ALT-1 What Nursing Students should know
My entry application to nursing school required a written essay on why I wanted to be a nurse. At the age of seventeen my essay sounded a lot like "I want to help people and make a difference in people's lives. There will always be sick people so I will always have a job helping sick people." Something vague and repetitive, sort of like an answer a beauty contestant would give to the question of how they would end world hunger.
Like many other nurse wannabes my heart was filed with goodwill and naivety. I had no real concept of what the job entailed or what would be required of me on a day to day basis. I had some angelic illusion that my mere presence at the bedside of a sick person would sooth them and somehow make them better.
The cold hard truth is we nurses have to hurt people all day long in order to heal them. We stick them with needles to drain their blood and then pump in liquids that can burn like fire. Shoving tubes in any orifice we can find and then obsessively measuring whatever goop that comes out. Then we make our patients move and breathe deeply when it hurts to do so and starve them because "those are my orders."
In school we learn the basic concepts of nursing, but there is a vast world of difference between competence in the class room and what the job is really like. Some of the top students in our class loved the idea of nursing. They performed beautifully in the class setting and aced every written test. Then when they got to the bedside and were required to actually touch people they'd practically vomit on the spot. They'd break out in cold sweats and run from the room.
One particular student in my class had proven exceptional knowledge in the skills lab on giving an intramuscular injection. It just so happened she and I had clinical together. Her patient required a shot so she went to get our instructor. The three of us went together into the patient's room.
The patient was, unfortunately, cachexic. Meaning she was so thin she literally had no meat on her bones. My friend positioned the patient and located the proper spot, looking up to the instructor for her slight nod of approval. Once she had prepped the site she proceeded to advance the needle in with a flick of her wrist. The needle only went in half way. Our instructor said, "That's Okay, just advance it on in." The student looked up horrified and said "I can't! I think I hit bone!" This incident was so disconcerting to that A' student she dropped out of nursing school.
In order to better prepare future generations that are contemplating going into nursing, I decided to come up with my own list of qualifications and expectations. If I could design the perfect nurse colleague to work with they would have these basic traits. If after reading them you don't see yourself, you need not apply.
The ability to laugh and cry; along with this comes the sensitivity to know when to do both.
Multitasking; you will get interrupted at least ten times during any task. You will even get interrupted during the interruption. Expect it and plan accordingly. Stay organized by whatever system that works for you. Do not act annoyed. Your fellow nurses are just as aggravated as you and to hear complaining just makes everyone more irritable. Deal with it.
Compassion; this encompasses the ability to superimpose the face of your loved one onto your patients, so you will give the care you'd hope your mother would receive if she were the patient. If you don't love anyone but yourself then picture your own sorry self in the bed. How would you want to be treated?
Vein seeking finger tips; One of my mother's unwitting contributions to furthering my career in nursing was her veins. I remember sitting in church and squeezing off the circulation at her wrist with one hand and playing with the veins that would pop up. I liked the bouncy, spongy feeling of them and -call me a weird kid- I thought it was fun to watch them fill up and empty when I released the pressure. I'd even close my eyes and find them without looking, a skill that I have used countless times at the bedside.
Critical thinking; this refers to having the brains to think a situation all the way through. A nurse may notice and duly document a fresh surgery patient's urine output of less than 20cc/hr for her entire shift. But what might that mean? Will this nurse have the sense to look for other potential danger signs? Is the patient's blood pressure dropping? Is their heart rate increasing? Is the patient ashen (pale) and diaphoretic (sweaty) or complaining of feeling lightheaded? Will this nurse be able to add two and two and come up with, "Oh my God! Someone call Dr. Heza Butcher. I think my patient is bleeding internally!"
Confidence; or at the very least possess the ability to fake it. This is a crucial necessity in nursing. Sometimes as nurses we forget that we leave lasting impressions on our patients and their families during critical moments of their lives. The patients are in a state of complete vulnerability and are extremely sensitive to every nuance of our expressions. Only 7% of communication is the words we choose. 38% is para-verbal, meaning tone, emphasis, volume rate and rhythm. That leaves a whopping 55% in the non-verbal category.
If I show the slightest bit of fear, my patient will pick up on it with animal like instinct. There might as well be alarms ringing in their room. DANGER, DANGER! Trust me, they will notice the slightest shake to your hand or tremor in your voice and then their own anxiety will skyrocket higher than yours in a nanosecond.
The day I delivered my first fetal demise patient I was literally shaking in my shoes with fright, but you'd have never guessed. Although I had been given an in-service, I really had no idea what to expect. I had told the patient the reason she was in the hospital for this procedure was to have qualified professionals assisting her through this potentially dangerous process. When it was over, I had to escape to the med room for a good cry.
I learned long ago to control shaking hands and exude confidence. If a patient asks, "Have you ever done this before?" I learned to say things like, "This hospital performs this procedure all the time." All with a little shake of the head and flick of the wrist like piece of cake. You fake it til you make it.
The poker face also falls into this category. I may know the results of the tests but I have to wait until the doctor tells the patient. I can't let the sadness show on my face when I walk into the room of a young mother of three whose pathology results came back positive for cancer.
Another part of this is switching faces' from room to room. I may leave one patient's room with a beautiful healthy baby where everyone is rejoicing to go next door to a patient whose world just collapsed when their baby died that morning.
Physical strength; as the saying goes every nurse needs a warm heart and a strong back.' Humans as a species are being harvested bigger and bigger every year. Blame it on whatever you want, lack of self control, super sized menus and evil sugar filled sodas, hormone indoctrinated animals that later end up on our dinner tables, or just plain inactivity.
Whatever the cause, the increasing incidence of morbid obesity across the life span is alarming. This translates into the need for extra wide hospital equipment, bariatric beds, double wide wheel chairs, and nurses with muscles and a working knowledge of proper body mechanics.
As nurses we are required to move the unmovable. When a person is weakened and unable to do for themselves, we do for them. Part of our job is to turn patients every two hours after surgery while they are still groggy and under the influence of anesthesia and narcotics. We pry the unwilling out of the bed the next day to walk the halls. We rush the patient still in their bed at breakneck speed back to the OR when they start hemorrhaging. We push the 500 lb patient in a wheelchair to the lobby at discharge. We heft heavy bags of dirty laundry into the bin.
Despite our coaching them on how to best get out of the bed, some patients don't listen. They grab and pull, injuring nurses at an alarming rate. Our days are long and nonstop. The weak need not apply.
Obsessive Compulsive Disorder; if you don't have OCD tendencies before nursing school you will have them when you get out. The obsession with hand washing alone would qualify us for the disorder. We are to wash our hands prior to touching a patient then prior to actually performing a procedure like inserting an IV access. Once we remove our gloves we are to wash hands again. I read a study on nurses that said we spend an average of 84 min out of a twelve hour shift just washing our hands. That's seven minutes out of every hour.
The constant checking and rechecking of orders, meds, patients, labs, it goes on and on. From the first time I ever caught a pharmacy error I have never trusted or assumed a medication is right just because that's what they sent. I use that level of distrust to spur my diligence to confirm all the variables before giving even a simple aspirin. Is it the right patient, drug, dose, time, and route.
After an order is written the secretary enters it into the computer and the pharmacy verifies it. An RN will black line' the order confirming it was entered properly in the system and then another nurse will red line' under the black line for a second confirmation.
Before giving a medication we are trained to read the order prior to pulling it from the Pyxis, a computerized medication dispenser. Then we check the drug and dose against the order sheet. Once we confirm the drug and dose are correct and the expiration date is still good we draw the medication up into the syringe and label it before leaving the med room. We then recheck the vial one more time prior to discarding it in the sharps box.
At the patient's bedside we visualize the patients arm band and ask them to repeat their name and birthday to confirm we have the right patient. Then we ask what the patients allergies are and tell them what medication we are giving and why. All that checking and rechecking just for one med pass, and people wonder why it takes so long to bring them their meds.
Nerves of steel; noises and distractions can create a mounting level of tension. I recently transferred to a different hospital within the same organization due to its proximity to my home. The new hospital required that I go through orientation again.
When I arrived at eight in the morning the facility was having trouble with the air conditioning. Meaning there wasn't any. On the third floor in Florida where the outside temps are in the 90's, it felt like a sweltering 130 degrees inside even that early in the morning. If that wasn't enough the ballast in the light above our heads needed to be replaced and was flickering on and off at a pace that could have easily induced seizures. There were three of us in the room taking test after test, both written and on the computer.
Before long men from the engineering department came along to try and fix the AC. Apparently the problem with the system happened to be in the ceiling directly above us. Ladders, buckets, and hoses where brought in to drain the building', whatever that meant. The men were yelling back and forth to each other and practically dripping sweat onto my papers.
The proctor for the multitude of tests took pity on us and set up a large stand up oscillating fan about two feet from my face. Every 10 seconds my papers would try to escape across the room as my hair was blown all up in my eyes.
Through it all, not one of us complained. I kept thinking if they were trying to test my ability to function under adverse circumstances they'd have to try a lot harder. Where were the crying babies? Why not throw in a fire alarm or two. Where were the ego inflated doctors demanding I stop what I'm doing to pull up a lab result that they could just as easily do themselves. What about the dozen or so machines that alarm indicting your patient may not be breathing or their pain medication has run out. All in all I can count that as one of the least stressful days I've ever had in nursing.
The patience of a saint; one of the first things I learned in school was that when people don't feel good they generally aren't on their best behavior. People aren't perfect, period. They will behave badly, make poor choices and disappoint you. As a nurse you can't take it personal or you'll hit burnout very quickly and be of little help to anyone.
Despite the education given to patients regarding what will happen if they don't follow orders they'll do what they want anyway. We nurses can see into the future of a surgical patient that had their family sneak in food before they were allowed. We know that tomorrow the abdominal pain will begin. Maybe by that night the nausea and projectile vomiting will double them over. If they are lucky they won't have to go back to surgery and they will only end up with a large tube rammed up their nostril that sucks disgusting liquids out of their stomachs into a canister on the wall for all to see. If only they had listened and done what we told them to do.
Sometimes it's not the patients that test our mettle. For the most part families are helpful and pick up the slack where we leave off. Don't get me wrong, I appreciate all the help I can get, but every now and then a family member comes along that is more exhausting than the patient. Can't they see that taking up an hour of my time with their own issues is depleting the time and care given to their loved one? I don't mean to sound insensitive here, but I really don't need nor want to hear about the last time Aunt Susie was in the hospital for a hernia repair. The energy expended on these high maintenance visitors could be far better utilized in direct patient care. Time is a precious commodity in this job.
And God help us all if there are complications. They happen. Through no fault of anyone, sometimes they just happen. Why do you think patients are asked to sign informed consents with potential complications up to and including death? Our society is so warped that if a patient stubs their toe while in the hospital twenty family members all come rushing in to attest to the condition of the toe before the stubbing.
The cousin from Jersey, "who by the way is a lawyer" calls to get the details of how such a thing could possibly happen in our care. Pictures are taken and family members are sent home to scour photo albums for pre-stub comparison. There is a giddy air about the room as if the winning lottery ticket is within grasp. Questions are worded just so "Now if the doctor had only warned our poor little Amelia that such a thing could have happened, in your professional opinion, would we be in this situation right now?"
Heavy sigh. This is when I shut up. With a big, bright smile I say, "You really need to direct all of your questions to the doctor. May I page him/her for you?"
Another time consuming and particularly annoying behavior is the resume inquisition. "So how long have you worked here? And how long have you been a nurse? Where did you graduate from? How long have you known Dr. Butterfingers? Is he any good?"
With all the negativity that can be directed at me during a given day I have one nurse to thank for her sage advice. I was still in nursing school when we met. Kathy was attending classes to upgrade her RN to a Bachelor degree. She came and sat with me at lunch one day and asked why I looked so worried and stressed all the time. I gave a quick run down of my life's struggles which included juggling an infant and a toddler with nursing school and less than fulfilling marriage.
Kathy shared with me how in the past she had let her own troubles erode away the lining of her stomach to the point where she developed bleeding ulcers. Then she said, "As we go through life we may not be able to control what happens, but we do have control over how we respond to it. No one has the power make you feel in a way you don't want to feel."
That one little encounter changed my outlook completely. I was suddenly empowered. I could now look a rude, ranting person in the eye and detach myself. Not take it personal. I could view the situation as their problem and not internalize all the angst until it affected me physically and emotionally. This simple yet powerful advice has served me well in both my career and personal life. For the record, I'd like to say that if making a difference in someone's life is what defines a nurse, Kathy was the best nurse I've ever known.
Nursing is hard. Nursing is challenging. But you will not find a career that is more versatile or rewarding. Would I recommend nursing as a profession after eighteen years of practice? Absolutely! This primer is meant to eliminate some of the illusions that some students enter the field with. Hopefully, by being more informed up front on what to expect, they will have greater job satisfaction in the end.
