The Night Before...Independence Day

I'm writing this on November 26th, 2013. Tomorrow morning I am scheduled to work my first shift as an independent registered nurse...and I'm scared out of my mind!! I have no idea where this anxiety is coming from. I know I can do this. Working as a nurse has been my top priority and goal for the last few years. I've had more than enough training and I've had opportunities to care for patients on my own. However, there's something about knowing that there will be no preceptor at all watching over me or my charting that I feel like I'll be doing acrobatics tomorrow without a safety net! There have been moments this week where I have suffered a panic attack or felt a fear so intense it takes my breath away. The only way I've been able to survive is to focus on what I know I can do as nurse. I've reminded myself repeatedly that I know how to assess a patient. I know how to care for all aspects of a patient's well being. Also, most importantly-I am a smart and competent nurse who cares about her patients and tries to make them healthy and happy in everything she does. Now if only my brain would listen to me and stop playing the "what if" game.

This week I shared my insecurities about being on my own with my boyfriend Arnold* and best friend Darius*. Each one had some very good advice. Arnold reminded me of all the compliments my preceptors have given me about learning so quickly and working in such a way that it shows I'm ready to be on my own. It helps to be reminded that other professionals believe that I can do this job and it's not just me thinking it. Also, Darius asked me what I'm most afraid of. I told him that I'm worried I'll get a patient with something that I've never had before and then I might make a mistake that could end in that person's death. Darius told me that no matter what floor I rotate to there will always be someone to help me if I remember to ask for it. He told me not to go at anything alone. There is no shame in asking for help-so do it. Lastly, Darius reminded me that I a very safe nurse. He said that I am not going to kill anyone. He said that when people die its because it's their time to do and I have to be prepared for this to happen regardless of the care the patient receives. Talking to both of them really helped my nerves.

This evening I found out that my grandpa is in the hospital. It turns out he's been fighting a cold or the flu and his blood pressure was high. He was rushed to the hospital via ambulance and after tests were run it was determined that he has a bladder infection. He is in stable condition and will spend the night in the hospital to start on antibiotics. I was worried when I found out he was in the hospital. I felt better when I learned that he was stable and that it was only an infection. This event made me hope that the nurse who cares for him treats him well. I want him to have a nurse that takes the time to explain the medications he receives or talks to him in his primary language (Spanish) and is able to make him feel comfortable so that he can rest. It made me realize that this is the kind of nurse that I am and the kind of nurse I still want to be forty years from now. Tomorrow when I show up for work I will treat every patient like they are my family member and give them the best possible care I know how to give. 

Now if only I could find a way to fall asleep. My body is still confused from the night shift. Zzzzzzz.....

Graduation

My graduation "ceremony" took place on Friday, November 22, 2013. It was a fairly simple gathering. The hospital had all the new grads gather in the conference room with all the nurse managers and nurse educators or charge nurses and we enjoyed a nice lunch. It was fairly informal until the CEO of the company joined us along with the CNO (Chief Nursing Officer). The CEO is a very approachable guy and he gave us a motivational speech about what a great time we'll have working at this organization. The CNO encouraged us to ask for help as often as necessary and to be proud of the accomplishment we had just achieved. Then we were asked to go around the table and introduce ourselves and tell a little about our background. I had jokingly told my peers to prepare a five minute speech to recite at our "ceremony." It turns out we did have to do a presentation only the topic was to present ourselves. I hadn't really prepared anything special but if you know me, you know that I can give a put together presentation on any topic, for any length of time in a positive and engaging manner at any given time. I didn't treat this opportunity any different. I figured if I have the CEO and CNO's attention then there was no better chance to step up and show them they made the right choice by hiring me. When it was my turn to introduce myself I stood up instead of sitting in the chair and told the audience what a journey the last four months have been. I went on to discuss what I've learned, what my passions are for the company and included some of our core values into the speech. I also made a few people laugh (a true success when presenting). By the time I sat down, I felt confident that I had made a good impression.

We were then each awarded a certificate and a pin that signify's our completion of the program. Now that we are done we automatically enter the Float Pool. Float Pool means that you float to any of the four units we have been trained on (4S, 4E, 3E and 5E). However, you don't have a permanent "home" until you find a full time position one of the units. I was offered positions on both progressive care units (5E and 3E). However, both positions were night shift. The choice between choosing home on night shift or staying in the float pool was very difficult. Luckily, I have amazing friends and support that listened to me weight the pros and cons and offer advice. In the end I chose what was best for my body and my sanity: day shift on float pool. I hope to gain some insight and learn from every unit. Then when I hopefully get a home I'll be able to implement all the information I learn from all the units to that one place. Float pool isn't my ideal choice and there might come a day when I have no choice but to go to nights in order to find a home but right now I think it's the best choice for me. 

After graduation was over it really hit my peers and I that were were no longer "new grads." It's a scary thought. 

Emergency Department

My new grad program allowed us to sped one week training down in the Emergency Department. I had high hopes for lots of action. However, sadly we did not get to be where the other Emergency Department RN's are but in a separate area that is used for holding. When a patient is going to stay in the hospital but there is no bed available they are sent over to the telemetry holding area and this is where I was. I was still on night shift so it was very quiet. Apparently this can happen as well as the opposite-some nights are crazy wild.

While I didn't get to do too many exciting activities I did get to look at what the other emergency department RN's do on a typical night. There's a different feel to ER nurses. They have this constant buzz about them. I really hope one day I can join a ER team-my highest hopes include joining a trauma one unit. Until them I will continue learning all I can from the nurses that are willing to teach. I also learned that ER nurses have the best sense of humor.

Two other new grads and trying desperately to keep each other awake during night shift in the ED.

One night in the ED there was enough downtime for the nurses to do their annual skill evaluation. It was fun to watch them practice all these skills and it reminded me a lot of nursing school. It was interesting to see that skills are always evaluated no matter how long a nurse is in practice. 

The Dark Knight: Surviving Night Shift

During the month of November I will complete my last month of the new grad program and it will be night shift. After we graduate on November 22nd half of the group will go to night shift and the other to days so the supervisor has us all working nights on our last unit in preparation for the change in the event that we go nights. Let me first start off by saying that there are many people out there that LOVE nights. Not just nurses either! I used to work in theatre and I noticed that most theatre folks don't go to bed before three am. My roommate thrives on staying up late and so does my boyfriend. I on the otherhand am NOT that kind of person. If I'm awake past ten pm it's because I took a looonnnng nap during the day. I get cranky when it gets late. I've always been this way. Also, I absolutely need a minimum of eight to ten hours of sleep every night or else I'm a walking zombie. So you can imagine how hard this transition has been for me.

So far I have only completed four of my seven night shifts. Those four shifts have been on a Progressive Care Unit that focuses on stroke/telemetry patients. Ideally, this is the unit that I want to end up on (days please!). My best friend *Darius works on this unit and the fact that this unit has a neurological focus is right up my ally. I have a B.A in Psychology and my favorite psych classes were the ones that included neurology lectures. The brain is one of the most fascinating organs that we have in our bodies. When someone has a stroke it can affect so many different aspects of a person's life. The person might need to learn how to talk again or how to get dressed in the morning due to a weakness on one side of their body. I have the amzaing talent of finding accommodations for challenges such as these. When my stroke patients have difficulty talking because of a facial droop I give them some paper and a pen to write down what their trying to say. This doesn't always work-sometimes their dominant hand is the one that is weak and writing goes out the window. In this instance we end up playing one of my favorite games-charades-in order to figure out what the patient needs.

Let's talk about the biggest changes on night shift. First of all-it's not only the patients who go to bed (although this doesn't always happen) but the hospital itself feels like it's asleep. There are no supervisors, case managers, social workers or diabetes nurse practicioners. The nutritionist, physical therapist and occupational therapist have all gone home. All that's left are the bare minimuml required staff to keep the hospital running until morning. This means that the hallways are quiet. It almost feels like a library. Most of the nurses communicate in whispers and I've become really good at seeing in the dark. Below I've listed some of my recommendations in order to survive the the world of darkness called night shift.

-The night before your night shift try to stay up until at least midnight or a littler later if possible. Then wake up between seven and nine in the morning and get in a really hard and intense workout. I go boxing. Then come home, shower, make your lunch/dinner and go back to bed. Try to sleep for at least 6-8 hours before your shift. I've only done four shifts so far but its worked for me. While everyone else is falling asleep or slapping themselves awake at 2am I on the other hand am wide awake. 

-Pack a healthy lunch/dinner and multiple snacks-night shift nurses thrive on eating junk food. But it's not always the best choice. I think that some of that junk food can contribute to the exhaustion that hits around 2am. Also, as a nurse I think we have a responsibility to be healthy people. 

-Buy a mini flashlight. Yes I can see really well in the dark. But I don't let that stop me from checking and assessing my patients with some light on. I had a clinical professor who once told me horror stories about nurses that did not check on their patients throughout the night and in the morning when they went to wake them up to give medications the patient was cold and dead. That fear has me checking on my patients constantly. In fact, I think I check on my patients more than I do in the day time because I have more time. Sometimes I check on my patients four times an hour. I always make sure they are breathing and then I trace any lines that are attached to the patient and make sure they are hooked up accordingly and running. I also look at the patients environment-if my patient was to wake up confused in the middle of the night with no lights on are they going to trip on anything? Is there clutter? Is the call light button close by to the patient and is there bed lowered as much as possible? I make sure to check all of these things before leaving my patients room when rounding. 

-Research your patients. I've said this before. However, on night shift you have so much extra time there is no reason for not knowing your patients entire history. Read all the doctors notes, look at their labs and double check their medications. This will help you give a detailed report to the day nurse and allow you to make a list of any necessary items that need to be done before the patient gets discharged.

-Be nice to all the night time staff. I have witnessed some nurses be rude to housekeepers or transport staff. Yet on night shift you are limited to how many people you have helping you and there will come a time when you need a favor. Don't burn any bridges or it will be so much harder to find someone to help you when you need it.

-Use the extra time you have at night to practice your skills. Tell all the nurses you're working with that you're the person to call if someone pulls out an NG tube or if there's any fun procedures that need to be done. This is the best time to learn because their aren't as many interruptions. 

-Get a really good eye mask and ear plugs. I got an amazing mask from REI. It makes everything pitch black. I honestly can't tell if it's day time or night time when it's on. And it doesn't crush your eyes the way others do. I know some nurses love the blackout blinds but an eye mask was so much cheaper. 

-Bring a book or crossword puzzle for lunchtime. People tend to be take lunch a different times during the night shift and if you end up in the break room alone a book or puzzle will keep you awake during that short 30 minute break.

-If you find yourself getting sleepy I highly recommend stair sprints! Our lab is located on the first floor and sometimes an influenza swab or other item is needed I always volunteer to run down and get it. That rush from sprinting never fails to wake me up.

-Ease up on the caffeine. I can go an entire 12 hour shift without any caffeine but sometimes I'm exhausted and need the pick me up. On night shift however, I try not to drink it past midnight-otherwise I won't be able to sleep in the morning. Be careful-you don't want to be wide awake during the day and then have to return to the hospital for a night shift.

-On your days off try not to switch your body back to days. I do a lot during the day when I'm not working but I usually take a nap and then try to stay up late in order to keep the my body in the rhythm of night shift. 

-After a night shift I get a surge of adrenaline and that's usually enough energy to get me home before I crash. However, if you find yourself exhausted after a long night shift do yourself a favor and don't drive home. Call a friend or relative to come pick you up-at worst just fall asleep in your care. You don't want to be the reason that someone else gets hurt. Drive safe and get some sleep. 

Now it's time for my nap....

CODE BLUE

While I was on 5 East one day I heard a Code Blue on 3 East. That's our other PCU and *Darius works on that unit. Call it intuition or a sixth sense but I had this feeling that it was his patient. I remember stopping what I was charting on and having this feeling in my stomach that made me sense doom. My preceptor asked why I'd frozen and I told her that I was pretty sure the code blue was a patient of my friends. I could almost see him doing chest compressions. The only other time I've ever experienced anything like that was when my uncle passed away and I was driving to go see him. My preceptor was able to look up the nurse for the patient the code was called on and it wasn't *Darius's name. I went back to charting, but I couldn't shake this sense of feeling like something was wrong.

An hour later when my shift ended I turned on my cell phone and I saw text messages from *Darius saying that the patient from the Code Blue was in fact his. He didn't make it. He told me it was his worst day ever. I raced down the stairs to meet him. When I arrived he was giving an oncoming nurse report and I could tell he was upset. He still had to finish charting, post-mortem charting and give report. I told him I'd wait in the break room. While I was waiting for him to finish I could hear other nurses leaving and saying to him "Good night *Darius, you did great today." When we finally walked to our cars and started talking about what happened we both started getting emotional. This was his first time doing CPR and the first time one of his patient's had passed away. At one point he started to second guess the care he gave his patient. He started to say "What if..."and that's when I stopped him. You see, as nurses, it's really easy to go home and start to wonder what we could have done to save a patient's life. Yet, when you are a good and competent nurse and you actively try every single day to keep your patients safe and free from harm you have to tell yourself "There was nothing I could do. It was my patient's time to move on." *Darius is one of those nurses. He cares so much and does all he can to make sure his patients are safe and cared for. He just couldn't see why his patient died. It was a hard loss. But in the end-from talking about death and giving him hugs he realized that he did everything in his power to care for his patient. Also, his patient was so lucky to have *Darius as his nurse in the last hours of his life. I see so many nurses stop caring-they develop compassion fatigue and don't blink an eye when a patient is hurting or dies. I pray I never get to that point or know when to seek help because I'm there. *Darius and I support one another and are lucky to have each other as friends. We look forward to the days we both work because it means someone will meet you in the parking lot at the crack of dawn before walking into the hospital, someone will make you laugh during lunch break and someone will be waiting for you at the end of your shift to walk with you back to your car. I encourage every nurse to find a positive support system. Between *Darius and my boyfriend *Arnold I am lucky to know that if I need to talk about work or something that is frustrating I will have someone to vent with and get feedback. My nursing friends from school and I have also started having brunch once a month to catch up and talk about what we've learned in regards to skills or techniques. Sometimes we even discuss our mistakes. We know that we're in a safe place with one another and it makes us feel as if we can share anything that might be on our minds. I hope all new nurses find a good support system and it fuels you through the ups and down of nursing during the beginning of your career.

Telemetry

My third rotation took place on 5 East-a cardiac telemetry/progressive care unit. I was very excited to start working on this unit because my goal is to end up on one of the two PCU's after my new grad program ends. 

I love the heart and the unit I'm on has patients who are receiving open heart surgeries, bypass's and any number of other heart treatments. Telemetry refers to a constant monitoring of the heart. Our patients wear a box with probes and their heart rhythm is transmitted wirelessly to a screen that is monitored 24/7. My new grad program provides us with a tele course and you must pass an exam in order to read the EKG's and strips independently. 

My preceptor for this unit, *Sandra, would be precepting for the first time. I was her first student and I think that made the both of us a little nervous. We got along really well however, she found it difficult to let me be as independent as I had been on the last two units. Luckily, there were a few days when she was not my preceptor and the alternate did provide me with the independence I knew I was ready for. At this point I am taking five patients on the med-surg floors and four on the tele/PCU floors. The PCU is structured very differently. The charting took me awhile to learn because it felt like I was going back to the very beginning. It's almost like learning another language when you're learning to chart differently than you're accustomed to. Also on this unit, the nurses check their own vital signs in the morning. This isn't unheard of in other hospitals. However, I'd been spoiled by the CNA's who were taking vitals on my last two units. The reason the nurses do the first set is because these patients are more critical and anything can change quickly and that change can make a difference between life or death. 

I found myself going home after working on the cardiac floor and having to do some homework or research on the patients I had cared for that day. There are different medications that are being given and heparin/insulin drips. Also, it helps if you brush up on your pathophysiology. If you don't already know, here is some important information when it comes to medications: DO NOT EVER give a medication if you don't know why your patient is getting it. I know this sounds simple and most of us were taught this in nursing school. However, you might know that allopurinol is given to patients for gout-but what if your patient doesn't have gout? Why is it prescribed? Don't know? Find out!! Ask your fellow nurses or the charge nurse or do some research on your own. Just make sure you DON'T ask the doctor. Unless you know for a fact that the doctor likes to teach-there are some that love to and others who don't. I think a part of this rotation was learning the doctors and which ones like something a certain way and which ones want it done differently. 

That being said-don't ever let a doctor scare you. If they do scare you, don't show it. Doctors are like children-they can smell fear a mile away. One of the doctors on this floor likes to test new nurses and will ask you how many times the patient has used their incentive spirometer-yet there isn't one at the bedside. Don't lie to doctors-even the nicest doctor will get upset if you're lying to them. Also, it helps to remember that doctors are human too. They will make mistakes. I always try to remind the doctors I work with that we're a team and we're there to work together. If they make a mistake I will bring it up to them in a professional manner and I expect them to do the same. One way to prevent mistakes from happening in the form of communication is to always use "closed-loop communication." This means that when I am talking to a doctor in person or on the phone I always read back any orders and say "Do I have this information correct?" 

One time a doctor accused me of not calling him back after he asked me to with information he'd requested. However, I had made a note of every order he'd given me and I had read that information back to him. I reminded him of this information and he was quiet and went about his business. Always document conversations with physicians when it comes to patient care. *Saundra is the one who taught me that. She said it only takes 1-2 minutes but it can make the difference later when the doctor is mad or frustrated about something. 

I would love to work on 5 East after my new grad program. However, I'm still holding out for my last and final rotation. If you recall, my best friend *Darius is on that unit and it would be a dream come true for us to work together. I'm looking forward to starting that rotation next week. 

General Medical Surgical

My second until was a better experience than I expected. I moved to a general medical surgical unit. This unit is the only one in the hospital that does eight hour shifts. The nurses all voted for eight hour shifts and I completed the 3pm-11:30pm shift for the month of September. At first, I wasn't too happy because I don't do well past 8pm-my night time reflexes kick in and all I can think about is sleeping. Also, eight hour shifts means you have to work more days per week and I was loving the 12 hour three day shifts I did on the oncology floor. However, I tried to be positive since this program is such a blessing and I was really lucky and had amazing preceptors.

The unit is on 4 South and all the nurses are veterans. I don't think a single nurse has less than twenty years experience on the unit. That means that they are all asked to be charge nurse or resource nurse and because they know how crucial teamwork is to the job they are always helping each other. I have never seen a unit as cohesive as this one. Literally, every single nurse will pitch in and help out if one nurse is struggling or if someone is getting a late admission. It blew my mind to see so many helpful nurses. The other observation I made is that no one-not a single nurse does any work until 3:00pm on the dot. That means you don't start researching your patients until you clock in. Can you imagine? This isn't possible on other floors where you have to hit the ground running about one hour before your shift begins. Yet on 4 South the 3pm-11:30pm staff gather in the break room at about 2:50pm and greet each other, make coffee and add money to the lottery pool (I was lucky enough to be asked to join).

Since the nurses are always rotating who is charge nurse I had multiple preceptors. My main preceptor, *Jane has worked as a nurse for over 45 years. She is steady, calm, thorough and gives off this sense of peace that always helped me overcome any fears. If I made a mistake she didn't make me feel like a complete idiot. She would point it out gently and inform me of the rationale behind why something would be wrong. She introduced me to everyone on the unit and told the other nurses to treat me like family. I knew I was "in like Flynn" when I was asked to join everyone in the conference room for a "break."

The other thing I learned about the 4 South nurses is that they LOVE to eat!! There was a potluck every single shift. I felt bad because I often forgot to bring a dish to share. However, that was never a problem. I was told numerous times that I had to partake in the eating regardless of whether or not I'd brought something to share. During these "breaks" there would be discussion about patients who had been on the floor awhile. They'd talk about wounds and the best way to treat them. They'd let me know about patients that needed IV starts or NG tube insertion. I was offered first dibs on any procedures so that I could learn how to do these tasks. Most of these nurses enjoy a good joke and they'd play simple pranks on each other. I love that about them. I found myself making them laugh on a few occasions. I learned that the one thing that could make a nurse mad on this unit is if you don't provide an accurate account of the patient during report. They would say "I can't believe they didn't tell me this patient has a JP drain during report!" It was because of this that bedside report was being implemented during my last week on the unit. I had experience with this type of report from my externship so I found myself offering suggestions and feedback to my preceptors on the best way to do this task. It felt good to teach them something and give back since they had already taught me so much.

After I left 4 South I had to call and give report on a patient and it turned out the patient would be my former preceptors. Before I made the call I made sure to have as much information as possible. When I was done giving report I asked "So, how'd I do?" *Jane said to me, "Very nice job Andy. You gave me an excellent report." I'd made her proud.

Oncology Rotation

I finished up my first unit rotation at the end of August and it was a perfect way to start the New Graduate Program. My preceptor and I grew to enjoy working together and I learned a lot from him-including the the most efficient way to chart (which in nursing is 85% of your job). If you can learn efficient charting strategies than you are on your way to being a damn good nurse by most standards. Another positive point about my preceptor is that he took the time to find learning opportunities. You have to remember that whatever orientation period you have, you should use it to the fullest to learn. Ask the other nurses on your units if they have any interesting cases with wounds, ostomies, chemo medications or special treatments. Try to find something that you have not done before and ask if you can assist or watch in order to learn before you're on your own and expected to do it independently.

My favorite part of working on the oncology floor was perfecting my nurse-patient relationships. Death and dying is not my strongpoint. I'm still emotionally upset about the fact that Nemo's mom dies in Finding Nemo. However, my patients on the oncology unit taught me important steps about dealing with death or suffering. First of all-remind yourself that the patient you are caring for could be your mother, best friend or you someday. How do you want to be treated? How would you want your nurse to preserve your dignity? We're talking about patients who might still have complete capability to think and process information the way you and I do. Yet their sickness might have taken their ability to speak, move or eat. That can make a person feel incredibly depressed and not to mention undignified. I make this a focal point when I am completing any tasks with these patients. Even if I am only assisting in changing their bedding I try to talk to the patient as if they can understand every word I'm saying. When they make an effort to speak to me and I do not understand them I don't pretend to know what they're saying. I keep making statements until I know more about what it is they want to say. I play charades a lot to act out specifics with my patients (I have a background in theatre). Also, when all else fails I put a pen in my patients hand and put it up to a piece of paper.

The most important thing I've learned from working in theatre, with children and on the oncology floor is the power of touch. As nurses we spend so much time assessing, counting, passing medications and reviewing labs or charting that we forget how much power we have in our hands. The simple action of holding your patients hand (with gloves on if you're a germaphobe like me) can speak volumes to them. I have seen patients in extreme agony and experiencing agitation relax when I hold their hand or place my hand on their shoulder. Often I find my patients seeking out my hand when I walk into a room. Imagine being in and out of consciousness from medications and your sickness but the one thing you can count on is the touch of your nurse. That hand that you place in a patients might be the only "real" thing they can count on while they are dealing with suffering and death. Don't be afraid to touch your patients (appropriately!). I always ask my patients or assess for a reaction when I hold their hand. My hospital also offers basic teachings in Healing Touch therapy. I have seen such a difference in the patients who are hurting, depressed or restless by simply holding their hand. I know that we don't have time and we have so many other things to do. I'm not saying you have to hold someones hand for an hour. Give your patient two minutes. I can't describe every emotion that the patient or you will experience from this action. All I can say is to give it a try.

New Grad Nurse 101

My first day of work was a little nerve wracking. The new grad program started off feeling a lot like high school (not my favorite). For the first two weeks you're in a classroom with your cohort going over different policies and procedures (a nurse's best friend) and getting a variety of lectures on subjects such as body mechanics, Rapid Response Team, Dialysis, Wound and Skin and more. At lunch my cohort sits together and its during this time that it really feels like high school.

There's a member of the cohort who's first words to me were "I'm surprised they hired YOU because you only have an ADN. I thought they were only hiring BSNs." It kinda set my teeth on edge. Like I said before, this is a hot topic. And those of us with ADN's are stuck having to prove just how wonderful we are even though we only had 2 years of nursing school. Needless to say-those first few weeks of the program I would go to my boxing gym and beat the crap out of a punching bag just to let the frustration out. *Arnold would listen to my stories and in the end he always said "Just wait until you get on the floor. You're going to show them just what an ADN is made of." And as usual-he was right (just don't tell him I said that). I would like to take this time to point out a very important tip for new nurses (and veteran nurses!). I can't tell you how important it is to exercise. I don't care what type of exercise you do-just do it! It helps with the stress. I highly recommend hitting things, but that's just me. I also like hiking. One of my professors who worked in pediatrics and oncology is an avid hiker. I think she considers a "short" hike to be ten miles. I'm more of a one to three mile hiker. It's just great to be sweating outside in nature and it helps clear your mind before your next shift. Let me guess- you have excuses right? You're tired, can't afford it, hate sweating, can't find something you like? My advice to you...suck it. Just suck it up and do something, anything! Do you have back/neck/knee problems? Go swimming! There's classes offered by the community college for $27 for about four months. Don't know how to swim? They teach you! There's really no excuse for not working out. Look at it this way-90% of our patients are in the hospital because they chose NOT to exercise or make good eating choices. You don't want to end up in that bed. Do yourself a favor and start this habit now while you're starting your career. I work out four to six times a week. I have a boxing membership to the best damn boxing gym there is-Xplicit Fitness (my trainer doesn't pay to say this-in fact he just makes us suffer more in the gym). These people care so much about your health and mind while at the same time their realistic. They understand the challenges of work (a lot of their clients are nurses) and scheduling and eating right. They guide you everyday to making those good choices. I also have a 24 hour membership  and so does Arnold and some friends. If I feel like hanging out with someone I usually suggest a good kickboxing or weight lifting class together. This membership is also good for when we travel. Lastly, I have a trainer that I've worked with for years in Coronado. I love her when I'm not at the gym. While she makes me do 60 lunges on each leg I don't really love her that much. Arnold has started going to train with me too and our trainer says "The couple that works out together, stays together."

Moving on....after the two weeks of our new grad program we started our clinicals. Our cohort was split between two medical-surgical units: Oncology and Orthopedics. Three of the new grads in my cohort have been hired directly onto a floor. So that means they won't rotate to the different units-just stay where they are for the four months of training. We still have classes we attend but not as frequently (thank goodness-sitting in the classroom for eight hours is hard for me).

I started on an oncology floor doing twelve hour shifts (YEA!!!). This was good for me because my externship had been on an oncology floor so I was hoping I'd still remember a few things. My first preceptor's name was *Matt. Our first shift together was just me shadowing him. At the end of that shift I was pretty disappointed. I had this feeling that my preceptor thought of me as a nasty little fly. I kept getting the sense that I was bothering him and he wasn't explaining how to do anything and I felt really lost when it came to charting. I went home feeling deflated. I had been so excited to learn and I have a people pleasing personality and I was worried that I wouldn't know how to do anything if my preceptor didn't teach me. I'm telling you this because I want you to know how distressing it can be to start off in this program. There's a lot of information being thrown at you every single day and you're supposed to absorb it and apply it by the next shift-that can be very stressful for anybody. What I want you to know is that you can do it. And that's exactly what I told myself after I left work that day. I gave myself the time to feel upset and worried-then I worked out and started to get my head in the game. I reminded myself (like I always do when in a stressful nursing situation) that I had received a damn good education at San Diego City College. Thanks to my professors I know a lot and I'm a fast learner. I also know how to teach so if I had to teach myself how to navigate on the unit I could do it. Lastly, I told myself that I have a job and how lucky I am to work in a hospital. I knew going in that it wouldn't be easy and that I was going to face challenges. Now I just had to face those challenges head on and come out on top and do lots of learning along the way.

The good news is that Matt and I ended up getting along pretty good-more in my next post. But first, here are some general getting started tips that I've picked up from nurses, my mentor and friends.


1. Find a brain that you LOVE. Nurses know that a "brain" is not the one in your head. It's usually a piece of paper that you organize your patients information on. I found my brain while at Scripps Green Hospital during a clinical rotation in school. The nurses on the cardiac unit had a brain for the floor. We started using it and I love it. When we left I kept a blank copy (thank goodness!). When Darius started working at the hospital he asked if I had one and he's been using it all year. When I started last month I couldn't find any of my copies. Luckily, I'd kept one in my box at the rec center and used that to make plenty of copies. My favorite thing about it is that it has numbers at the bottom: 1 2 3 4.... and you circle  the number to correspond with the time your patient needs medications.

2. GET ORGANIZED. If you didn't learn this in nursing school you shouldn't of graduated. Have a system and a way to do things that can become ingrained in your mind so that it becomes a habit. One clinical instructor told me to always have an area on my brain where I write down tasks that need to be done for a patient and then make a box. At the end of the shift if the boxes aren't checked off you know what needs to be done. Examples: Collect urine sample, give vaccine, call doctor about patients blood pressure, etc. Also, a different instructor taught me that if there is a lab value, treatment, procedure or medication that I don't know I should put a box around the world (preferably in a different color pen). This reminds me to look it up when I sit down in front of a computer.

3. Come to work prepared. On classroom days this means I bring a bag with paper, pens, highlighters, sticky notes, snacks and my New Grad binder. Some of the people in my cohort gave me crap for bringing all that stuff but then guess who borrowed my pens and paper when it was time to take notes? Don't be the person who needs to borrow something. Always come prepared. On clinical days I bring a bag that has all my supplies. I keep everything in this bag and put this bag in the same place at home. Here's what's inside:
-Stethoscope (get a good one-you're a real nurse now!)
-Pens (I have a few lucky pens and thanks to a friend I have a really cool multiple color bic pen)
-Sharpies to write the date on dressing changes, names on urinals or hats, to write my name on my lunch (so help me if I find who ate my hummus....)
-Hemp hand lotion (your hands get really dry from washing them so I use the Body Shop's hemp hand lotion after every wash and I love it-no skin breakdown for me!)
-Tape (paper and regular-I prefer to use the paper tape on elderly patients because their skin is really fragile)
-Epo-jet (sp?) It's this injector thing that lets you give your IV narcotics without having to draw the medication out of the syringe this means faster med passing and save some time. You do have to clean i after each use.
-I have this special pocket protector thingy that I keep my pens and scissors in and just slide it in my pocket so I don't have to look for anything-it works for me.
-Notebook-one of my mentors told us in school that it's a good idea to keep a journal of your first year of nursing. It helps with reminders and special information. I have a section in the back that says "meds." Whenever I find a medication that I don't know I look it up and write it in my journal so that I can review it later. I also have a section for each unit with important numbers, etc
-Multiple copies of brains
-Stickers and a finger puppet-I used to work with kids at the clinic and these came in handy when giving shots. Now I use them to give to patients children or visiting kids. I haven't used my finger puppet at the hospital yet but you never know.
-Book-I like to read on my lunch break. I'm reading a book called Trauma and I absolutely love it.
-Lunch box-I always pack a ton of healthy snacks. One girl in my program has a special diet and allergies and she loves my snacks because there's always something she can eat in there. Nurses don't have a lot of time to eat or drink so I always try to stash my water bottle somewhere nearby and I can eat a string cheese really fast along with dried apricots and almonds.
-Water bottle-I hydrate all shift long.
-A bag of hershey's kisses-I use this as bribes, give to my patients (non-diabetic) and to say thanks to fellow nurses who help me out.
-Once I get to work I stuff my pockets with alcohol swabs, sterile caps, sterile 2 x 2 gauze and flushes.

4. Research your patients. This was something I learned in school and it was mandatory. You had to do research before starting your shift and I assumed all nurses do this. Guess what? They don't. I feel that's how mistakes happen. I understand-it's hard enough to come to work, let alone early to do the research. AND you don't get paid to do it. But guess what? If you make a mistake that can hurt a patient it puts your license on the line. I worked too hard to get that license and I'll do everything I can to protect it. So if that means I show up early to work every day and research my patients-so be it. I try to get a clear picture of my patient before stepping into the room. I look at their patient summary, medications (and look up meds at this point that I don't know and know WHY their getting the medication in the first place), labs and orders. It's taking me awhile to understand orders because it wasn't always something we looked at in school and we weren't allowed to order anything. I'm working to make this a habit. It can be confusing having all these orders listed for one patient and you do have to sort it out but ultimately it's one of the most important sections there is. I always check a patients diet and last vital signs and blood sugar if their diabetic. This lets me formulate questions to ask the nurse who had the patient before me at report. Do NOT rely on report as your research. I like to think of report as a time to confirm everything I've researched. I've had nurses tell me things that are the complete opposite of what the orders say should be done. It's usually because someone told them to do it that way but no one looked at the order.

5. Don't be afraid to make mistakes. I'm still working on this. In school we're expected to be perfect, no mistakes allowed whatsoever. At least that's what it felt like. However, here's the thing-if you don't make mistakes you won't learn. Whenever we do something wrong we learn how to do it right and our chances of doing it wrong again decrease substantially. Now, this doesn't mean make catastrophic mistakes. I'm NOT encouraging that. What I'm talking about is those moments where you're not sure if you should do something for a patient (take off their SCD's because they say they can't sleep with them on) because it doesn't spell it out for you in the orders and there's no one around to ask-in those instances you have to trust your best judgement and make a critical thinking decision. I always ask myself "Will the patient die if I do this or don't do this?" If the answer is no I do it. Then I follow up with my preceptor. Have I been wrong? Yes. There have been times where I chart something incorrectly and then I have to fix it or it's charted in the wrong section. I've learned that it's ok. In fact, I've become a better charter because of it. I know where almost everything is supposed to go because of those mistakes I made early on. I pray no one reads this section of my blog then gives someone a deadly medication and says "Well you told me I could make mistakes." I do not condone those kinds of mistakes. In fact-when it comes to medications I still try to be perfect. I do double, triple, quadruple checks. It's just something I learned in school and it's not a bad habit to have.

6. Don't be afraid to ask for help. I learned this one from Darius. At our externship we rarely had nursing assistants to help us. So the nurse did everything-vital signs, bed baths, ambulating, assist with feeding, everything. However, the hospital we're at now has great assistants and more of them. Try your hardest to build good relationships with your CNA's so that when you ask them to get another set of vital signs they don't give you the death glare (this is where the bag of hershey's kisses comes in handy). There are plenty of assistants who DON'T want to help you and their always "busy" with a different patient when you need them. But there's plenty of those who will go out of their way to help you if you treat the with respect and bribe them with candy. Also, never underestimate the powers of being a nerd/geek. I have a Star Trek lunch box (my Wonder Woman one broke) and even though I'm not a Trekkie I like the new movies and watched the old show and Next Generation. The floor I'm currently on has a limited supply of helpful CNA's. Well, as it turns out one of them is a die hard Trekkie and when he saw my lunch box a bond was formed. He is always willing to get a patients weight, transport a patient to ultrasound during shift change or get anyone some water when I ask him nicely. Now if only I could find a CNA that loves Star Wars....

7. Always volunteer to help other nurses-this is what opens you up to new experiences. Everyday I go to work I learn a ton of new stuff because I ask other nurses to let me know if I can help them with any of their special cases. I never knew how to use the PCA's (for pain management) well now I'm a pro and I've had tons of patients on these machines. Same thing with feeding tubes and TPN. If I don't have any patients with any special issues I try to seek out someone who does and offer to assist so I can learn how to do it. That's what's great about this program. It's all about learning. It's best to learn it all now while I have the help than when I'm on my own.

8. Have fun. I love to make my patients smile. I look up stupid jokes to tell them online so that I can make them smile. I always include the family in my patients care. If there is someone at the bedside visiting them then that means their important because they took time out of their day to come to the hospital and sit with their loved one. Try to make them feel important too. Those of you who have heard my "gun show" jokes should know that my patients love them or their really good actors. I usually sing some random song when walking down the hallway or charting and by the end of the shift I hear at least one other person singing it too.

9. Don't treat doctors like their God's. I see so many nurses do this. Guess what? Their HUMAN beings just like you and me. Do they do great things? YES! They do some amazing things-especially those surgeons. But if we treat them like their above the rest of us down here on Earth then they start to act like it. And some of them already believe their wonderful so why feed the ego? I treat all the doctors with the utmost respect and I expect them to treat me in the same manner. Some of the doctors are unbelievably kind and love to teach and will ask for your input (what?!? Unheard of, I know). And others want nothing to do with you and will yell and scream at you if you even think of suggesting something to them let alone call/page them. Those are the doctors you just gotta deal with. I was spoiled in the last year working at a clinic. The doctors, PA's and NP's were the nicest you've ever met. Even when I made a mistake they were always willing to help you out. I miss my interactions with them. But the doctors in the hospital aren't too bad. I don't care if a doctor is mad or yells at me. I just remind myself that I'm doing the best I can for my patient and that's what is most important. Again, this is where boxing comes in handy for the stress relief. I haven't had a doctor yell at me yet. But hey-there's always tomorrow...

10. Treat the housekeeping, nutrition staff, lift team members like God's. These guys do the hard work. I use that bag of hershey's kisses with these people too. I always say hello to them and make eye contact. I try to learn all their names. I see most people ignore them completely. But guess what? When your patient has thrown up all over the floor (or worse) or clogged the sing with their chunks housekeeping is who you call and they can choose to come quickly or take their time. Also, if your demanding patient wants more chicken soup nutrition is the one's who will find it or say "sorry but there's no more." If your 600 pound patient needs to be turned the lift team is the one who is going to help you and in my book this deserves a truckload of hershey's kisses-although that might make them weight 600 pounds. These people are good at their job and support you in your job so treat them with the respect they deserve.

I'm sure I'll have more tips to add later but for now this is a great start.

*Names have been changed to protect identity.

Getting the Job

ADN vs. BSN: This is the constant battle for new graduate nurses and since it's a hot topic I'd like to add my two cents (has anyone seen my soap box?). The main difference between these degrees is the amount of time you spend in school. An Associate Degree in Nursing graduate will go to school for about two years and a Bachelor's of Science in Nursing grad will have had four years in school. However, those four years a BSN grad spends in school includes undergraduate work (that are prerequisites for an ADN grad to get into the program) and they will have had a few additional classes in theory and leadership. An ADN grad tends to have more clinical hours by the time graduation rolls around. I think this is the most important difference between the degrees. When you have more time to spend in the hospital you get to actually see the pathophysiology at work and you can apply the theories you learn in school directly to your patients. Also, you have more experience with organization, time management and critical thinking. In my book, those are the skills that nurses need more than anything when first starting out their career. Since starting the RN to BSN program through Grand Canyon University I've met students with an ADN from around the country. I can see why some people have a negative view on the degree. San Diego City College does not just put a regular ADN graduate. Their program is intensely rigorous and so hard core that by the time graduation rolls around its really hard to spot any difference between an ADN and BSN graduate. They pour so much work and assignments into those two years and the requirements placed on the students are so immense that in the end we end up covering almost three and a half years worth of material in two. While I was in school I didn't appreciate this fact. The stress level was like nothing else I had every experienced (and I didn't think anything could be worse than UCSD Finals week). However, in the end I'm thankful to all the instructors we had for sharing their knowledge and passion of nursing. I still keep in touch with my professors and consider some of them to be my mentors. Not a single shift goes by that I don't have to use some insight or information I was taught by one of them and it makes me smile. I currently go back to the San Diego City College new graduate panel and speak to the upcoming graduates about taking the board exam, finding a job and experiences. I love going back and seeing the look on the students faces. I remember that look-that feeling of "this is never going to end!" And I enjoy talking to them and trying my hardest to lift their spirits and say "it's all worth it in the end."

The reason I bring up the whole degree thing is because in San Diego it is VERY hard to get a job in a hospital without the BSN. Things are getting better-the current graduating class from City College received more hospital jobs out of graduation then the year before. Yet most hospitals still only have about 100 open New Graduate Nurse positions a year and yet they receive thousands of applications. When it comes to selecting candidates to interview the type of nursing degree a candidate has can make the difference between an interview or not. I couldn't get an interview in a hospital to save my life after my first year of graduation. It was a very depressing experience. I applied to 20 or 30 jobs a week and would always get the email "thanks but no thanks" or hear nothing back. I did my best to stay positive but it wasn't easy. After all the suffering with school and no interviews made it hard to wake up every morning. But I didn't give up. With every new season of new graduate programs that became available I applied. I finally got lucky and got a call from my current hospital. *Darius says it wasn't luck he said it's meant to be. However, he works at this hospital and for the last year has spoken to almost every nurse manager at the hospital about me and had me email each and every one with my resume. I personally think the managers were sick of getting hounded with emails that they finally thought "might as well interview her." Little did they know that I was going to bring my A-Game. I spent weeks preparing for my interview-researching and studying and doing mock interviews. It all paid off.

The interview itself was intense. It was a panel interview with seven people and lasted one hour. Each person asked me three very difficult questions and I answered them to the best of my ability. At one point, while talking about nutrition I made the interviewers laugh  and that made me feel good. When I left the room I felt that I'd done everything that was in my power to make a great impression. Then I played the waiting game....for THREE WEEKS!!! That's a long time to wait. It honestly felt like three months. I had my cell phone on my 24 hours a day. Whenever I'd get a call from a number I didn't recognize my heart rate would increase and I'd get all sweaty-only to answer the phone and hear "Can we interest you in a seven day cruise to the Bahama's?" When the call finally did come I almost passed out. I was shaky and sweating and I felt like I couldn't breathe. My dream to work in hospital was becoming a reality. And not just any hospital-the same hospital as Darius. While we were in school and doing our externship we always said how cool it would be to work together-now that it was going to happen made this dream an even better reality.

The program I'm in is called a New Graduate Nurse Residency Program. They include clinical hours and classroom hours as a part of the program. It's honestly a lot like nursing school except you get paid for everything. I have a preceptor on every unit I rotate too and the classes we take relate directly to the unit we're working on. There are ten people in this New Grad group-we call it a cohort. My next post will be about the basics of the program and getting started.

History of Me

My main reason for starting this blog is because I'm currently working an evening shift and I need something to do after work to unwind before going to bed.

I'm a new nurse-I graduated with my Associate Degree in Nursing in May 2012 and passed my NCLEX the same year. I spent my first year as a nurse working in a clinic setting. As educational as that experience was I was dying to work in a hospital. My chance finally came this August 2013 when I was offered a position at a hospital in San Diego in their New Graduate Nurse Residency Program. The program gives you four months of training. You float to a different unit each month: Oncology, Orthopedic, Stroke/Telemetry and Cardiac. At the end of the program you become a part of the float pool and are able to apply to positions on all four units or apply for training programs in the critical care units. 

Educational Background: I currently have a Bachelor's degree in Psychology from the University of California, San Diego. I graduated from San Diego City College with my Associate's in Nursing. Currently my boyfriend, *Arnold and my best friend *Darius and I are working on our Bachelor's in Nursing through Grand Canyon University. 

Important People: I consider myself a very lucky gal to have met the love of my life in nursing school. I met one of my best friends in school, *Darius, and we're still very close with other friends from school too. I've heard from different nurses that the friendships they made in nursing school have lasted a lifetime-so far they are absolutely correct. One great thing about having a boyfriend and friends that are nurses is that when we all gather together at the bar our conversations tend to include the following: descriptions of what a GI bleed smells like, bowel movements (for the record my non-nursing friends and I talk about this too), new medication names we've never heard of and "what would you do if" situations that we've experienced. 

Philosophy of Nursing: My nursing philosophy is centered around the patient. I'm a big believer in treating all the patient's needs-physical, psychological and emotional. I also try hard to incorporate cultural sensitive care into all my interactions with patients. You'd be surprised how much culture plays a role in nursing. Also, I'm a big believer in alternate methods of treatment-especially when it comes to pain management. I love it when patients are willing to try non-pharmacological treatments to deal with their pain management. Overall I pride myself in always advocating for my patients and making them laugh and smile at least once during my shift. 

My goal for this blog is to share the adventures I experience during the beginning of my nursing career. There's plenty to learn and I'd love to share it with anyone who reads it. Even if you're not a nurse and just want a good laugh-I recommend this blog. My other reason for writing about these adventures is because nursing is not an easy career. It's rewarding and I love it, but it's hard work. And maybe one of the challenges I write about will motivate another newbie nurse to get through their next long shift.

*Name has been changed for identity protection