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.