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.

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:

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 impactednurse.com 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*

"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 :-)

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!