Saturday, January 28, 2012

Time flies.....almost RN2!

Tomorrow is the final shift of my grad year. As my first year draws to a close, I find myself reflecting a lot. Have I become a "Real Nurse?" Have I earned the title RN? I really don't know. I do know that I have gained confidence and knowledge, so much more than I ever learned at uni. I think I've evolved into a fairly competent nurse, at least I hope so! I don't get an awful lot of feedback, but I guess the old "no news is good news" kinda fits. Most of my colleagues speak to me on the level now, and I haven't heard the term "just the new grad" in a long time now. The next eager graduate is about to start, and I am embarking on my next challenge - student midwife! L plates on again!

I was just thinking the other day how things have panned out for me. Moving my family 400km from everything familiar, out into a small town, with a small rural facility was daunting to say the least. The first few months, as you can tell from the nature of my posts, had me thinking "what have I done?!" and wanting to just go back to my comfort zone. But you know what? I'm glad I didn't. My city friends don't know how easy they've got it - and I've experienced so much more than I ever would have in a big hospital. I've been in the thick of it with critically ill patients, where a MET team would have taken over in a big hospital - some made it, some didn't. I've helped resus a child (frightening). I've helped bring babies into the world. I've been on my own in ED with the doorbell going nuts. I've done transport duty to escort patients. I've worked with the retrieval, RFDS and NETS teams, who are just amazing. I've helped people leave this world how they wanted to. I've been part of a research study. I've been the only RN on the ward, with all the responsibility that entails. All these things that I bet few of my classmates would have done! It's this constant challenge of not knowing what you'll have one day to the next that is exciting about rural nursing. It's a world I never really understood until I arrived up to my neck in it. And what a ride it's been!

My grad year has been more than consolidating and learning skills. It's also been about finding myself, finding my path in this world of nursing. And I think I have. It's far from concrete, but it's more than a scrubby bush track ahead of me now.

Sunday, January 15, 2012

The nurse's view.....

Patient goes to doctor's office.
Doctor: You have high blood pressure. Take these tablets and see me in a month.

Nurse: Oh, you have high blood pressure. Have you always had high blood pressure? Are you under any stress? Do you have pain? What about your family, do they have high blood pressure? Hmmm, you're a little overweight, do you exercise? What about your diet? Have you had a medication review lately? Can I refer you to someone to help with *any and all of the above*?

Now, I know this isn't true of everyone, but a recent conversation with a colleague highlighted that yes, this does happen! Doctor's tend to be diagnosis focussed, identifying the immediate problem and trying to fix it - and this is not a bad thing. We go to them when something is wrong, and we want it fixed right now, we don't think about why we had the problem in the first place. Of course, we don't want to hear that it MIGHT be our own fault! Society is like that these days. We want to just take a pill and be done with it.

Nurses tend to be more holistic, interested in the bigger picture. We assess, refer and follow up. Bear in mind that it's often our information that the doctor relies on (in a hospital or aged care setting at least) so it's in our patient's interest for us to dig up the full story. We aren't interested in your excuses, because we've heard them all before. We want the whole story, so we can give you the best care. You can't hide anything from us! Ha!

And here's another interesting conversation I had - things that are supposed to make our life easier. Take gloves for example. If you are allergic to latex like me, the night mare starts when you can't find anything but latex gloves in the place. I don't know about you, but having itchy hands all day is not what I would call pleasant. Then, when you find the blue ones, you try to pull out a pair of gloves, and fifteen fall out - maybe onto the floor, maybe in the sink, maybe into whatever procedure setup you happen to be carrying. This is seriously annoying, not to mention wasteful (you have to throw them out) and time consuming because you have to pick them all up!

Then there's hand gel - useful to save time when handwashing, yes? Well, mostly. (We'll ignore the fact that some patients have been known to drink the stuff!) Once you get about halfway through the bottle of stuff, the nozzle starts to clog, so when you try to pump some out, it squirts in every direction BUT onto your hands. My shirts have been gelled that many times I don't think any bugs could even try to live on them. Not to mention my shoes, and the floor! I've even squirted a few patients with it. Luckily nowhere near any eyes but the potential is there I suppose. Then once you get the nozzle issue sorted out, there's the problem of when you get about three quarters through, and it just doesn't come out any more. You can pump and pump and pump, and all you get is a piddly little squirt that barely covers your index finger. Some of the full bottles have these fail pumps too.

So, share your items that are supposed to make life easier, but drive you nuts instead!

Friday, September 9, 2011

Technology - friend or foe?

Medical science these days has a lot of impressive machinery designed to keep people alive and make life easier for personnel. In many cases, it is a modern marvel and really does save lives. And yes, it can certainly make our life easier!

But - have we lost that "nursing sense" in the process of creating, and using, these technological miracles? Do we rely too much on what the screen says, instead of using our own assessment skills, and our very own, highly tuned senses? Have we forgotten about, or ignored, our own intuition because "the machine said so?" What has happened to hands-on nursing? I know I have been worried about a patient before even beginning my obs, and I'm usually right. You can often see just by looking if they are unwell or not - the machines should be used to confirm your suspicions, not just as a routine thing because you have to do obs 4 times a day. Have we taken the "nurse" out of nursing?

A few recent cases spring to mind that make me wonder about all this technology.

A patient with an irregular heart rhythm would always show up as bradycardic on the obs machine, whenever her obs were taken. EVERY TIME. Another nurse initiated a "rapid response" as the heart rate was in the red zone on the chart - those who use SAGO charts will know what I mean. This meant interrupting the doctor at his rooms, meaning he would need to come over to the hospital and assess the patient. Upon palpation, the patient's pulse was of an acceptable rate - its irregularity tricked the machine, as is often the case. The doctor was not impressed. It is also difficult to get accurate blood pressure readings on such patients. One thing I always do is to check any anomalous readings manually - and I notice that not all nurses do this. It's one of the basic things I've been taught along the way, and it surprises me that not everybody does it. Machines are renowned for being inaccurate the further away from normal things are. And besides, if you really want to be sure of something, do it yourself!

Another case was a patient with abdominal pain who was x-rayed, and that x-ray interpreted at the time to show faecal impaction, despite the atypical symptoms and the doctor thinking otherwise. This patient was then subjected to various methods to "get things moving" so to speak, which are not pleasant. The next day when the official report arrived from the radiologist, it described no impaction. It was a normal x-ray. The patient's carer was most upset, as you can imagine. I do not know what the eventual diagnosis was, but they left the hospital most disgruntled about getting two different stories, and being subjected to treatment which really was unnecessary. While this case was a more difficult one to understand without the use of technology, it highlights that once again, intuition is lost to technology, and is not always correct. It is open to interpretation, like everything else.

Have we lost our intuition, and our holistic assessment skills? Surely we can see if things look good or look bad? They spend three years teaching us about critical thinking, judgement and assessment skills, yet once we go out in the field, in many cases this is all forgotten, and the easy route of using the machine rather than our brain takes over. We are still the ones who have to figure out what those numbers mean for our patients, and it's this part of the equation that makes the difference between nurse, and skilled nurse. We can all push a button, but can we all put the pieces together to form the right picture? And can we all gather the RIGHT information to build that picture? I hope so, because people rely on us to get it right.

Are all these machines better than doing it the old-fashioned way? I truly wonder. I'm sure it's possible, on some wards, to get through an entire day without even touching a patient, and that truly scares me.

Sunday, July 17, 2011

Old-fashioned respect.....

I always try to treat my patients with respect, no matter who they are or what their story is. Sometimes this is difficult - such as the repeat drunk who comes in regularly in withdrawal, people in police custody etc. These people do create judgemental thoughts on our part, even though we try not to. I had a student placement in a jail, and it made me realise that they are all just people. Sure, they've done the wrong thing, but they are still people. We don't know how they got there, we don't know why the drinker drinks to excess. It does not make them any less worthy of our attention and respect than any other person. In giving them this respect, we hope that we can make a small difference to them. They might not know how to address their issues, and by creating trust and respect we might be able to crack the surface and offer some assistance without it being rejected.

I've noticed a few strange looks from other staff when I address patients by their surname - ie Mrs A, Mr B etc. Part of this is because in a small town, everyone knows everyone, and are often on a first name basis. I've noticed that many of my colleagues seem to know the "business" of a lot of patients, and will make judgement calls based on this. I don't believe this is appropriate, as the hospital environment is a very intimate setting, where the patient is very vulnerable, and what has happened on teh "outside" is generally not relevant to our provision of care. Being from elsewhere, I do not know these people, most of them I've never met before, and so I address them more formally until we are more comfortable with each other. I feel that this is important to create the necessary trust in me - it's a small gesture of respect that gives them the idea that I don't just think of them as "another patient," I see them as a person worthy of my attention, and that they are in control. Another facet is that most of them are older than I am, and I have been raised to respect my elders. I grew up calling adults by their surnames until I was given permission otherwise.

I believe this is also a part of my issues with some of the other nursing staff. Many of my colleagues are of a similar age to my own parents, and I find it extremely difficult to "talk back" to them. While they might be assertive, even aggressive, with me, I simply cannot return it - it's not part of my make up at all. Some of them, I think, have picked up on this and do push the limits of what's acceptable at times. This has been one of the most difficult aspects of working as a new RN - I am now apparently "in charge" of people who are my elders, and have 30 or 40 years nursing experience as ENs. Legally speaking, it's my butt on the line even if they make an error. Yikes. And I seem to get all the paperwork......blergh. But I am pleased to say that there are some wonderful staff who have really helped me out in some tough situations, and my thanks to them.

So please remember this:

Thursday, July 7, 2011

Moving forward.....

I imagine my fellow new grads are, like me, beginning to look to their future careers again. It's time to start researching and applying for RN2 programs if you want them, and/or begin to look into where we would like to go in the future. Today I finally submitted my application for a student midwife position for next year, which as my friends know, is the reason I did nursing in the first place. That's not to say that I don't enjoy nursing - I love nursing, but my heart still lies in midwifery.

 This did mean I had to do more darn selection criteria responses, yuck! The things are just awful, I am never sure what to write - it's a fine line between selling yourself well and sounding like you are right up your own arse. And fancy limiting me to 750 words when I can rave on about myself all day! *wink* Writing those criteria answers was tough. I agonised over them for several late nights. I think my uni assignments are easier! But it's done now, my references are on board and I can only wait for the selection process to go through over the next couple of months.

On another note, you probably noticed in my last post how disgruntled I am at times with the culture of the workplace. I will be interested to see what happens when the mid year new grad starts work in a few weeks time. I won't be bottom of the food chain any more, so I am curious to see if they treat her the same way I have been treated. And if they do, I will be the first to step in and at least try to prevent it, or to support her if she needs it. In my experience it's the subtle, almost subliminal stuff that does the most damage, and it is often difficult to recognise, particularly when you are new to something. I have noticed that nurses who came to the facility after me, but with prior RN experience, are treated very differently. I am not going to stoop to that sort of behaviour. I don't need to put other people down to make myself look good. I am always going to be a hardcore nurse - see for the details. Who's with me?

But on the flipside, I am beginning to be noticed by some of the people that matter, which is the most important thing. Yay. An agency staff member was doing orientation today with management, and asked for me to show her our IV pumps - apparently I am known as the guru of the new IV pumps! I got a chuckle out of that. I'm also often called upon to explain or fix computer "things."  It makes sense though - if it's new or technological, the new grad will know all about it. (Although, I am certainly not Gen Y, so not as technology minded as some of my younger counterparts! Tee hee.) Now all I need is some of those nursing iphone apps........*sneaks off to app store*

Saturday, July 2, 2011

"Just a new grad"

I think if I hear that one more time, my head will explode.

A couple of months ago I was talking about how I felt in control and increasing in confidence. This is still true, however I am finding certain aspects difficult to wrap my head around. We are expected to function as part of the team - but what if that team won't accept me? It very much depends on which staff are on - some seem to think I'm capable only of menial tasks like making beds or emptying pans. The things I am "allowed" to do changes with the tide, it seems. Some days I don't know if I'm coming or going! You'd think I got my registration from a Corn Flakes box! The changing standards are frustrating. While these basic tasks are important, yes, and I have no problem with doing them, I am still an RN and capable of the full scope of RN practice. Grad programs are meant to be about developing your practice and consolidating your education, after all. I have even had people turn and walk away when I have asked them to assist me with something. It's like they don't quite know what to do with me, like I'm an inconvenience. There even seems to be a thing among some staff that new grad RNs are automatically lazy and must be hounded to do every shower, bed change and linen bag swap in the place. Anyone who knows me understands that I am definitely NOT lazy!

I have been speaking to some of my colleagues about how I would like to try some other areas, such as theatre and ED. My fellow new grads are now into their second rotation, and yet I am still doing the same thing. I am not unhappy with what I am doing, however being the ambitious soul that I am, I want to experience more. It's what I'm here for. The problem is, many of my colleagues do not agree. The usual response to my discussions is "you're just a new grad." Ah, yes, bottom of the food chain! And I am supposed to integrate into this team?

But seriously folks, what has being a new grad got to do with it? New grads work in EDs, they work in theatres, they work in critical care in many places. Everyone started with no experience in a new area, whether they were an experienced nurse prior to it or not. Even our students work in all areas. The only way to learn is to experience......and the grad program is about learning different aspects of nursing. There are staff ready and willing to have me rostered with them and show me the ropes, yet others continue to block me. I swear that I did more as an AiN, before I graduated! It's most disheartening. I can only look at it as some kind of possessional thing - ie, it's OUR domain and YOU don't belong here. I passed my final practical assessment in a far busier ED than this one, and immediately prior spent 4 weeks doing theatres, so I know I can do the job, and I think I've adapted to rural nursing quite well.

It's no wonder people leave! To be made to feel you aren't good enough, when you are busting your backside to do your best, can really cut deep. Why would you want to be surrounded by people like this? I don't know. But you know what? It's their loss, not mine. I am keen, willing to learn and adapt, full of ideas and VERY ambitious - and if they don't want that, if they want the same old thing, if they want to stagnate, then so be it. What happens when all their "experienced" staff retire? Once the program is finished, I have the choice to stay or go, provided there are positions available. That choice is not yet made of course, but the culture of the workplace is always one of the biggest factors in any job. There are always people you don't get along with, which is to be expected, but to be openly discriminated against is disheartening to say the least. I see it as the biggest barrier to my professional development at present.

Not that everyone is like this, far from it. Most of them are great! The problem is, you remember the bad ones.....and how they made you feel. And it only takes one on a shift.......Although, it was nice to hear that the students prefer to be with me. Apparently I'm a natural teacher, so there you go! (And the person who told me that WAS a teacher, so should know, lol.)

And here's a cartoon to brighten your day :-)

Monday, May 23, 2011

Uh oh, I'm a teacher now?!

Hmm, so I haven't written for a real reason, just busy as always! Assignments, kids, horses, and working hard of course ;-P

This past week was my first with student RN's buddied up with me. The students were first years, and like sponges, eager to learn and asking lots of questions. I must admit, I think I felt a bit like them - a bit nervous and unsure what to expect! I'm not used to being the teacher - especially when I'm so new at this myself. I hope I didn't lead them down the garden path.......they came back the next day so I couldn't have been too bad. I guess it's just another progression on my path from "baby nurse" to "real nurse."
 I had a very sick patient on that day so I am guilty of forgetting my student was there at times. (Sorry). She was ok though, being first years they were told to "observe" and couldn't really participate in a lot. They were there to experience what we do. My first year placement I was allowed to do oral medications (under supervision), whereas these students don't do meds until second year. I was surprised that they did not know what S8 meds were or about the "locked cupboard" though. Different uni, so I guess they all do things a bit differently. Still, it must be so frustrating to just "watch" all the time and not participate. I know when I had mentors on placement that made me just watch, it irritated me no end!I wanted to DO stuff!

I must say though, it was actually nice to have a one on one patient. Even though she was so ill and took most of my focus the entire time, it was good to be able to concentrate on only her, and not have to think about the 15 or so others in the ward as well - one of the pitfalls of team nursing that I have found is trying to keep track of everyone, patients and staff! It's hard to remember what everybody needs done, and then keep up with the other nurses to figure out who's done (or not done) what for them. But I have to admit, doing meds for the entire ward has certainly improved my knowledge of medications! And my ability to decipher the special heiroglyphics the doctor's use on the chart - oh wait, that's called handwriting? Who knew?! ;-P