in the current health care climate.

A sick and depressed caregiver is no use to anyone in this world. Given that so much of the nursing profession is spent dancing on a very highly-tensioned wire, how does one successfully fight-off the depression, stress and anxiety incumbent to this line of work?

Self-care is paramount for any caregiver, especially since caring for others from a place of woundedness or poor health does little to serve anyone. Nursing can be very physically and emotionally stressful and demanding. The healthy nurse uses wholesome food, exercise, proper hydration, stress management techniques, and other forms of self-care to mitigate the stressors of work. At times, taking advantage of Employee Assistance Programs (EAPs), individual psychotherapy and other tools can also relieve the stress brought on by the challenges of a career in nursing. If one works in hospice, the ED, or other venues where death and dying figure largely, finding a place to process those feelings and nurture one’s spiritual life is certainly a priority.

———————————————

Thanks for sharing your experiences and wisdom, Keith! Be sure to check out Digital Doorway to read more of his award-winning work.

Come back tomorrow, as our series talks to a nursing student (Lovlei McKinnie) who is very close to reaching the end of her schooling.

Our second installment talks to rehabRN, a rehab nursing specialist who has been actively blogging about it for over four years at RehabRN. Her bio states: “RN living down on the farm with Dahey, Bubba, WildDog and other wild animals, working at the Hotel Rehab to pay the bills and get material for this blog and for my standup comedy routine (if I had the time to do it…maybe when I retire!)…Hope you enjoy this dramatization of my little world. Finally, say thank you to your favorite nurses, ’cause we not only wipe you, we also just might have to save you, and we do it with a smile 24/7.”

The bold statements are taken directly from her posted works, followed by our questions and her responses.

One of our long-time people decided to become a DNR this week after much discussion with the medical staff. We’ll see what happens next. Convincing a patient that a DNR is in their best interests cannot be an easy task – what are some of the things you have learned as a nurse that help a patient to see their condition from enough distance to make a call like this with less emotion?

Many patients with long-term illnesses or debilitating conditions don’t have a lot of control over some things in life, but choosing their code status, is for many, a choice. Some are confident they have family members who will honor their wishes; others do not. Some people think if you make a choice, like choosing to be a no code, that you are choosing death, pain and suffering. Some people don’t realize that being a full code can be a lot of pain and suffering.

I feel strongly that people of sound mind should choose. It is my job to advocate for them by giving them as much information in a non-threatening, non-judgmental way for them to make a decision.

In a way, I feel like a nurse has a lot in common with many tradesmen. I had to apprentice and learn and then go out as a journeyman (or person as you wish) and ply my trade. Everything I learn colors what I do, and I don’t look at things the same anymore. Do specific moments have to be very pronounced to have this kind of influence – to “color” what you will do after it happens, or are some things simply absorbed slowly over time? In viewing things differently today, do you see your new perspective as a plus, a hurdle, or balanced in-between?

A lot of what nurses do is learned tasks and psychomotor skills. This can take time to learn. Some skills people pick up quickly. Putting the physical skills and the mental skills together and synthesizing it all is what makes a good nurse great.

What we do as nurses is immediate and visible in our practice and the lives of our patients, even if we don’t see it directly. This is why I really enjoy rehab, since we see this happen literally right before our eyes. Would you consider exploring other areas of care based on this feeling of direct results (such as ER), or does rehab nursing fulfill you both personally and professionally?

Having worked in rehab for over four years, and knowing what I know from others, I would not do any other type of nursing. There are so many facets to what I can do as a certified rehab nurse, from direct patient care, to case management, to management and education, that I feel as if I can go down many paths and still be a rehab nurse at heart. I enjoy having long-term relationships with patients and in a large facility, I can practice in many roles.

And at this point in time, I can’t imagine doing anything else. At other points and times, what are the factors that could make you start to question your decision? How firm is nursing in the definition of your character, and how specific is that definition?

What has made me question what I do? Working with people who see work as a “job” or a “paycheck”. I see nursing as a vocation of caring and service.

I’m dreaming of passing my certification and GRE exams before summer, since after that, it will be a long time before I get any more vacation. However, I do believe that we need to dream. It keeps you going. What are the best dreams of a rehab nurse these days?

I dream of using new tools to help my patients and my fellow staff members. I am a technical person from my previous life and I have always been interested in doing things different ways to see what will happen.

In my wildest dreams, I dream of cures for paralysis and injury, but I live in the reality that even if we never get there in my lifetime, working to make life better for people is not a bad thing at all.

…you second-guess if you did the right thing for the patient that died. Did I miss some signs they had or were there so many problems which could mask another, that I couldn’t keep them straight? You find out that you weren’t the only nurse to wonder…and maybe the MDs are pissed because they couldn’t see any signs, either. It seems to me, completely removed from the situations described, that nurses with concerns would be voicing them. Is this not the case in most situations? What helps a nurse to be able to express themselves more openly and which factors have you experienced getting in the way?

Sometimes, as noted in literature, nurses are bullied and do not speak up. I can tell you that I have felt this way often. I have also learned, however, ways to navigate around the systems that might thwart me in my job. First, I follow the number one nursing rule and go through the chain of command. I tell my boss what we need and I document it. If I can’t get what I want from my boss, I ask to advance, and with permission, I continue.

I’ll either get shot down as an upstart, or I will keep going until I get to the top (usually someone in between can help).

I’m not too afraid of bodily fluids, but vomit gets me. Everything else–nasty, draining wounds, poop, etc., rarely faze me. It’s that rascally vomit that is my Kryptonite. Everyone has their Kryptonite, but an emergency situation requires a cape – not cowering. How do you get past personal hang-ups and things that are simply yucky to be able to provide the best possible care to your patients? Any tips for maintaining professionalism when you are about to hurl?

Very simply: fake it until you make it. I’m not the world’s greatest actress, but I surely try! I learned early on as a mother that if you model calm behavior, kids will be calm. The same applies with adults: if you get frazzled, people will get frazzled with you.

How do you maintain professionalism while you hurl: Excuse yourself and hurl somewhere out of sight. Apologize profusely, and then take care of your patient as if nothing happened.

It never bothered me if a foodservice person wasn’t wearing gloves before, but it really does now. I found it interesting to see the number of nurses who talk about hand washing and fears of germ-passing. Have your nursing habits and observations traveled over to your family life? What, besides germs, have you done to try to make sure they are protected as much as possible?

Somewhat. I try to be lenient, but I will wear a mask at home if I’m taking care of a sick kid and I will be cleaning all the doorknobs once someone gets a cold. Besides, it’s all about hand hygiene, don’t share food or drinks if you even think you’re sick and sleep in another room if your spouse is ill with something contagious. Thankfully, I have a very comfy living room couch!

I’m now fluent in several types of wheelchair drive systems. Would you recommend that a nursing student interested in rehab work become familiar with the mechanics of it all – or does the technology move fast, so they might be better-off concentrating on it when they are more actively involved with it? To clarify: is there going to be clear benefits in learning the hardware ahead of time? And if so, where would a student be able to learn about these things?

Technology changes quickly so get used to that. Your best friends when learning about wheelchairs and other equipment are the therapists. They can teach you a lot, as well as reading the manuals if you have them. If not, go online and look them up.

The docs are impressed that I read notes. I talked to one of the residents running around with the doc there and they were talking about someone’s recent surgery. I told them what I knew about it, asked a couple of questions and got a quick 101 from the specialist. They seemed impressed that I knew what type of surgery it was. What other things about the way you work has made an impression on those around you? In other words, what are the traits to strive for as a nursing student looking to “fit in” and perhaps make a difference in their environment?

Realize that some people like nurses and some don’t. Some people like to talk about their jobs and some don’t. I have found that many people like you to ask about something that may be a specialty, especially doctors.

You may feel others still have the “high school mentality” that you can’t talk to certain people, including doctors, but I don’t believe it. If you’re uncomfortable talking to the docs while they’re at the nurses’ station using the computers, talk to them on rounds. One of our specialists liked to tell stories, so I learned quite a bit about him and his practice by talking to him on rounds. He liked to share information, and was known throughout the medical school as a great doc to work with. Some of our nurses did not like him, and looked down on people who talked to him because they said you were a “brown nose” if you talked to him. Talking to him on rounds eliminated this behavior because the bullies were never nearby.

You really must have a strong constitution to be a nurse of any kind. Remember that, and don’t be too hard on yourself. Self-care is the most important thing a new nurse can learn. If you don’t, you’ll burn out quickly.

—————————–

Thanks for sharing your insight and experiences, rehabRN! You can read more work by rehabRN on her blog: RehabRN

Tune-in tomorrow as we talk to Keith Carlson to delve a bit deeper into some of the emotional and spiritual questions facing today’s emerging nursing students.

A Nursing Student’s Lessons are Rich, and Varied

Every nursing student today has a lot to think about.

Nursing and healthcare do provide very rich, diverse and rewarding career paths for many… yet knowing you want to be a nurse is different than knowing what kind of nurse you want to be. If nursing students share one thing, it might be feelings of uncertainty when transitioning their lessons into practice.

Students (by definition) are meant to be opening-up to potentially life-changing beliefs and making many important decisions without experience. Unfortunately, first-hand experiences are usually limited. Exposure to new ideas may also be dictated in-part by location or time.  In cases like these, guidance from trusted advisers and others who intimately know the struggles being faced become the means for students to see new directions and make better choices.

Often, insight from the right person at the right time enables a student to see their profession in a different light: it literally helps them to become a better nurse.

Reaching Out: Nine Nurses in the Know

To learn more about how nursing students mature into seasoned healthcare providers, we studied popular nursing bloggers to see what they had to say on the subject.

We found the voices of dedicated professionals with intelligent conversations and compassionate stories illustrating what is happening: in hospitals, classrooms, organizations, public health, state-run or federally sponsored institutions, private hospice care, and more. These are nurses (some currently students themselves) who intimately understand the questions, concerns and the feelings shared by many nursing students: they embody the statement, “Been there, done that.”

As a way to help nursing students understand more of the thinking that they don’t teach you in books, we asked nine popular nursing bloggers to expand on ideas found in their body of work. The bloggers we selected shared more than 100 years worth of combined nursing experiences. All of them talked frankly about what it means – to them – to be a nurse, as it happens. How it changes, how it grows.

Our hope is to inspire conversations that move beyond the textbooks and the lecture halls, introducing new ideas about what it means to be a nurse. By talking openly with professionals who understand and care what you are going through, we hope to bring you to a deeper understanding of what it takes to become the kind of nurse you want to be.

Part One: Interview with Shrtstormtrooper

Our series begins with a discussion with a practicing RN who uses the online name “Shrtstormtrooper” to blog freely about nursing at New Nurse Insanity: The Adolescent Years. In covering and re-examining some of the many topics she discusses on her blog, we were able to capture some insight on how a “newer” nurse feels when they are transitioning from school into real-world working situations.

You can view the full interview with Shrtstormtrooper, and offer your comments here.

Part Two: Interview with rehabRN

The series continues by reaching-out to a nurse specializing in rehabilitative care who uses the online name “rehabRN” to blog freely about her nursing and experiences at RehabRN. Her specialty and willingness to talk about it will help to show nursing students some of the challenges, benefits and decisions being faced in providing specialty care.

You can view the full interview with RehabRN, and offer your comments here.

Part Three: Interview with Keith Carlson

The third part of this series connects us to Keith Carlson, a well-known nurse blogger who has been in the field for 15 years.  Focusing on delivery of specialized care to those living with AIDS, diabetes, and other chronic illnesses, Keith has effectively worked with hundreds of patients across the socioeconomic spectrum. He has also taught nursing. Keith owns an award-winning nursing blog at Digital Doorway where he has shared his adventures since 2005. He shares here, some of his well-earned philosophical views and how to maintain balance in a hectic nursing career.

You can view the full interview with Keith Carlson, and offer your comments here.

Part Four: Interview with Lovlei McKinnie

The fourth part of our series continues by connecting with Lovlei McKinnie, a nursing student who is currently in her senior year. Lovlei has a perspective that will be very close to many nursing students, as seen on her blog The Dog Ate My Care Plan, but she has a wizened outlook and warm way of communicating that will help many students in their own journeys. Lovlei has been sharing her ups and downs as a student, wife and mother for over two years, so we dug deeper into some of the lessons she shares.

You can view the full interview with Lovlei McKinnie, and offer your comments here.

Part Five: Interview with Gina Rybolt

The fifth entry to our series connects us to Gina Rybolt, a practicing RN with her BSN and over 14 years of nursing experiences to share. The insights Gina has offered fills her popular blog Code Blog, where she has been active and outspoken since 2002. We talked to Gina about how nursing has changed for her, how it is affected by her 13 years in the ICU, and what influences change in the way she thinks about it.

You can view the full interview with Gina Rybolt, and offer your comments here.

Part Six: Interview with Nurse Teeny

The series continues by reaching-out to Nurse Teeny, a well-known blogger who has been sharing her own journey on The Makings of a Nurse. In addition to the normal routines juggled by nurses, like many in the field, Nurse Teeny is also adding in wedding plans to her future. We asked her a little about how nursing and her personal life mingle, how they affect each other, and what time means to a nurse’s sense of confidence.

You can view the full interview with Nurse Teeny, and offer your comments here.

Part Seven: Interview with Kim McAllister

The seventh part of our series reaches out to a well-known nursing blogger named Kim McAllister who is an RN, BSN, and CEN also currently working on her Master’s. As a practicing nurse for over three decades Kim has seen a lot, and she is willing to talk openly about her experiences. Her blog Emergiblog has led her to more writing and contributing to the nursing community everywhere, but we were able to get a few moments to talk to her. We listened, as she discussed her experiences and her thoughts regarding changes in her own perceptions over the years, and what she suggests to younger nurses to help find their own personal and professional success.

You can view the full interview with Kim McAllister, and offer your comments here.

Part Eight: Interview with Terri Polick

The series continues with an in-depth interview with Terri Polick, better known to the nursing community as blogger MotherJonesRN of Nurse Ratched’s Place, her blog that gives readers an insider’s look at the mental health system. Terri has seen a lot as nurse, and she has even traveled to Washington to support the causes central to the nursing community. We asked Terri to expand on some of the ideas offered in her blog, and how she sees her nursing career as it fits into larger pictures.

You can view the full interview with Terri Polick, and offer your comments here.

Part Nine: Interview with (nurse)-Dr. Lorry Schoenly

The series continues by reaching-out to Dr. Lorry Schoenly PhD, RN, CCHP who has been a nurse for 25 years and is currently specializing in correctional healthcare. She is also a clinical education specialist and blogs regularly at CorrectionalNurse.Net. Lorry provides us answers to some of the questions regarding her experiences, giving commentary on what might affect misconceptions about participating in providing state or locally-run correctional healthcare.

You can view the full interview with Lorry Schoenly, and offer your comments here.

Our first installment of this series talks to an RN who blogs at New Nurse Insanity: The Adolescent Years using the pen name Shrtstormtrooper. Her bio states: “I’m in my mid twenties, love Jesus, and have no verbal filter. I’ve been a nurse for a little over two years, and it’s amazing how much I’ve learned in such a short time – and even more amazing how much I still need to learn! At any rate, I’m loving my job and loving the learning. Life is good.”

The bold statements are taken directly from her posted works, followed by our questions and her responses.

What I enjoy most about the ER is that we can fix people in one visit. Have you been interested in exploring any other departments yet, or does the ER provide you with the ideal balance of challenge and reward? What is your least favorite aspect of the ER?

So far, I am very happy working in the ER. My attention span is fairly short, so I love the aspect of triaging a patient, taking care of them for a few hours, and then either sending them home or to a different area in the hospital. During my nursing school clinicals, I had one patient for almost an entire semester – it was nice for about three clinical days, and then I was sick of seeing the same patient, same chart, same stuff. Working ER allows me to always have different patients (and a huge variety of problems, from trauma to cardiac to GI to surgical stuff).

I also really love not knowing what sort of shift I will have. If I worked on the ortho floor, I know that all of my patients are some sort of bone problem which can get kinda boring. With the ER, I never know what will roll through the doors until a few minutes before they come in. Sometimes we even have something crazy like a stabbing victim walk into the ambulance bay and start banging on the doors, or a woman roll in the front door two minutes from giving birth. It keeps me on my toes, and I always have to push myself to learn a lot of information about a huge variety of stuff.

I suppose this love for variety and the unknown ties into my least favorite aspect too – I strongly dislike the frequent flyer people. Some of them I can understand. Those who have no money and no primary care doc, and no social support system, they truly view us as their only way to health care and so we see them often. These people I don’t judge their misuse of the ER. The ones I dislike, however, are those who just abuse the system. They come for their narc fix, are rude and hateful and abusive to staff and we can’t throw them out or WE are the ones who are wrong. I hate having to smile through my teeth and tolerate this blatant abuse of resources, money, staff, and time. I hate that we have people who come to the ER 28 times a year for vague complaints and who know how to work the system to get what they want. I hate that dealing with these people takes away my time and mental attention from those who are very sick. I just don’t like it…but that is part of the ER package, and the cons of dealing with these people are far outweighed by the pros of the ER in general.

Plus…I just enjoy the general ridiculousness of it all. The docs I get to laugh and joke with, the absurd complaints from patients, the dark humor of the other nurses, and the overall camaraderie with the staff. They really are my second family now.

Having just taken a Spanish for Nursing class, and still feeling Spanishly Dumb, I really, really wish I was bilingual. This seems to imply that you’d suggest nursing students take advantage of learning another language while still in school, correct? Does being bilingual open new doors professionally, or does it simply make patient care scenarios easier, and more complete?

Oh, I wish I were bilingual. I would definitely suggest that students take advantage of any second-language opportunity. Do it now while you can! Being bilingual is advantageous for so many reasons in the hospital setting. The region where I work has a large number of Hispanic and French Creole people, and few of our staff members speak these languages – I find it unfair to these people that I, as a healthcare professional, sometimes can’t accurately assess them or treat them because I don’t know the extent of their complaint due to language barriers. Even using the language line is a poor substitute to open and easy dialogue.

In addition to making patient care easier and more beneficial to the patients, it’s also great from an employer’s point of view. My boss flat out stated he positively views bilingual staff members, and being bilingual will definitely give applicants a leg up in hiring.

Sometimes, though, I feel like I don’t quite get the opportunity to interact with patients on a basic level…. I am glad for this slow night, for the chance to be able to be there for someone. I didn’t need nursing school to do what I did. What are some of the things that you think made you strong here, in providing emotional support – ideas that may not be common among all nursing students?

Follow your gut instinct. If you think someone needs comforting, they do. If they need someone to listen for an extra minute, do it. If someone is hesitant, ask what you can do to make them feel more confident. Offer an extra pillow.

I find that the best way to do this without being cynical or condescending is to look at the patient as if they are a beloved family member. They deserve the best care because that is what you would expect for your family. These patients are scared and hurting and overwhelmed – you have the chance to alleviate some of these feelings, so take advantage of that!

I don’t think my nursing school did a great job on balancing the technical aspects of nursing with the emotional ones. They either focused solely on book knowledge or tried to justify emotions with all sorts of studies and journal articles and grief models. All this stuff is nice to know in the back of your head, but kind of useless when you’re facing someone who needs your comfort. Just use your common sense and treat them like you want to be treated. Golden Rule for the win, I guess.

When you have 26 hours of school work to do in 24 hours of the day, something has to get cut. For me, it was exercise. I swore to myself that when I got my RN and a job, I would start working out again. So here I am, almost two years into my nursing career. And I haven’t worked out more than a dozen times. Are there other things that you swore would happen when you got a job as an RN (looking at it wishfully from your student-shoes), that are not happening, or really (with the vantage point of experience) now kind of silly?

Ha, I swore when I had a job and income that I would buy as many fun shoes as I wanted…which I have proudly accomplished! On a more serious note though, I promised myself that I would be able to better balance a personal life with work life after graduation. Nursing school was so intense that I rarely did things just to relax, and I didn’t want my post grad real life to be that stressful. I promised that I would always be balanced, and not spend so much time at work that I forgot to enjoy life.

There really isn’t much that I have failed to have happen so far – I am a very laid back person who doesn’t wish for much on a grand scale, but I’m also driven for what I do want. Now that my life isn’t so hectic from nursing school, the few things I do want, I have the time to accomplish them.

Perhaps the only thing so far that I still wish I could accomplish is the goal of traveling. I went into nursing partly because it was a portable profession, and I very much want to see the world. I’m not in a panicked hurry yet, but I would like to do accomplish this sometime.

I’ve only been a nurse for less than two years, but already the number of times I’ve been verbally assaulted has been too many to count. Physically assaulted? Also quite a few. It’s not acceptable to press charges, since I should have “talked the patient down.” When does it become acceptable to press charges, or consider yourself affronted as a nurse?

In the eyes of management, it’s never acceptable to press charges. We are there to help the patient, not make things worse. Unfortunately, this is so far removed from the rest of all professional careers that many of us nurses are fed up. Why should I bother to put my ass on the line to take care of people if I’m going to be blamed for the times when a patient is just out of line? I can understand a demented patient lashing out, or a person with meningitis acting out of the ordinary, but the drunk idiot who spits in my face and tries to hit me? Not okay. You make the decision to drink or get high or just generally be an ass, you should be held accountable to that.

I was sitting in triage the other night, and the other nurse and I were discussing the lack of bulletproof glass at the window. “How long before they make this glass bulletproof,” I asked. She replied, “only after someone gets shot.” Sadly, it’s true.

If I could give any advice to incoming nurses, it would be to start becoming active in the ANA or unit-specific associations, and know what the legislation is. Know what the laws are, and start early with making it known to the public that abuse will not be tolerated. If enough nurses take this stance, we’ll slowly be able to change the current attitude towards our profession.

I saw you leave this world, and I was so busy saving you that I forgot to be there for you. I don’t think there was anything we could have done different medically. You were going to die, and I couldn’t have stopped that. But I should have helped you die with more dignity, and I failed. Is there anything you can offer to nursing students as things you’ve seen that help people to die with more dignity – things a nurse might affect, but aren’t really taught in class?

Class will teach you the five stages of grief, and how to document in a SOAP or SBAR note, and how to watch for a reaction to blood products, and know that a patient needs this drug and not that one, but they can’t teach you how to be ready for death. It comes down to this: everyone dies at some point. All you can do as a nurse and as a person is to understand that you play a part in their life. Make that part count. If you were dying, what would you want someone to do? Of course you want them to be sound in their medical knowledge, but you want them to care.

I think that as long as you truly care and never allow yourself to become flippant about death, you will find a way to show your care in small ways. While I try to keep my emotions under control, I attempt to always be aware of what my patient or their family might be feeling. Be it pain, anxiety, sadness, or resignation, I watch for it. Sometimes, all it takes is acknowledging that yes, things do suck right now – but you are there for them.

All this advice is well and good, but really I’m just one person who has one way of attempting to show dignity. Everyone will have different ways. Like I said before though, you need to make sure you care if you want to do this job. The minute you realize you don’t actually care about the emotional status of a patient…you need reevaluate your career path.

Because no matter how highly administration might think of me, and trust me with orientees, the real measure of a good nurse is whether or not I can take my uncertainties or deficiencies and learn, improve, and use that new information to take better care of my patients. Accepting deficiencies as bridges to lessons, especially as a new nurse, must be difficult – are there any pointers you learned that could potentially help an aspiring nurse in recognizing/appreciating these moments in this positive manner?

Just know a few things: First, every single student and new grad feels the same way you do – scared and trying to hide it or at least not be reduced to a blubbering mess. If they deny it, they’re lying.  Second, the staff knows you don’t know everything, and most of them are willing to help you learn. If they critique you or offer to show you something or even just spout off random knowledge, soak it up. It’s a learning opportunity. Third, know that you start off knowing very little. Even if you’re great in classes, book knowledge and real-life hospital knowledge are very different. So even if you think you know something, ask questions about it. Ask the staff why. Ask the doctor why. If you’re embarrassed, preface it with, “I’m new and just want to get your opinion on this.” No one will ridicule you for that. In fact, if you don’t ask questions and start off being unsure, the staff will definitely view you as arrogant and dangerous. So don’t be like that. Lastly, everyone has a learning curve. You’re not alone in that.

(On one year anniversary) Sometimes it’s been kinda overwhelming. To go from student to new grad orientee to shiny new nurse in the space of six months…there are days where I just shake my head and wonder how I got through it. When I signed up for this career, I knew it was what I wanted to do. But still, I was most definitely not prepared for most of it. If you could go back now and better prepare the younger you for what is coming, what would you say?

This is a hard one. I honestly think there is nothing that anyone would have been able to say to me to adequately “prepare” me for the emotional aspects of my job. Really, what can you say to someone to prepare them to watch someone die, or comfort a family who just suffered a tragic loss? There is no class available to truly teach this stuff; experience is the only thing that will show you how.

Instead, I would tell my nursing school self this: no matter how hard it seems, you will get through it. You’ve made the decision to become a nurse because you want to help people and that decision alone means you have the strength to be the nurse you imagined. It will just take time. And of course, follow your instincts when you give comfort. They are usually right.

This goes for the mechanical stuff as well – you might not know the ins and outs of how to do procedures yet but you will learn in time. One suggestion though: get a job as a CNA or patient care tech before or during nursing school summer break. If your program has an internship, sell (or promise) your first-born child to get into the internship. You’ll learn more in that 8-week program than you will in a whole semester in terms of the reality of nursing. It will most definitely help your comfort level too.

She mentioned how a lot of her nurses had been crusty and mean and impatient, but that I had been very pleasant and willing to listen to her complaints. I thanked her, then jokingly replied that I haven’t been a nurse long enough to be heartless yet. She says, “you nurses never lose your hearts, you just learn to protect them better.” How have you learned to better protect your heart since becoming a practicing nurse? Any tips for nursing students on how to do this effectively?

Mostly I am able to deal with sad stuff because while it is emotionally hard, these people are complete strangers. I’m able to distance myself from it because I don’t know their history, I don’t know their life stories, and I find that by not letting myself know these things, I am able to view the patient as a medical problem to be fixed, and the families as extra people who come as part of the package deal. This seems kind of harsh, but it works for me. I still am affected emotionally, but I’m able to keep it in check when I need to. I guess my method of not letting myself know a patients’ life story lends well to the ER, since you get to know more about a patient if you take care of them on the inpatient floors for many days in a row – another reason why I prefer the ER.

I have also found that a lot of things that happen in the ER weigh on me even after my shift is over, and I didn’t have any idea how to handle that. I was talking about this with one of my charge nurses and she told me to go home, make a cup of tea, and cry my eyes out. I did and felt so much better. I think the take home point is that emotions can be held in check, but you can’t discount them completely. These situations are sad and tragic and any normal person would cry – so be a normal person and cry!

It’s been almost six months since I’ve been off orientation and I still sometimes wonder what I’m doing here. While I’ve become competent in the small things, the big things still make me think, “there’s no way I’m allowed to do this!” As time passes, do these thoughts tend to become smaller and less frequent, or have they remained relatively constant or actually increased in any way for you? What specific things help to make this feeling diminish?

Honestly, the more I learn about being a nurse, the more I realize how little I actually know. It’s humbling. I don’t feel so overwhelmed every shift with the small stuff which is due to me just generally knowing more information than I did when I started, but I still every single day have to question myself and double check information and look up meds and re-read stuff about disease processes. If anything, I have the thoughts of inadequacy even more now because I am no longer a brand new nurse and I feel like I should know this stuff. If I don’t know something, I almost sometimes feel guilty. So I make sure I fix those feelings every time they pop up.

I can do the mechanical processes without much thought now; trach suctioning, obtaining a nasal washing sample, starting IVs, getting EKGs…this stuff is easy now, but it’s not what makes a good nurse. The critical thinking, assessing, and ability to look at someone and just know they are sick – doing these things well make a good nurse. I’m getting better at this stuff but I’ll never be perfect. Thus I will always strive to be improving. I’ve been told that the day I feel completely comfortable is the day I should get out of nursing because I’ve become dangerous. This thought is always in the back of my mind, and is a very effective motivator for keeping on my toes.

————————–

Thanks for sharing the insights, Shrtstormtrooper! You can read more of her work on her blog: New Nurse Insanity: The Adolescent Years

Join us tomorrow for the next installment of this series, as we talk to rehabRN, a nurse who specializes in rehabilitative care.