Found my bogie....literally!

Every nurse has that one body fluid that they can't handle. I've discovered mine. I have suspected it for a long time, but it's now official - this nurse cannot handle sputum! Hearing a patient with a big productive cough, then hoiking it up and spitting it out makes me gag. And then, sometimes, they'll pass you the tissue to get rid of.......or worse, a specimen jar where you can see it!!!!! YUCK!!!!! I find nothing worse than someone sitting in an emergency waiting room, coughing all over everyone and not even bothering to cover their mouth. Way to spread your germs people!

You can give me profuse diarrhoea, projectile vomit, pee all over the floor......just keep the big wet coughs away from me! (Unless it's a kid - for some reason I can handle paediatric sputum, but not adult. Meh.)  And do not EVER think of giving me a patient with a tracheostomy to look after - NO WAY. I think I would faint if I had to suction a trachy. Ew. Somehow I don't see myself ever working in a respiratory ward! ;-)

Time Management
One of the biggest things a newly graduated nurse may find difficult is time management. You can always get help with a skill if you're unsure, but managing your patients and their priorities is yours, and yours alone. Just how do you decide what is more or less important?

I've found that the team nursing environment here makes that a little more challenging. With allocated patients, I found it a simple matter of using a grid on paper to note down what needed doing at a particular time, such as medications, then fitting in other tasks in the gaps, and this worked well. I knew what needed doing, and when it needed doing. I'd need to think about what had to be done, what should be done, and what would be nice to get done if I had the time. Sometimes I'd need help deciding the priorities, but I was usually pretty close.

So do we give this now or later?

Here however, everybody looks after everybody, so it is a bit different - sometimes I can plan to do something and find it already done, or someone else may say they are going to do something but not end up doing so, for whatever reason. I find we constantly refer to the in-charge, and to the others on duty to figure out who's done what, and what else needs doing. Sometimes the ED nurses will come up and help too, if they are having a quiet day, adding just a little more confusion! There are some nurses who like to get out of doing certain things, and leave some jobs for everyone else, so that also has to be factored in. Some in-charge nurses are very proactive and set the tasks (as well as check up on what's been done), others are more relaxed and let you do your own thing. Sometimes it's tricky if the in-charge is the midwife and she is attending a birth the whole shift - but you find a way around it.

I guess as I get to know everyone's quirks I will be able to plan more effectively. I don't think I'm doing a particularly poor job though, I always seem to get everything done. I know a lot of student nurses read the blog, so my only real advice for you is to never be afraid to ask for help! You soon get into the swing of things, and only time in the job can really give you the insight to "know" what comes next. Make sure you jump in to do things at every opportunity - don't be a wallflower, even if it's a really bad arrest. The only way to learn is to "do" so make sure you "do" whenever you can! You might not know immediately what needs to be done, but even just being the scribe or the gopher makes everyone's job easier, and gives you a bit more experience that you might have otherwise have missed out on.

Town mouse, country mouse......

It's interesting to see the difference between nursing in a big hospital and a small country one. Separate wards for each specialty, critical care units, doctors on the ward 24/7, specialists in abundance, all the major services nearby, on-site pharmacy, and access to plenty of staff, plus good education makes the city hospital a fine place. The country hospital looks like the poor cousin in comparison - no doctor (of any kind) on site, one ward which takes all comers, no pharmacy on site, very limited radiography services, and the list goes on. Most of the nurses tend to be locals who've worked there for 20 plus years, with a few younger/newer ones thrown in. Resources are stretched really thin.

But for this nurse, it's a great place to be. My fellow graduates in the big hospitals may have all the luxuries and expertise available to them, but they are limited to the specialty of their current rotation. If you're in orthopaedic, you do only orthopaedic. If you're in renal, you do only renal. If you have your heart set on a specialty, then that's fantastic for you. I, on the other hand, in only 3 weeks, have taken part in "general" nursing (including pre- and post-op), palliative care, high dependency, and paediatric nursing, as well as the odd assistance to the midwives with maternity patients. It's exciting, but boy can it be scary at times!

Nurses here are "jack of all trades" and they truly have to be. The scope of practice is so much broader, and the nurse is often the real decision maker. On the flipside though, is the greater accountability. With more responsibility in terms of scope of practice, comes more responsibility in terms of your own actions.

It's very interesting to note the differences. It's something I'm definitely still adjusting to! Sometimes, with the lack of resources, you have to be a bit creative in your thinking, since not everything is available immediately as it is in a big hospital. But that's all part of the challenge that is rural nursing.

Why me?!

As if it wasn't hard enough to learn and adapt to this new role - it's just been one of those dreadful days where nothing went right! It started off so well......nice and quiet, and with the NUM on the floor so I could ask questions and practice plenty of skills! However, the ward went from really quiet to full on busy in the space of about an hour, and somehow it was my fault that everyone turned up and the in-charge didn't know who was going where.

Now I don't mind getting in trouble when I have done something wrong, it's how you learn, but what I am finding frustrating is that somebody will explain something to me, so I'll do it, but then I get dressed down by someone else for doing it that way! Or, even more irritating, nobody will own up to something and it's automatically assumed that the new grad did it. (Such as accepting patients!) Or sometimes they expect me to know something and if I don't, I get the old "why don't you know that" spiel. Aaargh. It felt like everyone wanted a piece of me today - and as I am still learning, and in a completely unfamiliar facility, I often have to rely on them to show me the way. I will admit I wanted to just run out of there and hide today! However, I will also, in fairness, say that it is only the minority of people, as most of them are so willing and accommodating, but you know what they say....one bad egg.......

We all know that nurses are there to help people. But how far does that extend? When do you draw the line between "helping" someone and pandering to their every whim? None of us want to be a "helicopter" nurse, especially for a fully grown adult patient who can, and should, do as much for themselves as possible - and quite frankly, we don't have time for it. I have no problem with assisting people who really need it, but there are some patients who just push it too far. Some of these patients know they are doing so, and others don't.  And on a flat out, busy day, these are not the type of patients you really want to have taking up your precious time.

One in particular springs to mind, and though I can't go into detail, let's just say they had a problem on the lower half of their body, but there was nothing wrong with their HANDS!

This patient was on IV antibiotics, which were given at the same time each day, as you do. As they had constantly complained of pain at the IV sites (which were changed at the correct intervals and monitored every shift), we ran the antibiotics over an hour instead of 30 minutes to try to avoid irritating the vein too much. As I entered the room to set up the IV, the patient's mother informed me "they haven't had a shower and needs the toilet." The patient complained about having an IV running for an hour so they "couldn't do anything for themselves." Well, they'd been lying there for a few hours with only a capped IV cannula, plenty of time to do those things! Mother then complained that nobody had helped with lunch. This person (in their 20's) even expected somebody to put the soap (soft soap from a dispenser) on a washer while they stood there and showered! 45 minutes later, I was able to connect the IV line.

Now, seriously, how far does nursing care extend for a fully ambulant, young and fit patient? I don't think doing everything for this patient is in their best interests - what will happen when the time comes to go home and there are no nurses to do their bidding? As I said before, there is nothing wrong with their hands! Pain relief had been given which the patient stated gave good effect, so with the pain issue out of the way, there was really nothing that I was aware of that stopped them doing things for themself. They could quite easily get up and go for a walk, visit the loo, or whatever took their fancy, even with the IV pump!


I realise this post sounds a bit judgemental, which is something we are trained to avoid. But just where do you draw the line between helping someone and being taken advantage of? We do not have time to do every little thing for everyone. It just isn't possible.

And now it begins....

Supernumerary time is over. I am now expected to function as a fully fledged RN. This is scary! I knew there would be some transitional problems, and I've found them! So for the moment, RN means (for me) Really Nervous! :-P

My first medication round on my own was sloooooow! As the doctors here use brand names on their charts, I spent a good deal of time looking up the MIMS to find out what each drug was! This is good practice anyway, but to find some that I knew already, just under a different name is frustrating! And being a country hospital with no pharmacy, finding nil stock was more than frustrating.......however, they teach us to problem solve and that is what I did! "Oral" doesn't always have to be a tablet! And PO can be substituted for PR, right? ;-)

IV drugs are a little different. They, well, not scare me exactly, but make me more than a little nervous. Putting something straight into someone's bloodstream is not exactly an every day task for most people, and can have disastrous consequences if something is amiss. Even after the second RN checked, I think I re-checked every drug about a million times, and it felt odd to not have someone over my shoulder as I administered the medication. I'm paranoid about making a mistake without a mentor over my shoulder to give me instructions! This is probably a good thing, as complacency has no place in a hospital, especially in today's society. I know time in the job will increase my confidence, but I feel like I'm just keeping my head above water right now!

Something else I have found strange is writing notes. Prior to this, I have written as a student nurse and an AiN, and had an RN to counter-sign. But to write those two letters, R and N, after my signature feels quite odd. They aren't just a couple of letters you can just add on once you graduate. They mean far more - writing "RN" after your name implies an enormous responsibility, and accountability for your own actions. Its not just a job - you are dealing with people's lives and wellbeing every day, and one small mistake can snowball into something nobody wants to think about.........

No wonder I feel a little nervous!

Hoorah Hoorah Hoorah!!!!

Just a quick post today - after all the frustration, I am finally REGISTERED!!!! Although according to the website it doesn't start until Monday.......but it's there and I have a registration number! So now when the keys are tossed my way, I can actually catch them..... ;-P

The garbage problem.....

Ok, so you're used to this recycling thing right? Two bins, one for rubbish, one for recyclables. So what is THIS?!?!?!?!

(Ok, sorry about the sideways picture, I have no idea why it did that, and I'm too tired to fix it right now.) But what's with the THREE bins?! Thankfully it is written on the lids - red for rubbish, yellow for cans, jars and bottles, blue for paper products. It certainly threw me a curve ball there for a while! Now I just have to train the rest of the family in proper recycling separation techniques, and recycling receptacle roadside placement, and all will be well. I wonder if there's an evidence base to guide me? ;-P

Then there's the phone lines that were chewed apart by the former tenant's dog........but that's another story! And we won't get started on the Austar installation-that-was-meant-to-happen-but-didn't either......oh the joys of moving!

Ok this one's upside down!!!! What the? Anyway, here's the cat "helping" me pack the dishes away - I probably shouldn't put this up as we have an outside pets lease and I wouldn't want to get evicted after less than a fortnight.......but it was too cute not to! Just stand on your head to see it properly. ;-P

Today was another of those 100km drives for an education day. Of course, somebody forgot to book me a car.......so I was left standing forlornly in the carpark for a bit! However, the country "network" kicked in and one of the cars came back to get me so all was well. Love helpful country people! A little stressful at the time, but as with most situations, it's now rather amusing! We'll just find someone to blame who is on holidays ;-) (Joke, people, that's a joke.)

The drama with the registration board continues, although apparently by tomorrow morning my name will appear on the Register of Practitioners. We shall see. After numerous attempts at emailing (as the recorded phone message tells you to call back later as they are too busy) with only an auto-responder reply, I decided to brave the phone again. Several times I was put on hold and then promptly hung up on. As you can imagine, I was not impressed by this at all! It's downright rude. Anyway, to cut a long story short, I finally got through to someone, an actual person! Wow. They first of all asked me why I hadn't called earlier (don't go there!) and then told me my application had not been assessed yet. NOT BEEN ASSESSED?!?!?!?!?! When they took my money two months ago and told me it was being assessed?! It took all my self control not to explode at the poor girl on the other end of the phone. Then she tells me they are processing applications in order of employment start date - a completely transparent story, obviously designed in an attempt to placate all the angry graduates! The board does not know our start dates, they do not know the facility we work in, so that isn't even possible. I also know of graduates, yet to start work, who are already registered. The next excuse was that they only received confirmation from the university today - another obvious fabrication as I also chased the university to send my paperwork in a hurry! I really didn't want excuses, I just wanted to know what was going on so I can be paid properly and do the job I trained for! I can tell you, I'll be checking the Board's website every hour tomorrow! The other issue with all this, is that I can't be accepted into my post-grad course until my registration goes through - so my plans are really getting messed up right now!

Registration issues aside though, I am enjoying things so far. It's a very different world to the one I trained in, and there are so many things to get my head around, but every staff member has been so supportive and helpful - so I haven't felt too lost. Three deaths in the first fortnight has been a bit heavy, but it goes with the territory I'm afraid. Most of the senior members of staff have asked me if I am all right after a big arrest the other night, and this has been a surprise! Not that other places don't offer you a debrief - but to have several people approach and see how I was doing is a new experience for me. Just shows the different culture here, and it's great.

Oh, and yes, I am fine, it was not my first arrest, and I am savvy enough to realise it's all part of the territory. So you needn't worry about that, there will be plenty more blog posts to entertain you. :-)

Well the first week is over and I survived it! 40 degree temperatures, and aircon that is, to put it nicely, "ineffective." Although, in this heatwave, I don't think there are many aircons that are going to work well!

The frustration with registration continues - I am still not registered and therefore still not able to receive the RN wage, plus I can only work within the scope of an AiN. Which means that everything I do, I have to stop and think "am I allowed to do this?" In many cases, the answer is no, and I am finding it difficult to be a part of the team when I am constantly second-guessing myself in this way. The team here is fantastic - all helpful and accommodating, and it's very lucky I am supernumerary at present otherwise they might all be feeling as annoyed as I am! The scope of practice for an RN is very different here, when compared to a tertiary or referral hospital, and I am really keen to get in there and start doing things. Aaaargh! I did everything asked by the new Board - I sent in my pre-registration in November, they charged my credit card in mid-December, and emailed me a couple of weeks ago to tell me my registration was being processed - but still nothing. So they'll gladly take your money but not provide the service. Typical. Imagine what it will be like in May when everyone Australia-wide (including us new grads!) renews their registration! Yikes. There is another nurse here who sent in her renewal in December and is also still waiting.

 In other news......this week also included some testing moments for me. The week closed with my first death in this facility. Having worked in aged care, deaths are not new to me, plus I experienced plenty on my placements. This was a new experience though, as being a country town, everybody knows everybody. As it's a team nursing environment, all the nurses were involved, and the support given to the family was fantastic. I think there were more nurses than family in the room for a while! Things are not so fast-paced, so you have the time to give people attention, and when you have a death, or the patient is close to it, no matter where, you go from caring for one patient to caring for a patient PLUS a family, and it's never easy. It's probably the hardest part of the job. To complicate this one, down in the other end of the ward were two patients who were neighbours of the patient who passed, and kept asking about him. Naturally confidentiality does not allow staff to discuss other patients, but it was tricky trying to keep them from running up to see what was going on.

It made me think about the small town issue though. I imagine there will be times when nurses here will have to care for their own acquaintances and perhaps family to some extent, and probably care for them when they pass. It's not as simple as in a big hospital where you tell the NUM you know someone and they just assign you elsewhere. Obviously with team nursing you can avoid them as much as possible, but the patient or their family is going to seek out that familiar face and there will be a time they will find you.........what to do then? And out in the community, people will know you're a nurse and ask for advice. An interesting year awaits me for sure!

I've also never encountered the bedside handover before. I'm still in two minds about it. I like the idea of including the patient, but I worry about the confidentiality issues it brings up. I think it is easier to give a proper handover when you are standing there, as you have the patient there to jog your memory of what occurred on that shift, rather than just a sheet of paper with their name. But you also have another patient in the next bed listening to every word you say...........and I don't think I'd like people discussing something embarrassing for all to hear! There may also be visitors present, so you may have half a dozen people listening to how your haemorrhoids were treated today! Hmmm. The curtain is not a wall, although we often think that it is. I've noticed that some of the nurses here are less than fastidious about patient privacy - which was one of the only things picked up on in my final assessment, so remains something I am rather picky about. But being the new kid on the block, it is not the time for me to jump in and tell people that I don't like how they do things - all that would achieve would be alienation and a tough year for me. But I can remember, and reflect on things, and improve my own practice - because the only person who will protect my registration is me.

The culture shock hasn't been too bad though, not yet anyway, and everyone has made me feel welcome and helped me out immensely when I was a bit lost. I have another week of supernumerary time, and competency assessments, and then I am on my own, but with a great team to support and teach me along the way.