Uh oh, I'm a teacher now?!

Hmm, so I haven't written for a while.......no 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

Just what is on our shoulders.......

Thinking about a post on impactEDnurse.com made me wonder - do people really understand what it is a nurse does, and what the implications of our job are? Do they see us as bum-wipers and vomit-catchers, or do they see us a the professionals we would like them to see? Do today's nurses display the professionalism expected of us? Do we still appear to be the "doctor's handmaiden" or are we showing the world that we are a profession of our own?

Some days I wonder.

I handed over recently that a particular patient would need to be turned later in the night. The other nurse replied "oh, he can turn himself." This shocked me a bit. The reason the patient was there was because he was unwell (der!) and to be judged as able to turn himself, without this nurse ever laying eyes on him, is completely unprofessional. If he were to develop a pressure area, where would this nurse stand if she had not turned him - and documented that he'd been turned? Not to mention the pain that may be caused by staying in one position for too long.

We had an awful arrest just last night, which will be a Coroner's death, and probably the first that actually shook me up a bit. While it's very sad, foremost in our minds now, is thinking back over things and wondering if we did everything right. A mistake could mean a visit to the Tribunal, de-registration.....or worse. A split second decision can mean far more than a simple correction in the notes! An accountant makes a mistake, he can just recalculate and it's fixed. A nurse makes a mistake - someone may die, and that nurse's life will be forever impacted by that mistake - not to mention the family of the deceased.

It's appropriate that the last 2 days I've had a student EN with me and was talking about documentation (and therefore covering your own butt!) with her. Sometimes it takes something like last night to bring it home to students and new grads just what their registration means, and how easily it can be lost.

 How nice it would be if nurses could "just nurse" - without all the complications! But then, I think we'd still have the same attitudes, the same bullying, and the same doubtful practices we see now - probably worse. Accountability is here to stay, for good reason, but boy does it complicate things! And really what does "just nurse" actually mean?

How to educate the public on a modern nurse's role? I have no idea. But every one of us must remember that to be accepted as more than "handmaidens," we need to be people of integrity, showing professionalism in all that we do, showing the world that we do possess knowledge of our own, can think independently, and be responsible for ourselves.

But don't forget the basic, fundamental nursing care along the way. It's the little things that make the difference between a nurse and a GREAT nurse - the one the patients remember long after they go home.

Slowly but surely.....

So it's now 2 months down the track......and I think I am starting to get the hang of things. It took a flat out, scary day such as today to tell me that yes, I do know what I'm doing, and I think the trust in me from both myself and others is increasing.

Today was just flat out. We are on "critical beds" - in other words, there is not an empty bed in the place. We are full. I spent most of my shift looking after a very sick patient in our High Dependency room - something I could not have imagined doing just a few short weeks ago. I'd been told on my first day or two that I wouldn't have to look after that room yet, so it was a bit daunting to say the least. Add to that, the patient's family were getting rather upset that he hadn't been transferred out despite our best efforts. I wish I could just send them all where they needed to be immediately, but unfortunately we cannot create beds out of thin air, even in major hospitals! Not even for private patients - I'm sorry people but a private health fund doesn't give you preferential care, it's still on a needs basis. The sickest people are seen first, that's how it works.

The other RN, being the midwife, spent the entire shift in maternity as it was also full and there was a lady in labour, so here was I, thrust into a full on RN role whether I liked it or not. The buck stopped with me - I had to look after this very sick patient, plus the other 20-odd patients with the help of the EN (who was wonderful I must say!). We called in another RN to help, but even so, it really was flat out. It seemed that every time I went to do something, someone would ask me a question, or need S8 drugs from the locked cupboard, or need their IV antibiotics, or their cannula was leaking - those small but necessary tasks designed to divert your attention!

Last week was one of those weeks where I doubted my ability to do this job. Just a lot of niggly little things, where it seemed that nothing was ever easy, lots of those days that erode your confidence without you even noticing. Today freaked me out when I realised what was on my shoulders. But the only thing to do is get your head down and bum up and do the job you trained for - and remember that you are only human and must prioritise your tasks. A patient won't be really inconvenienced if they miss out on a shower today, but if you miss their pain relief, that's a problem. There were some hiccups during the day, but overall it went well, despite our limitations! The hardest part was not letting the sick patient's family see how nervous I was in that room. I think I should be nominated for an Oscar after that performance!

Pic: Ambulance Service of NSW

My sick patient was successfully transferred to the major tertiary centre via air ambulance at the end of the shift, and was also the first transfer I handled completely myself. I spent the whole shift freaking out that if something went wrong with this person, I would not know what to do, so the paranoia is not gone yet, but today has certainly proven to me that I can do this job. Whether my resolve stays this certain tomorrow, who knows!

One of them days.....

I often get asked how I deal with the death of a patient. In all honesty, I can't tell you. I just deal with it and move on, I don't do anything in particular. You do sometimes get staff asking if you're ok, but interestingly, recent research has shown that a formal debrief is not helpful, and I've never felt the need for one.

If I've been looking after the patient for a while, especially with lots of family involvement, I do allow myself to get teary. I'm still human after all! I'll even give the family a hug, and let them know by that simple action that I understand, and that I am there to support them through their grief. If necessary, I'll take 5 minutes to myself to process, then it's back to it. It's just part of the territory, and everyone reacts differently.

Having worked in aged care, death has not been a new thing to deal with in this new role. But days like today do test the resolve of anyone. To lose three in one day is rough - no other way to put it - following on from one on the last shift too. It's very emotionally draining. None were unexpected, but it doesn't make it any easier.

It also disturbs your whole plan for the shift. I don't mean this to be selfish or disrespectful, but even one death puts your whole day off, as you have tasks to do with the deceased, not to mention looking out for the family - and they may often spend a good deal of time coming and going to pay their respects. It makes time management difficult, and you often feel like you've been running around all shift with the weight of the world on your shoulders, and the physical tiredness adds to the emotional drain.

Another not so nice thing to have to deal with is bed block. You still have an occupied room that may be desperately needed by someone else. This hasn't happened in this country setting, but with the pressure on hospital beds these days, you can bet there are places who need that person to leave ASAP. Imagine being told you have to leave because someone else is coming in ..........ugh. Awful. I hope I never have to deliver THAT particular piece of news.

I do not regret my choice of career, but boy, there are some really tough days, that's for sure!

The hierarchy issue

Those in the business will understand how a new Registered Nurse can be (legally speaking) higher in the hierarchy than an Enrolled Nurse of 20 or 30 years experience. This is an interesting phenomenon, and one that takes a while to get your head around when you first start. We are used to learning from EN's while on placement, and even as a New Grad, they are a brilliant source of information.

But EN's report to RN's. That's how it works. Time in the job doesn't matter in this instance. While we may still listen to the EN's, and ask their advice or help with something, the ultimate responsibility rests with the RN.

If an EN notices, for example, a patient's obs are in the yellow zone - they go to the RN. In other words, me. Then I get to make the decision on how to proceed. Usually this means reviewing the patient, making a note of the issue, and re-checking the anomalous reading in half an hour or so. I may initiate interventions, such as pain relief, or back to bed for a while, or withhold/give medications. Sometimes it means a phone call to the treating Doctor. Whatever the decision, it is mine to make.

This has caused me some anxiety, as most of the time, the EN will clearly know what to do (and usually do it), and reporting to the RN is just a formality. I may not necessarily know what to do. I'm still a little afraid of getting something really wrong - which I know is silly as there are plenty of experienced staff to help me. I haven't made a wrong decision yet, but it weighs heavily on my mind that a little error or omission on my part could end in disaster for somebody - and then I am up before the Tribunal.

Because the EN has reported to me (and documented this) it then falls on my head. Even if I report to the doctor and they decide not to do anything, it still falls on me, as the RN is the one there with the patient, and it is my job to give the right information for the doctor to make their decision - if I miss something important, it's my fault. If something goes wrong, I am the first line of intervention for that patient. Equally, if I choose not to inform the doctor, it rests with me. Even if I asked the EN for advice and followed it, it's my decision in the eyes of the Coroner.

There are days when I do not think I am cut out for this. It's bloody scary! So much rests on everything we do, and the only person who will protect my registration (and therefore my career) is me. Nobody else - as they will be protecting their own butt. It's a tough lesson to learn, but in health care in today's society, it's every man for himself. We may work as a team, but everyone is always protecting themselves. They have to.

My advice? Something given to me on one of my first days. Whenever you do anything, no matter how innocuous it seems, document. Don't wait for the end of the shift, you'll forget something. And when you do document, imagine the Coroner is reading it. Keep that foremost in your mind - yes, it is frightening, but it sure helps keep my mind on the job!

Mmm....chocolate!

Nurses get a lot of chocolate! At least, they do in our hospital! Not a day goes by without a box of chocolates arriving from a grateful patient.....it's a wonder my arse isn't as wide as the state of NSW by now. Naturally I end up sitting closest to the box and everyone knows I have zero willpower when it comes to chocolate......

So when a big fruit basket arrived, we all thought it was such a lovely gift.....(and perhaps the patient's family who sent it thought the nurses were fat enough? Nah, they own the local fruit shop!) We naturally searched further and what did we find? Chocolates hidden at the back! Aaaaaahh..........

So to all the patients out there - yes we LOVE our chocolate! It's about the only gift we are actually allowed to accept :-) Although a nicely worded letter telling everyone what a wonderful nurse I am would go down well too ;-P

Now, for some comedic relief......

In our hospital, on a busy day, once a bed is stripped, it's left for the porter cleaner to remake. Imagine the sight of a big burly bloke, who has never made a bed before, trying to wrestle our tiny little sheets over a big air mattress........classic!

I was reading about bullying in nursing, and came across this blog by Phil Baumann on Health is Social. It hits in on the head, for me anyway. Some people take nursing, and themselves, far too seriously.

Most of us have heard the term "nurses eat their young," and it's a rare student or graduate that hasn't experienced it at some point. I certainly have! And on the other hand, you often see nurses joking and laughing at work, which some people see as inappropriate. Many people believe that nurses need to be "serious" as nursing is a "serious" business.

Without a sense of humour, a nurse would quickly become sour. I could not do this without being able to share a laugh or joke with my colleagues. You certainly cannot make jokes about a patient or their condition, as this would be completely inappropriate, but to have a laugh with your colleagues is, in my humble opinion, imperative to keeping your sanity in a tough profession. Many patients also like having a laugh with you, although you do need to remember that you are representing your employer, and nursing as a profession, when you interact with your patients. Keep it appropriate!

As Phil says, being "serious" is not the same as being "responsible," and it is the latter that is important for nurses. Being serious is emotional and personal - being responsible is to do with assessing, understanding, and taking the right actions. Serious = create anger and blame, responsible = find a solution.

I brought this up because I too am experiencing bullying. Not just at myself, but at a patient. And this is totally unacceptable and unprofessional. I'm not going to relate the entire incident, but would just like to say that a patient's comfort is always of high priority in nursing care. Just because the nurse thinks something should, or should not, be done, is not the key here - if the patient requests something in their own care plan (that is not unreasonable) and is documented to be done, then it should be done. One nurse does not have the authority to arbitrarily change something and then tell the patient that too bad, this is how it is. Consultation and respect are required, especially when the patient clearly tells you that changing things would make them uncomfortable. To not be allowed to speak on their own behalf is belittling! In this instance, the current regime was working, however the nurse wanted to change the care plan. They felt that the current strategy was impairing healing, however to do so would cause discomfort and distress to the patient. While it may have been of better clinical value, the stress and discomfort caused may well negate that value. The patient clearly made their wishes known at all times.

Never forget your patient (or your colleague, or your student) is a person. They have feelings too.

And don't take yourself too seriously. :-)