NursingZen

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.”

I’ve been independent for 8 shifts now, and I like it.

I like the sound of “my patients.” They’re not “my nurse’s” or “my preceptor’s.”

I like the sound of “Hello, I’m your nurse this evening,” not “Hello I’m a student nurse,” or “Hello, I’m working with so-and-so today.”

And I confess — I feel a thrill when:
- giving report
- taking report
- signing “RN” after my name
- being asked to witness a narcotic waste
- being asked to check a heparin or insulin

There’s even something satisfying about charting — when there’s time.

Along with the thrills is the responsibility. In the beginning it felt unbearable, but my mind and body are learning to shift and balance the new weight. Sometimes the responsibility feels like a burden, but usually it does not. I’m hoping it’s a new dimension that will eventually fit naturally into my everyday.

Three months of culture shock at the community clinic gave my ego a mean bruising, but it’s recovered and I’m suddenly enjoying my job there one day a week. I’ve learned to focus my energy on the patients and on my own growth.

For example, I’m having conversations with patients that I had no skills for three months ago. Last week, a patient came in concerned about his blood pressure. I asked him if he smoked and he said yes. I asked him whether he knew that smoking increases his risk for hypertension, coronary artery disease, and stroke. He said no. I scolded him, explained in simple terms how smoking constricts blood vessels, and scolded him again. (All this I learned by listening to a health podcast in Cantonese, over and over again.) A more seasoned Chinese nurse might have pulled out other culturally competent communication tools (listed below), but this time, I was simply happy that I could bring myself to scold him and speak well enough to be understood.

In another cultural setting, I might have taken a different, softer approach, but since working at this clinic, I’ve observed the following about communications between Chinese providers and Chinese patients:
- our patients are deferential to doctors and nurses, and expect us to speak to them authoritatively
- old Chinese people can be sassy — and to be heard you have to be sassy back to them
- it’s not rude or offensive to raise your voice
- sarcasm can be quite effective

These are not communication skills that will get taught at any politically correct school; they come out of real life. Needless to say, we all know that these things are not generalizable to any providers or patients outside of my clinic!!

Once again, I’d like to try to pick up from where I left off in October. I hope at least a few readers are checking in periodically. Since my last entry:

- I have renewed optimism.

- I finished the fall quarter of the UCSF Master’s of Nursing program. I’m pursuing my Master’s part-time over three years (instead of two years full-time). I’m starting with two classes per quarter in the first year and perhaps three or four classes in the second and third years.

- I cut back on my hours at the community clinic to one day a week so that I could start a part-time acute care job at a hospital. I’m a Staff Nurse I, which indicates less than six months experience.  Being a new nurse is a highly coveted role that one thinks back on with warm, fuzzy memories!

All nurses will hear only sarcasm from the last sentence.

Being a new nurse, especially in an acute care setting, has been a nail-biting adventure. Adjusting to the hospital, my floor, my co-workers, and learning how to handle a full patient load has been crazy. No day is the same. I go in with eyes wide open, adrenaline pumping, and leave either relieved, exhausted, distraught or all of the above.

To center myself each morning before work, I light incense, meditate, and give myself pep talks while walking to work. Each evening after work, I light incense, lie on the floor in the dark, and wait for my head to decongest and legs to unswell.

Next week I’ll be crossing a new threshold: I just completed my 8-week precepted orientation at the hospital and will be on my own starting Tuesday!

<Insert excited, nervous, and disbelieving face here.>

Due to the overwhelming experiences of being a new nurse, my entries here will be focused on … being a new nurse. However, I’m still in school, so I’m more than happy to answer anybody’s questions about the MEPN or Master’s program.

 Happy holidays.

This week I will have been a real, live, working registered nurse for one month! I almost didn’t make it (at the current place of employment). Here’s a summary of what happened:

Week 1:

I’m sitting behind my preceptor, observing, taking notes, and reading a half-foot-thick binder of triage guidelines for dozens of conditions. My preceptor doesn’t tire of explaining every little detail to me, multiple times. The clients are more than I had bargained for. More on the cultural complexities of working with this population in a later post.

Internal monologue: This is fun … this is too much information …  how long are they going to let me train? … I feel like I’m in China … No way, my vocabulary just doubled.

First half of Week 2:

I’m sitting in the triage hot seat; my preceptor’s in the background. When I get stuck, which is every 1 to 2 minutes, she explains procedures, hints at questions I should be asking, interprets for the clients, cheers me on, and relieves me when clients suddenly pile in. I rejoice when I take care of two patients in a row without asking for help.

Internal monologue: My preceptor is fabulous … but she must think I’m an idiot … but she’s so nice and patient … hey, I’m going to get the hang of this.

Second half of Week 2:

Another triage nurse fills in for my preceptor, who is out for two days. I sit in the hot seat again and with confidence, I dive right in to the cases, eager to extend the time in which I don’t need help from 2 minutes to 5. But, wait, something’s amiss.

Suddenly I can’t say more than 10 words or pause to think for more than 15 seconds before the substitute preceptor jumps in, talking a mile a minute to both me and the clients. I can barely follow and she can’t bare to listen to my broken Chinese, which only gets more broken as the pressure to speak, act, and think at bullet-train speed mounts. For 8 hours, I’m pummeled by her urgency, anxiety, frustrated sighs, and the following refrain: “You’re a nurse now, you should know all this!” At the end of the day when my blood pressure is sky high, she tries to be kind: “Don’t look so upset. You’ll get it.”

Internal monologue: Can you please slow down … we are NOT in an E.R. … do you realize half the patients don’t understand what you just said … no! no, I’m not supposed to know all this, I just graduated 2 months ago! … grrr, if you just. let. me. try. … Is that my heart pounding? … I want to crawl into a hole … God, I’m a fraud! … Oh why did they hire me? … I wish they never hired me.

Week 3:

My preceptor is back and I try not to kiss her. We’re back to the relaxed and steady, the positive reinforcements,  the room to try, make mistakes, and try again. She unwittingly helps build back some of my decimated self-confidence. Still, I’m plagued with doubts and anxiety.

Internal monologue: I want to quit … I think I’m going to quit … but I like a lot of things about this job … I don’t want to let anyone down … no, I think I should save everyone time and money and quit. Who else is learning to be a nurse in a foreign language? Why did I get into this situation?

Week 4:

My ever-grounded and patient partner talks me down from making knee-jerk decisions over the weekend. He encourages me to give the clinic and myself some time, at least a month. He makes a good point — why not let the clinic fire me if they think I can’t cut it or get tired of training me; as long as they want me, I can’t be doing too shabbily.

I go back with renewed vigor … I won’t give up without trying my very hardest. I study day and night. I dive in with broken, ugly Chinese, and refine it as I go along. I make mistakes and own up to them. I work a little more smoothly and independently each day. Nothing catastrophic happens, but I still worry.

Internal monologue: I can do this, I think … how much time will they give me to train? I hope I can do this on my own soon. I hope I don’t have to work with those other nurses. Why am I doing this job again? 

There’s actually one more day before I can really sum up my fourth week. Who knows what will happen tomorrow?

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Lesson learned: Apply for that job you really want, even if you don’t think you meet the “minimum qualifications.”

My new job as a per diem triage RN at the community clinic has been exciting and overwhelming in many ways. Clinic triage involves fielding phone calls and drop-in visits involving everything from simple prescription refills to ambiguous complaints of “I don’t feel well” to “My chest hurts” to “I think I’m having a baby.”

The majority of the patients speak Chinese, the remainder speak Lao, Mien, Mongolian, Korean, Vietnamese, and English. I’m quite certain that in just a few days my listening comprehension has improved 100-fold and my vocabulary has doubled. It’s thrilling! Not only is my brain working in hyperdrive to process the Chinese into English and English into Chinese, I’m also learning about a multitude of medical conditions, how to make quick assessments of a patient’s condition, how to ask the right questions about signs and symptoms, and about what nursing interventions are appropriate.

Although the job description asked for a year of acute care experience and good Chinese language skills, the nurses are training me with patience and enthusiasm. Over and over again they say to me, “Don’t worry, the more patients you see the more conditions you’ll recognize,” “Don’t worry, when I started here, my Chinese was terrible but now everyone says I sound like a native speaker.”

Sometimes I laugh at their confident proclamations, but I try to trust in their experience and I try to believe in myself. Sometimes I feel badly because I know I’m not doing the patients justice yet, but most of them have been incredibly forgiving. I don’t mind that some of them laugh at my American accent and poor grammar; I laugh–and groan–with them.

When a patient does speak English, I get so excited and speak with such confidence and enthusiasm that I’m sure I come across a bit manic.

So far, I’ve been leaving work with a slight headache, my brain stuffed to the brim, but I have a feeling it’ll be worth it!

It all happened so fast. One day, I was worried about finding a job, the next day I got a call and interview, and then this week I started a per diem triage job at a community clinic where the majority of the patients are from low-income and underrepresented communities. Working for this clinic and with this population has always been one of my dream jobs, one that I didn’t think I could be hired for until I had more experience and better language skills. All week I kept wondering if they made a mistake…

I have much to talk about regarding this job, but will do so after I return from my camping trip.

Joy!

After breaking it to my high school kids that unlike what our parents had told us, our world isn’t a meritocracy, I forced myself to put on a Type A thinking cap to help me figure out how in the world I’d find a job in this dismal Bay area market, because obviously no one had read my resume in the previous few months.

The thinking cap told me that I’d have to  network like never before. For two weeks recently 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. It wasn’t a pretty time. I imagined my eyeballs bulging from the sockets and blood vessels bounding in my temples. You see, I grew up with the belief that it’s a big deal to ask anyone for favors, such as recommendations or referrals, and it’s unseemly to talk about ourselves, much less say how great we are, so even after 10 years of playing the game, it doesn’t get much easier.

After I had put my application in every pipeline I could find (except openings that require night shifts (I’m not going there yet)), I was hell-bent on writing a tirade about the Bay area job market for new graduates and what it takes to land a job … But I’m happy to say that I’ve since recollected myself, reestablished my balance, and am now waiting to see what the universe has in store for me…

About a month ago, I took the NCLEX, surprised myself by how long it took for me to complete it, left feeling like I had flunked it, and found out 2 days later that I had passed.

I didn’t write about this initially because a) I was really pissed off at the test (for example, the NCLEX will try to trick you by making just one word be untrue in an otherwise long and correct sentence) and b) my whole being automatically switched over to a non-nursing related mode after the test was over.

Now, however, I’m starting to pick up from where I left off. I might have lost some readers, but hopefully new ones will come around as I transition my entries to being A New Nurse and  Nurse Practitioner Student.

Oh, but I’m jumping the gun — first, I need to tell you about the job hunt in the SF Bay area, which has given new meaning to the words frustration, dejection, and connections. To be continued…

“Our parents are always telling us that we don’t have any special talents, so we need to just work and study hard to get what we want, so when people [counselors, colleges, teachers] tell us we need to talk about how great we are and all our skills and talents, it’s really hard. We don’t believe we’re special and we don’t know how to talk about ourselves like that.” — C.C., 16-year-old Chinese-born American.

C.C. tells me this as I help her rewrite her practice cover letter and resume and figure out what makes her stand out. While searching for RN jobs in this dismal market, I’m also working as a counselor for a 3-week UCSF summer program for underserved high school students who are interested in careers in health care. Like I was, most of them are going to be the first in their family to attend college and most are Asian American.

As C.C. shakes her head dejectedly at her letter, I can’t help thinking: “Ah, the way of the immigrant Chinese parent in America persists through the generations! Dish out loads of “constructive” criticism and stand doggedly by the belief in the “American dream” and in the fact that the dream can be built upon a meritocratic system, and ta-da — your hard work will be recognized and you will get what you want.”

But every savvy American, seemingly many UCSF students, and enlightened Asian Americans know that it’s not that straightforward. Work hard and you will gain knowledge and confidence in yourself. But to get exactly what you want? For that, you have to strategize. You have to (loudly) praise yourself. You have to market yourself. You have to knock down doors. You have to raise your voice. You have to network and make connections. This is what’s real in our society, and this is what I begrudgingly tell C.C., while at the same time empathizing with her…

• Yes, it feels strange to call attention to one’s self.
• Yes, it feels wrong to boast and self-aggrandize.
• Yes, it’s just plain weird to call out something personal like “worked at 7-Eleven to help support family” as something notable to write in a college essay or cover letter.

“‘Work to help parents pay the bills’ – I’m not proud of that, no one wants to do that, but all of a sudden that’s supposed to be amazing?’”

I asked this more than once when I was trying to figure out how to present myself to colleges. As the first in my family to go to college, my parents couldn’t give me advice other than “study hard.” Through pure heresay, street smarts, and a tiny bit of h.s. counseling, I learned that for someone who didn’t have the opportunity to take piano and dance lessons, to do volunteer work in Guatemala, or to attend pre-college programs at Yale, my edge over other college applicants would come from the seemingly mundane. I had to learn to be proud of my experiences, believe that I had something special to offfer, and express it to strangers.

I know it’ll be a long time before many of these students are convinced that anything they’ve done or experienced will be interesting to college admissions officers, scholarship committees, or internship recruiters. Over time they’ll get how to play the game and over time they’re going to find a way to reconcile what they need to do in reality with the values their parents taught them. Over time.

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The summer h.s. program ended a couple weeks ago. I had an amazing time supporting the kids and seeing them come in day after day at 8:30 a.m. to soak up knowledge about the sciences, health care, and higher ed. The kids were smart, motivated, spunky, sassy, and they affirmed my growing interest in outreach to underrepresented students in health care. The program culminated in a reception dinner where they made health-related presentations to their parents and friends. They made me teary-eyed with pride … so this is what it feels like to be a teacher or parent!