Getting My Sea Legs

Many days have passed and I have changed as a nurse since I last wrote here. My orientation ended in August, and with it ended my ability to hide behind the ultimate responsibility of my preceptor. I was the nurse. I could go to my coworkers for help, advice, or resources, by my patients, their needs, treatments and tasks, were up to me.

The first two weeks were an agony. I had five to six patients every day and had a patient who was "going bad" almost every day. Two, we had to send out to E.D. Each shift I ended up staying over two and a half to three hours extra to finish the paperwork I hadn't even had a chance to start until the shift was over, piecing together the day from notes in my pocket, reviewing orders, and tying up loose ends. Exhausted, I wouldn't even attempt the 50 minute drive home, but would crash on my parents' sofa and go home in the morning. Thankfully, I didn't have many shifts in a row - I would spend 12-16 hours sleeping after consecutive work days.

Slowly the situation improved. Staffing ratios dropped to 4 patients more days than not, and even 5 didn't seem so difficult. Soon I started having two good days to every bad day, and sometimes I had half my paperwork done before the shift was over. Still, I couldn't see how other nurses managed to sit at the desk for what seemed like hours and still have all their work done by shift change. I began setting goals with the end of being able to leave the unit at 1930.

Finally, one day, it happened. I had all my paperwork done and was out the door at 1925. That week, I left before 2030 every night. Other than typical frustrations, I was in no distress. I did not hide in the bathroom to cry (as I had done each shift for the previous weeks). But now I had nightmares every night, even when I wasn't working; I would forget a patient. I would contaminate an I.V. I would do something wrong, someone would die, the manager was angry with me, I had overdosed a patient, I had given blood without consent, a patient was choking on his own phlegm and I couldn't seem to get the suction catheter into his tracheostomy. I would wake up sweating, and once, screaming. Dreaming was worse than working.

But this past week, even that changed. I stopped dreaming of botched up nursing tasks. I didn't dream of the unit at all, thank God. I began to feel glad to come into work, and actually miss my work when I had a day off (though, I would rather be with my husband than my coworkers any day). It is good not to feel anxious before an upcoming shift, or fear what the next day may bring.

How did it happen? How did I become more comfortable? How did I learn not to fear making horrible mistakes?

First, by God's mercy and protection. I don't know how I made it through the worst of culture shock and initiation, but somehow I'm finding myself on the other side with each day better than the last.

Second, by practice. With time, I have learned more effective and efficient processes and task sequence for each type of patient. Certain tasks have become second nature, and I am learning to prioritize care more appropriately. I have started to establish a routine of activities for the shift that "works" for me and my patients. As I become more proficient in routine tasks and as I encounter and successfully accomplish more specialized or complicated tasks, I become more confident in my ability to provide care.

Third, by actually making mistakes. No, I have not done any of the horrible things I've dreamed about, nor has anyone suffered physical harm at my hands. But I am human, and I have erred. But each error is a choice and an opportunity. A choice of whether to acknowledge the error and correct the error or keep quiet and deny it's occurrence, and an opportunity to learn to avoid the error in the future and implement better practice. One would think the choice would be easy. Of course you should acknowledge your mistake and correct it. But it is not easy. To admit that one has erred in these regards is essentially to say that one has acted contrary to one's responsibilities as a nurse and that one has no excuse. Thankfully, I am gifted with a rather overactive conscience that will give me not rest unless I appropriately address what I have done wrong. With each mistake and it's proper solution, I become less afraid of that mistake - not because I regard it as less serious, but because I know how to avoid it and that if it does occur despite my best efforts, I can address it and will survive it.

I'm sure there are more factors that have contributed to my increasing comfort with my work. For now, it is sufficient that I have begun to feel that the I am doing good work and fulfilling my job responsibilities. I'm am glad to have reached this point. Each day I learn something new. It is my goal to begin to share these lessons here.

Till Next Time

Culture Shock of the New Graduate RN

After two months of orientation as a Registered Nurse Intern (Graduate Nurse)on a Long Term Acute Care Unit, I've finally taken NCLEX and I'm finally beginning to face my culture shock.

The honeymoon is over. I'm beginning to ask myself whether I really want to be a nurse after all. Or, more truthfully,whether I really want to be a nurse at LTAC. Unit jumping would be very, very tempting right now. As the reality of the unit culture rubs itself in my face, I tell myself that there has to be a place where things are done more efficiently, more safely, more pleasantly. Maybe in E.R. Maybe in O.B. Maybe in Critical Care. Maybe at another organization altogether.

Then I remind myself that every healthcare job in every location has difficulties, a culture to adjust to, problems endemic to its staff and management. I tell myself that culture shock is a stage of my new life as an RN that I must pass through, I must weather. To jump ship right now from LTAC would merely delay the crisis that must come to me on the next unit. Until I come out the other side of the nursing culture shock (or become entirely broken in the process) I feel I must hold my course.

So I have pledged myself to remain in this position (unless God clearly intervenes) for at least 6 months, preferably the more appropriate 9 months from hire. I feel I ought not to do otherwise by my employer than give the work for which I was hired. I also feel that in doing so enough time will have elapsed to allow me to more accurately judge whether my distress is truly a product of this particular work environment or merely arises from the inevitable culture shock of the new graduate nurse.

What is it that troubles me, then, about my job? Since I have clearly indicated that I am troubled.

It is the constant sense of inadequacy and futility against the wave of human ailment that surges against me. It is the limitations of my memory and time management. It is the revulsion of my mind against tasks which I must perform, not because they are intrinsically valuable, but because they are printed on a sheet which I must sign. It is the panic of my conscience against the crush of time which prohibits the detailed inquiry, precaution, and care I have been trained to undertake.

I hesitate to be specific about the above. Much of the specifics do not make sense outside of the context. One must live in that context to understand and justify the apparent travesty.

The ideal world does not exist: for nursing no less than for any other profession. All day long we fight therapists for access to our patients. Can I do a dressing change for Mrs. Smith? No, Mrs. Smith is having occupational therapy. Can I take Mr. Joe's blood sugar? No, physical therapy is walking him in the hallway. Assessments, dressings, medications, treatments -- all are displaced by a rush of Physical Therapy, Occupational Therapy, Speech-Language Pathology, Respiratory Therapy, Hyperbaric appointments, Dialysis, X-Ray, Phlebotomists, Physicians, Families, Visitors... I am learning to be pushy and possessive of my patients.

And items kept where one needs them? Everyday, I have to call Pharmacy for something not sent up for a patient: from Vitamin C to Venofer, from Culturelle (basically yogurt pills) to Vancomycin (a top of the line antibiotic).

It is true, I am clumsy and not very quick. But this is the kind of work where one cannot afford to lose even a few minutes of the 12 hours one has to work with in a shift. I must strike a careful balance between deliberate double checking and prompt decisiveness. I cannot afford to overlook anything, and yet, I cannot afford the time it takes to identify every consideration.

Perhaps it is also discouraging that I work in a setting where the very nature of the patient body prevents me from receiving visible affirmation of the benefits of my efforts. As my preceptor frequently tells me, "These people are chronic." Many never regain their health completely; we keep them from worsening and help them learn to cope with their conditions. Frequently, we have patients for months at a time, some of whom ask me every day, "When can I go home?" We get the sickest of the sick -- not at the moment of crisis, but in the gradual decline brought on by years of self-abuse, lifestyle choices, or unfortunate genetic and physiologic tendencies. When everything has been done for them, they come to us, to finish out whatever we can do. While I don't have a statistic to back this up, my estimate is that one fifth of our patients will die in the next year. It seems that at least every month I hear of another patient I've interacted with at some point in the past year since starting to work at LTAC who has recently passed. And for a while, the morgue's vehicle seemed to be at least a monthly visitor.

Of course, these aren't all our patients. Many come to us for conditions that we can fix -- with time. These patients become stir-crazy and bored, even when they are getting better. As their wounds close in and heal, they become more and more anxious to leave, and more and more frustrated when they cannot yet. Yet, we do have some pleasant patients -- people who understand our limitations as well as their own.

For all of our patients, our work is important, thought it can be difficult to see this, or appreciate it. It is easy to become cynical with myself and my inability to provide for my patients what I feel is the best I can give. Yet, I must try. Every day that I work I must try. God will do what He wills with my work - and my culture shock.