NursingZen

The Bay area has been sparkling with light. This was my hike in Oakland yesterday:

Warm, balmy nights bring me right back home to New York.

Tonight I walked home from work wearing my short sleeves and stopped every half block to be bowled over by the smell of freesia.

Tonight I was floated to the new-nurse-friendly unit and pigged out at a birthday potluck: chap jae, California rolls, chow mein, BBQ pork, adobo chicken, brownie, and ice cream.

Life is pretty good.

Tonight I left work floating on cloud nine. Tonight I experienced a warm and supportive nursing team, from working nurse to break relief to unit clerk to manager.

I was “floated” (assigned to work in a unit that is not my usual) for the first time tonight, but contrary to expectations, I wasn’t left hanging by my fingernails on a deadly precipice.

As soon as my assignment was given to me, my colleague, who happens to be a union representative, was assessing my assignment to make sure it was fair. When we learned that I was given a fresh post-CABG patient, with whom I have no experience, he tried to get my assignment changed.

When he couldn’t change it because of staffing issues, he said, verbatim: “I’ll be your back-up. Don’t worry. You come to me with any questions.” Unbelievably, he was also to serve as a break relief and help get vital signs.

At the same time, the manager pulled a nurse from a non-urgent assignment and said to her: “You watch after the two floats and help them.”

This nurse then said to me: “I’ll be the care partner (until we get a care partner in a couple hours). You just do your assessments and get yourself oriented and comfortable.”

Throughout the evening, I asked plenty of questions because I wasn’t used to the patient types or the charting. Not once did I get a head-shake, raised eyebrow or condescending tone.

The unit clerk answered call lights for me with a smile.

In the break room, nurses I’ve met only once greeted me by name and asked how I was doing.

At the end of the evening, the manager reviewed my charting and reminded me to fill in some fields. My back-up nurses both asked me how I felt and whether I had any more questions.

Before I clocked out (on time!), I thanked the manager (and everyone else) for watching out for me and I asked if I could get floated here in the near future to reinforce everything I learned tonight.

I know I was given fairly easy patients tonight and that I won’t always have back-up, but everything that happened tonight brings me energy, hope, and inspiration. It’s what keeps nurses loyal to a unit and to the profession. ‘Nuf said!

Six months ago, on my first day of nursing:

My preceptor, a nurse for 30 years, prepares a patient for a scheduled cardioversion. The MDs come in to do the procedure. The MDs leave. As she wraps up, the conversation goes:

Patient: Thank you so much for everything.

Preceptor:  Oh, don’t thank me. I’m just the nurse.

Oh no.

Certainly I’ve said “I’m just a nurse” and have kicked myself before the words were even out of my mouth, but I’ve only said it a couple times and never in response to someone thanking me for my help or skills as a nurse. My goodness.

So it was cool to come across this nifty poster on The Nursing Site Blog. It’s by Suzanne Gordon, a writer, activist, and adjunct professor at UCSF (but not a nurse) who lectured in one of the MEPN classes. I’ve always appreciated how much the UCSF nursing school reminded us over and over — and over — again to recognize and resist all the ways nurses are devalued and to take charge of and promote our identity and strengths. This might need to go up in my break room.

Bud Light Lime. Apparently it’s all the rage in some parts of the country. I learned this on my field trip to Budweiser brewery, courtesy of my Health Hazards and Safety class. It’s not your typical class. We have lectures about health hazards and safety in the workplace and then make site visits throughout the Bay area. Budweiser’s spiel was about its policies and procedures that address the health and safety of its employees. Without getting into the nitty gritty of all the different policies, some of the crowd-pleasers include: an onsite gym, $100 for employees after every annual physical, a ping pong table, and a foosball table.

An irony: Employees get cases of free beer every year and as prizes for various activities…yep, drink up and fatten the liver!

I love being in a small class again … and just in time for my flagging spirit. It’s a relief to talk to people who are going through some of the same learning and growing processes as I am. Some of them were nurses for several years before grad school, some come from totally different worlds, but everyone seems to be open-minded, outspoken, and willing to defy and resist the homogenization and impersonalization of regular hospital nursing. Or, maybe I’m projecting.

Sigh. I’ve been trying filter out my recent negative feelings, because well, complaining is a drag for everyone. But I’m human and this is nursing we’re talking about after all. I hope to write constructively about some recent challenges with hospital culture. I’ll try to work out the issues offline before posting them.

Friday night: Heard through the grapevine that I’m going to get a new admission — on side B, while also having patients far away on side A — a no-no. The manager and I saw each other on the floor, so why am I hearing this through my colleagues and not directly from her?

Saturday night: Several nurses and I are supposed to be practicing a new computerized system. Suddenly in a big flurry a manager says, “The word from UP TOP is that we need nurses to admit patients NOW.” Everyone jumps because the person UP TOP says so.

Some other night: I’m one-hour overtime because right before change of shift my patient goes bonkers and won’t stay in bed and is developing a gigantic hematoma. I let the supervisor know this after I’ve stabilized the patient and I’m asked:

“Why didn’t you let us know sooner?”

“Well I couldn’t, because my patient was confused, agitated, and bleeding and it took three of us to keep her bleeding under control.”

“Oh, but still…”

Last night, a plate of warm homemade cookies wasn’t enough to take away the bitter taste in my mouth.

When I have questions or need help, I can always count on one particular unit clerk and a couple particular nurses to give me a withering look, shake their head, and mutter under their breath. I don’t understand them, and I’m done trying. I don’t give a crap where they’re coming from — they should be able to treat me as they’d want to be treated.

As a new nurse, and worse, a cultural outsider, I feel voiceless and helpless. And the jerks must know it — speak up to them? They’ll only gossip.

One of my strengths is my positive disposition, but will it survive my nursing unit?

Nurses occupy a unique position…

Nurses meet the patient where they’re at…

As bad as it might sound to have to work every other weekend, it’s a relief compared to working on the weekdays. On my unit, the weekdays are always frenzied and sometimes terrible, but the weekends usually are a respite.

Tonight I worked with a nice, hardworking team and had stable, interesting patients. Of note were two patients who had never been hospitalized before.

**Mr. Lee (name changed) is a small, wiry elderly Chinese-speaking man with skin smooth as a baby’s. He came in, reluctantly, because of chest pain but has no significant medical history or problems. He takes no medications at home, has no hearing or vision problem, no dentures, no diabetes, nothing. “Wah!” (Cantonese for “wow”) was my response to him. He’s anxious about being in the hospital, agreed to come in only for observation, and declined the ordered medications that are “protocol” for our patients. I told him a little about the meds but I didn’t dispute him – after 79 years of not taking any meds, it makes sense that he doesn’t want to start now.

**Ms. Nelson (name changed) is a talkative woman with spunky short hair. She also came in reluctantly because of chest pain, has no significant medical history or problems, and takes no Western medications. She says she’s been successfully treating herself with complementary modalities and herbal medicines. She also declined the ordered medications. She expressed distress and anger toward the doctor who admitted her, saying that he has no conception or understanding of integrated or complementary modalities and that he scoffed at her anxiety toward the treatments he offered her. As she read her poetry, chanted her “Ohm”s, and listened to music, I understood precisely how alienated she feels from the way medicine and healing is practiced and communicated in the hospital and in our society.

For a split second, I felt “wrong” for not pushing these two patients to follow the hospital’s protocol of treatments and interventions, especially since I know that in my position I “represent” hospital-based medicine, but within the same split second, I realized that even though I’m a nurse in the system, I don’t need to agree with the perspective that medication and intervention are always good, for everyone alike.

In truth, I believe our society is too medicalized and our hospitals do not provide enough individualized care. As someone who has grown up in diverse family and social contexts, I believe in an integration of healing methods and perspectives. Some people might say that I’m working in the wrong field then, but suddenly I’m seeing quite sharply the “unique position that nurses occupy.” You hear about this “unique position” throughout nursing school, but it’s a great moment when you actually experience it. Certainly there are safety reasons to follow some protocols, but we can also use our judgment to fudge or work around them to “meet the patient where they’re at” — another banal-until-experienced nursing school mantra!

This week was finals week for the winter quarter. Next up is a week of spring break. Whoo hoo. Time has accelerated in recent months; if I think about it too long, I might panic, so instead I’ll just sip my caipirinha, marvel at the interminable feather-grey sky, and count my blessings.

Example of a blessing (as a pathetic way of summing up the 1st half of the year): I’m happy to say that doing the Master’s program part-time was the right decision for me. Yay. Inititally I felt pangs of regret and wistfulness when I saw my MEPN friends walking merrily to class together. Or if they were harried, they were at least present to support one another. Poor me was usually alone because I had only two classes that most others weren’t taking yet…

But by the middle of this quarter, I didn’t mind feeling out of sync because I knew I was moving at a speed that’s right for me. While the NP classes and clinicals sound exciting, I’m content to focus on general graduate classes while trying to get comfortable with this wholly consuming identity of “registered nurse.”

I almost can’t remember the life of writer-reader-a.k.a.-dreamer. This isn’t a sorry or wistful statement; it’s just fact right now.

Maybe being a nurse doesn’t have to be all-consuming or so damn serious, but right now I don’t know how else to do it, if I want to do it kind of well.

One month ago
I gave a patient Aspirin and Plavix, not realizing that he already received the once-daily dose at a different hospital before he transferred to the one I work at. A nurse told me about the error the next day and apologized for having to report it on a “Responsible Reporting Form.” I was shaken by the news – both of the meds reduce the blood’s ability to coagulate. Luckily, the doses were relatively small and the patient was unharmed. Still, I was kicking myself and terribly annoyed by the “med reconciliation” process, which I think is highly susceptible to errors.

One week ago
I gave a scheduled dose of 10 units NPH insulin along with a sliding scale dose of 10 units of Aspart – except that I didn’t actually give NPH; I gave Novolin 70/30, which I mistook for “NPH” and later learned is 70% Aspart and 30% NPH. This means I gave a patient too much rapid-acting insulin, which would bring his blood sugar down, fast.

Just as I was going home, the nurse who had “double checked” my insulin noticed that Novolin 70/30 was in the med room labeled with the patient’s name. She asked if I had given 70/30 or NPH.

The chain of errors immediately flashed before my eyes:
- I went to the Pyxis to get NPH.
- NPH was grayed out/not available in the Pyxis.
- I caught sight of a bottle of insulin on the counter with the patient’s name on it.
- I looked at the label and saw “NPH.” It didn’t register in my mind that there was also the word “Aspart” or that it said “Novolin 70/30.”
- I drew up the insulin in the med room and outside of the med room, asked a nurse to check my doses and co-sign.
- She didn’t see from what vials I had drawn the insulin.

And so there we were. Mild panic and disbelief as to why I gave 70/30. Didn’t I know the difference? The shameful truth is, I didn’t.

I notified the doctor, who was very nice. He ordered every-hour blood sugar checks for a few hours.

The nurse, while astounded by my ignorance, also kicked herself for not doing a real double check.

We also blamed Pharmacy for sending up Novolin 70/30 with the patient’s name on it.

I didn’t sleep well.

The next day I studied my insulins like I should have before. But I was also cursing and shaking my head – why is the naming of the different insulins so alike?

Thankfully, the patient was unharmed.

For a few days I was despondent and angry with myself and with the hospital system we work in. The errors were my fault, no doubt about it. But it’s also true that the hospital system, the “flow” as one veteran called it, sets the stage for us to make mistakes and take short cuts.

I’m still shaken up by last weekend’s mistake, but I’m also extremely motivated and determined to not make another med error again. I might even be a little paranoid now, but paranoia is probably a good thing in acute care.

     I’ve noticed that sometimes readers will leave responses and questions for other readers who have left comments on my entries. I’ve also left responses to reader comments at the end of entries and/or have emailed readers directly. However, it’s hard to know whether you’ve seen the responses.

Because I’ve always wanted this blog to help connect and support new and would-be nurses, I decided to integrate a robust “commenting engine” called Disqus (sound like “discuss”) into this blog. If you leave a comment, you’ll have to enter an email address, but your address will be hidden. You do not* have to “register” with Disqus to leave a comment. If anyone replies to your comment, you’ll get a notification, but your privacy will still be maintained.

I hope this feature will be useful to some of you. Thanks again for reading and chiming in once in a while!

I had a crap weekend.

Friday: Three of four patients, demented. Second medication error of my short career (alas, more on this in the upcoming Post of Shame). Went home 1-1/2 hours late.

Saturday: Literally up to my elbows in poop — cleaning diarrhea out of a 300-lb. bedbound patient four separate times. No care partner (nursing assistant) available on weekends. No break relief nurse available to me until 6 hours into my shift.

Sunday: Not a bad day, but exhausting because a demented patient required constant monitoring. No sitter or care partner available. More pooping from the bedbound patient. Went home a half hour late.

Monday: Since this day was my fourth in a row, I already knew two of my four patients (the demented one and the bedbound one, both with chronic heart failure) and by this day the demented one had a continuous sitter and the bedbound one was no longer having constant bouts of diarrhea. Although my patients were stable, I had a new admission in the middle of the shift at the same time that I had to manage a blood transfusion. Admissions throw everything off. I was flying in and out of rooms, up and down halls with hardly a breath. I got help from other nurses and used every time management skill and trick that I’ve collected over these four months, but they weren’t enough. At one point I took a chance on something because I was feeling desperate — and quickly knew it was the wrong corner to cut, but it was too late. I know I’ll be answering for it next week (to be continued in the Post of Shame). Went home 1-1/2 hours late.

The economic recession has become palpable as friends both within and outside of nursing have been unemployed for months now. Soon-to-be RNs are beginning to ask, “How did you find your job?,” but I’m afraid the answer isn’t helpful: It was 75% luck and 25% hard-headed determination (I’ve changed these percentages after protests about not giving ourselves more credit), because last year the job hunt was already frustrating. For every one new-grad position in the Bay area, we were told there were 200-plus applicants.

Looking back, I can’t find my story of how I found my acute care job. I thought I wrote about it, but I seemed to have left off at the tiresome job search. As I said, “For two weeks I gradually descended into an unnatural, feverish state as I churned out letters, e-mailed connections from two years ago, hovered around nurse manager’s offices, and called managers until someone picked up.”

Well, one day a manager did pick up her phone. I asked her if she had any positions for new grads.

Manager: “I actually do have one position open for 24 hours a week.”
Me (tone is ecstatic): “Can I please fax you my resume directly?”
Manager: “You should fax it to HR.”
Me (tone is urgent): “I have already, several times, but they keep telling me there aren’t any positions and you know how online applications just get lost in the shuffle. Can I please send it directly to you today?”
Manager (hesitates): Hmm, um, what school did you go to?”
Me: UCSF.
Manager: UCSF? Hm, OK. Fax it to me.

Within one week, I interviewed, and in the second week, got the offer. Did my nursing school make any difference? Perhaps. Was my urgency and persistence a factor? Probably. Did I happen to call the right person at the right time? Definitely.

Here’s another story that underscores the theory that this process is 75% luck and 25% hard-headed determination. During lunch today, a friend, who was in my MEPN class, retold how she found her job in pediatrics at UCSF. I’ve paraphrased her story here:

[My husband] says it wasn’t luck; he says I fought for the job, but I think it was mostly luck. I remember I’d already applied to many new grad (Peds) programs as early as December, but I hadn’t heard back from anyone. Then I heard that [classmate A, B, and C] all had interviews for the Peds program at UCSF. I was really baffled because none of them were going to specialize in Peds, but I am, and I applied early, online, because they [HR] said it was first come first served… More time passed and I learned that the classmates who got interviews all went to the managers’ offices.

I started to feel upset and frustrated because I’d done everything the recruiter assured me was the right thing to do, and I didn’t go to the managers because I was trying to respect their time, but still I wasn’t getting called. I wrote a long and up-front email to the recruiter bringing up this matter and the contradictions.I also went to see my advisor, who is a head person in the Peds units. I told her everything and asked her, ‘What is going on? What is the real process?’ I must have been really worked up because she immediately picked up the phone and called a Peds manager and said, ‘You have a couple positions coming up right? I have a student here and she is smart, committed …” etc. The positions had not been posted yet, but my advisor said I could arrange to see the manager.

Right after I left her office I decided to drop in on the manager, because I was determined. I happened to be in the elevator with her! Right away she said we could have a quick interview. After 10 minutes she said, ‘I like you. Come back for a formal interview.’ Within 10 days, I had my job. I couldn’t believe it.

The Lunar New Year is on Jan. 26. Beforehand, in the Buddhist tradition, my mother-in-law cooked our ancestors a nice meal. They feasted as the incense burned. When the incense finished burning, it was our turn to dig in. We stood by rather impatiently and joked about which ancestor would eat the fastest (we all knew who that would be).

It’s 10 o’clock at night.

Me: Hello, patient Smith in 5323 requests Colace before she goes to sleep.

MD: You’re paging me at night for Colace?

Me: [shit]. Uh, yes, it was D/C’d this morning because of soft stools the last couple days, but the patient wants Colace now.

MD (voice incredulous, a bit stern):  You’re paging me at night for Colace? Is it a medical emergency?

Me: Uh, I know it’s not an emergency…but… [absolutely no excuses in my head]

MD: You should only be paging at night for medical emergencies.

Me: I see. Uh, I’m new. I thought it was OK to get a verbal order.

MD (voice softens or sounds amused): It’s OK. Just tell the patient the day team probably had a reason to D/C the Colace so they’ll talk to her tomorrow.

Me: OK, thanks. Boy, I’m going to remember this one. Ha ha.

MD: Do you need my name?

Me: No, it’s OK.

MD: Yes, you do. You need my name. It’s Jones.

Me [let me go away fast as I can]: OK, thanks, good night.

Alright, please laugh. I’m not too proud to look dumb a few times (this might be the 20th time). I’d laugh if I wasn’t so mortified, because I’m still wondering whether I paged him at home. I thought I was paging a doctor on-call in the hospital, if that makes this situation any less embarassing. I’m still completely clueless about many, many protocols and dynamics in the hospital. No one ever told me when to call or not, because every time I’ve needed an order, my colleagues have said, “Page the doctor.” So, I did!

I cannot wait to pass this phase where I don’t know crap.

“Whereever you go in this world, I’ll find you. If you run to the end of the earth, I’ll find you.”

Imagine this lyric. What do you hear? Love? Sorrow? Vengeance?

Imagine the lyric again, this time from a 70-year-old Jamaican woman. How does it sound? Do you like it?

As my patient repeats this over and over, I can’t help but hear a reggae song. I marvel at how poetic she is at this moment that is as far from poetry as I can imagine.

Because at this moment, she is lying on her left side, her head is buried in her arm, and she is crying, yelling, and writhing in pain as a head nurse pushes a fecal incontinence tube into her rectum.

“Whereever you go in this world, I’ll find you. If you run to the end of the earth, I’ll find you.”

I don’t think the nurse hears her, but I do. I hear pain, shock, anger, and vengeance. Just when I assure her that the worst is over, the tube falls out. The nurse wants me to put it in. I manage to do it, despite the patient’s protests, because I trust the nurse’s judgment – she’s a manager and a veteran nurse after all. I do it, because … what do I know?

It’s burned in my memory. The plastic balloon at the end of the tube is quite large and my finger has to push it up inside. The nurse finally tells me I can release the tube.

My patient, whose baseline is confusion, yells, groans, and curses for hours. She tries to attack the head nurse when the nurse tries to calm her down. My patient lets loose language that reflects exactly how angry, soiled, and violated she feels. The nurse laughs and leaves to relay the “colorful experience” to anyone who listens.

My patient looks at me with pleading and trusting eyes like I’ve never seen before. I don’t tell her I was the one who put the tube in the second time.

As the evening wears on, I begin to think that the fecal management system (FMS) could not possibly have been the first, best, or only resort. I’m inclined to take out the tube, but without nursing experience on which to base my judgment, I feel helpless. I ask a few nurses if I should take it out, but no one gives me a clear answer. Finally a nurse appears who knows the patient, and she’s appalled that the FMS has been used, because the patient has had previous bouts of uncontrolled diarrhea, but that by no means called for a collecting tube. That’s all I need to hear. The tube is out in seconds and my patient sheds tears into my hands and whispers, “I love you.” All I can do is apologize.

Her groans soon dissolve into whimpers, then into quiet, tired sighs.

I leave work wrought with guilt, but also a shade less naive.

Hopefully this is the end of blindly trusting others, and the beginning of trusting in myself. All I have to remember is: “Whereever you go in this world, I’ll find you. If you run to the end of the earth, I’ll find you.”