Tag Archives: advice for new graduate nurse

Ten experiences every nurse needs before graduating from nursing school

Ten experiences each student nurses needs to have before getting out of nursing school

There are two trends in nursing school today that bother me. I know that I am an opinionated curmudgeon at times, but I need to say these out loud, just in case the act of putting it out there makes them go away like magic. In reality, I know that we can’t wave a magic wand and get what we want, but – work with me on this!

The first is a nationwide trend. Every nursing school is full to the max with students and it is harder to get optimal clinical experience. We are substituting simulated experiences for the real thing. We focus on “the standard patient” as if all patients are standard when they are not.

The second is, we are losing the old “what is nursing” battle. By that I mean, there is increased emphasis on medical content. Physiology, pharmacology, surgery, etc. less emphasis on psychosocial implications. This goes hand in hand with the lack of “role socialization” in nursing.

Tip: the NCLEX tests nursing, not medicine. Every question on the NCLEX is either an Assessment, Planning, Implementation or Evaluation question. The Nurse Practice Acts define nursing according to APIE and nursing diagnosis; the “junior doctor” parts are limited to the section on Delegation. Every nursing faculty needs to ask themselves about whether they are teaching nursing or medicine, and to have a clear handle on the difference. If your school is having problems with NCLEX pass rates, it’s probably because the faculty are confused about this specific principle.

Let’s explore the above, shall we?

To begin with, I first taught on a nursing faculty fulltime in 1990. I taught maternity and pediatrics, and took students to a hospital for OBGYN that did about 1200 deliveries a year. That meant an average of one baby born per shift. Sometimes more, sometimes less. In those days I made a pact with the students. If they would be flexible about their hours the day they were in Labor and Delivery, so would I. the goal was to help them have the experience of seeing a baby born. In the three years that I supervised students in L & D clinical, every one of them did see a delivery. One time I hung around until 9 PM. That specific student got the idea of how long it actually takes to deliver a baby. the idea was to get a first hand look at the way all the theoretical stuff translates into what is done in real life.

When we try to simulate every experience, there is a tendency to only present scenarios where the ideal is portrayed, and to sanitize everything somehow.

On a related note, on day one of maternity orientation, I always asked the nurses to save me a fresh placenta or two. We would all don gloves, look at the membranes, the cotelydons, the shiny and dirty side, etc and marvel at it. I always viewed this as an important experience to have. It desensitized the student to the appearance of body tissue, helped them to visualize what we were talking about ( so much of prenatal care is designed to help grow a healthy placenta) and removed some mystery.

Nowadays, I am sure there are people who would look on horror and say “Om My God, it’s exposure to body fluids!” – well – no – not when PPE is applied. even in those days we wore gloves.

Ten. maybe more

There are ten clinical experiences you should have. I sincerely hope that every nurse gets these while still in nursing school, but if you don’t you still need to find them at some point. The advantage of having them in nursing school is, an experienced person can interpret the experience for you. Guidance from a guru is critical to draw the proper conclusions. By proper I mean, conclusion which reflect the role socialization appropriate to nursing.  without the proper guidance any of these can do a number on your head.

1) Coaching a woman through labor and seeing a baby born.
2) Giving a shot to a 2-year-old. Getting a 2-year-old to do anything!
3) Being with a person who is dying from cancer. Two parts: talking to them before hand; and being present at time of death.
4) Seeing surgery
5) Smelling cautery. Or any one of about a dozen distinctive olfactory stimuli peculiar to health care.
6) Having a conversation with a person suffering from delusions or psychosis.
7) Talking with family members of a person having a serious illness, whether it’s acute or home-based.
8) Doing CPR
9) Dealing with a drunk person.
10) Helping a person who is a member of an oppressed minority, whether it is a racial or ethnic group, a group subject to bullying, or perhaps a homeless person.
11) Giving nursing care to a person who is seriously ill but who is your own mirror image in terms of age, social level, education, family etc.

The key to each of the above is, it’s not about the actual experience per se. it’s about incorporating the interpersonal flexibility required to actually be of use to the person receiving the care, and about dealing with your own feelings and reactions. There is only one way to do CPR ( the Heart Association protocols) but it is inevitable that you will have personal thoughts go through your mind when you are doing compressions, and these need to be considered “by hand.”

special note about autopsies

I was once asked by a student how come viewing an autopsy is not something we can arrange, or why we don’t include it or promote it. At the time I thought the student ( a male of course) didn’t quite “get it” and had a sort of voyeuristic quality to his request. “What is the goal?” I asked. Let me emphasize that simply getting these experiences checked off is not the purpose.  The purpose is to develop an overall professional approach that can be generalized to all such experiences that have any aspect of threat to the self-image of the student.

If I had to name a single concept that everyone needs to grasp, it’s “this is not a game, not just a well-paying job, but a critical service offered to society by members of this profession.”  Often by being the one  person in the room who is maintaining composure during a stressful event.  You could look at the above list in that way.

For each of the things listed above, there are certain professional expectations as to how a successful nurse conducts themselves. I could write a blog on each one to detail these, but hey – that is what textbooks are for!

hint: we can develop a simulated experience to go with each of the above, but it will never substitute for the doing of the actual thing for a real person. Not ever. just about every negative experience can be reframed into something positive with proper guidance. (for example, cleaning human fecal incontinence can be viewed as distasteful because it involves feces, or else we can reframe it into helping the person feel better and clean while retaining dignity).

Nursing Diagnosis sayonara

As to the “junior doctor vs actual nurse” argument – I worry. There is a trend by which nursing schools are quietly getting away from the teaching of nursing diagnosis. What does your school do?

I have heard all kinds of rationales – “practicing nurses don’t use it” being the main one. My answer is, “practicing nursing surely do use nursing diagnosis!” though maybe they call it something else. Maybe they have it down so well they it is less obvious, but I guarantee you that no hospital can have a functioning customer service program unless somebody in the nursing service uses psychosocially-based problem-solving. Caring is a learned behavior, and nursing diagnosis is the vehicle by which we teach people how to care. You need more than just warm positive regard for the person you are serving. It’s too hit or miss otherwise.

Hold hands before crossing the street – the lost art of curriculum design

Nowadays in the shortage of nursing faculty, we are pressing into service anybody with a Master’s Degree, including nurses that took a Nurse Practitioner course and never took even one course in pedagogy, test construction, curriculum design, or anything. Such a new faculty person needs guidance in how to be a teacher.

Curriculum Implications

When ever there is a transition from one curriculum to another, or whenever you are designing a comprehensive course of study, it’s useful to think of a “crosswalk.” In the parlance of educational design, a crosswalk is a comparison of two lists. The first is the “old curriculum” and the seconds is the new. Where does a theme of nursing school appear in any given course of study? If it was there before and you are changing your curriculum, where is it now? It is a useful exercise to make a list of things the student is expected to know (we call them “outcomes”) and to actually place them somewhere along the line, in a rational sequence. For example, if a student nurse has never dealt with a normal person having a crisis, why would a curriculum expose that same student to concepts of mental illness first? The crosswalk needs to be analyzed according to how to teach psychosocial needs in a logical sequence. This is simply lost when the coursework focuses on a tour of body systems or medical diagnoses.

Bottom line

To become a fully actuated professional nurse is a lifelong process. When a nursing school teaches you how to care, they are teaching you “how to be a human” – which sounds easy. It’s something we need to think about….. If we only present the “standard case” we are focusing too much on the basic medical care, and not enough on the psychosocial.

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Hawaii Nurse Jobs Update Oct 30 2013

Nursing Jobs in Honolulu

As of Oct 30, there are signs that the nursing market in Hawaii is looking better. In April I re-posted a link to an article in the Honolulu Star-Advertiser that said we had a “saturated” job market.

The need for nurses isn’t going away

It’s just that we have a mismatch in the number being produced and the number we can absorb. this mismatch is due to accelerate. click here for a nifty graphic update about the need for nurses.

Geography Lesson

For those of you not living here, some geography is on order.

Most of the big hospitals are located in downtown urban Honolulu (yes, there is a city here. about 900,000 people. if we were on the mainland we’d have an NFL team. we are the 11th-largest city in the USA. we are not a foreign country.). But the population growth on the island of Oahu is planned to take place in the western side of the island, in the part called Kapolei. For years, there was a hospital in Kapolei, run by the Sisters of St Francis. It went bankrupt after running deficits for years, and hundreds of nurses became unemployed. The job market could not absorb so many nurses at the same time. The building sat vacant for awhile. It was/is a nice building. ample parking. central to their neighborhood. convenient for a whole bunch of people.

During that time, if you lived there and you wanted to go to the hospital you would need to drive on H-1, the most congested interstate highway in the USA ( how we got an interstate here, while we are separated from California by two thousand miles of open ocean, is a whole nother matter).

The building was finally bought by Queen’s Medical Center, the biggest hospital here. QMC has a “Magnet Nursing Service” and is very forward-thinking. they have planned to reopen the Kapolei building.

Job Fair(s)

which brings me to the next step. they will hold two job fairs for nurses in Honolulu, one this coming Saturday Nov 2nd in Kapolei, and another Nov 9th, the following week, in Manoa. they are hiring for all kinds of jobs, not just nurses.

Also, anecdotally, I have run into any more of my former students who are now finally getting out of the holding pattern and into new grad residency programs, particularly at Queen’s. The general consensus is that things are easing. I know I am biased, but I think UH is a terrific school of nursing, and I want to make sure our graduates get properly launched into becoming the fine nurses we educated them to be.

the link

If you want to get to a specific link for the job fair, CLICK HERE.

good luck on the job hunt!

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dealing with nurse-burnout, a simple trick

Back to normal

The election is over, and we can all take a bit of time to decompress. I was of course, happy with the outcome, but I also note that a few people dropped their subscription to this blog. Oh well, it’s a voluntary system, people come and people go. The readers are not my prisoners, though of course, it can be torturous to read my writing.

Though I’d share something I have found to be useful when dealing with stressful situations. When I wrote my book about volunteering rural Nepal, I included a reference to this little Jedi mind-trick. People told me that they started using it and it made things better. I did not invent it and I suppose we could discuss what the meaning of “better” might be.

Inner child

The thinking technique is one that derives from the work of Eric Berne, the founder of a movement in pop psychology known as Transactional Analysis. “T.A.,” as it was called, was a way to express complicated theories of personality and motivation in terms that were accessible to the general public, and I think it is the place where references to the “Inner Child” started to become popularized.

I won’t rehash the entire theory, I leave that up to you. we live in the age of the internets, go use them!

But, the short version is, when you anticipate a stressful or upsetting situation about to take place, you take a minute or two to perform this exercise, and it will lead to better execution of whatever things you need to do.  I suppose that some lay persons will respond by saying “hey, when the s^&t is about to go down, take your self away from that place, wherever it is!” – yeah, well, that’s true but it’s not an option if you want to be on the trauma team or if you wish to deal with people in any kind of crisis.

the long term issue is “secondary stress’ which I have written about before. a health professional takes on the stress of helping. entirely understandable.

so here it is:

You visualize your self as a five-year-old, presumably a happy innocent version of yourself, but vulnerable to upsetting things like ghosts stories or anger or abuse. picture that five-year-old version of yourself, the part that would cry if a bee stung you, or that would be amazed to see a butterfly; or that likes milk and cookies.

Then put on the voice of yourself as the all-knowing mom or dad. The all-knowing mom or dad says

“grownup things are about to happen now but you will not need to be part of this. I am going to tell you (the five year old) a story, give you a glass of milk, and put you to bed now, where you will be safe while the grownups do some work. when you wake up, we will laugh and sing. I love you”

You know it is working when your mind is cleared while you run through the ACLS or ATLS protocols.

Mister Spok

A similar technique has been called “going into Spok mode” based on the Star Trek character. Spok was the humanoid from planet Vulcan who had no emotion or nonscientific judgement, and was only able to deal in facts and logic. to go into Spok mode, you just make a decision to do two things: 1) only open your mouth to share something factual; and 2) not respond to anything that is not factual (or at least, evaluate everything that happens as to whether it is fact-based or not).

Christian coping?

and finally, a technique many Christians use. prayer.

the shortest prayer in the Bible. Matthew 14:30  which is of course, a direct plea from the Inner Child…. but also has its place :-)

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Nurse Burnout, Reality Shock, Marlene Kramer

note: all words or phrases that are underlined lead to hyperlinks – be sure to click on them and see what happens ;-)

The B word?

In my recent blog about adrenaline junkies, I got a private message reply asking for advice: What if you were an adrenaline junkie now verging on burnout?

Well, naturally my first reaction is to tell that person to go to Amazon and buy my book about nursing in Nepal. One basic premise of the book is to explore what happens when you are a lifetime adrenaline junkie and you finally get to a problem so big, so overwhelming, that God can’t even deal with it. Yes, such problems exist, and yes, God has a special way to address them over the course of time. There is an answer – but you will have to read all the way to the end.

this book is about medical missionaries in Nepal. sure to become the number one beach read for summer 2014! go to Amazon and pre-order your copy at  http://www.amazon.com/Sacrament-Goddess-Joe-Niemczura/dp/1632100029/

this book is about medical missionaries in Nepal. sure to become the number one beach read for summer 2014! go to Amazon and pre-order your copy at
http://www.amazon.com/Sacrament-Goddess-Joe-Niemczura/dp/1632100029/

you could also buy my second book. see picture of the cover at left.

Marlene Kramer,RN, PhD

I read a lot of papers written by nursing students on the topic of burnout when I teach the senior-level leadership, management and issues classes. I always check to see whether the person was diligent enough to find the book “Reality Shock: Why Nurses Leave nursing” by Marlene Kramer. This one is old by now – written waaay back in the 1970s – but it was such a classic that it still deserves to be studied and cited. (note: On Amazon there are only three used copies, and the minimum price is $199.50… go figure…). In fact, one Google source indicated that it has been cited 743 times in subsequent scholarly work. Dr. Kramer is now retired but had a long distinguished academic career. Her work on reality shock and burnout created a national dialog at the time which led to the work of Patricia Benner and others.

Kramer and Magnets

There were many who thought that Kramer portrayed nursing in a highly negative way, and this reaction produced a result that is still evolving today. The argument was “Okay, you have showed us what is wrong but why can’t we focus on the good things that are happening?”  Which is of course, what a reasonable person would ask.  Nursing advocacy, the heart and soul of what nurses do, is based on righteous indignation and the desire to make things better, and so Dr Kramer was firmly in the tradition started by Florence Nightingale herself.

Magnet Hospitals

The reaction to Dr Kramer caused the American Nurses Association to promote the studies about magnet hospitals – places where the new nurses were being nurtured and developed. and from there to the whole Magnet Nursing Service movementThere is now an independent non-governmental agency which evaluates hospitals that voluntarily apply for Magnet Designation.  Can we agree that this is a good thing? We still have a long way to go, and the budget climate is not helping us, but an argument could be made for saying that Kramer gave the entire profession the wake up call that led to this work. She got the ball rolling. Every hospital should have a Magnet Nursing Service.

Return to wallowing in negativism

back to burnout. There are four phases.

the honeymoon. This is where the new nurse is still being oriented and everything is wonderful. The preceptor is so smart! The staff is amazing! The paycheck is HUGE! we all love to be around such a person and delight in the innocence of youth.

crash and burn. the onset of this is hard to predict, but usually about the six-month mark. Takes place when the nurse starts getting feedback from every direction, not all of it is easy to take because people are telling him or her that they are not perfect. The nurse is now saying “These people are jerks. This hospital has its priorities wrong. nobody is listening. Why did I ever want to be a nurse?”  This person can be angry and depressed.  Nothing is wonderful anymore. The road has a fork in it. One choice is to leave; the other choice is to stay.  When the nurse  leaves (regardless of where they go), it  causes the cycle to repeat with new nurses.  Turnover of this nature is expensive for all concerned. The National Council of State Boards of Nursing has recently recognized that up to 25% of staff nurses who do get a job, leave their first position within a year, which has caused the NCSBN to work on what they call “Transition to Practice” issues. In this way, we wonder if anything has changed since the 1970s……

recovery.  This is a phase of letting go of anger and depression, characterized by the return of a sense of humor. The preferred outcome of crash and burn.  The nurse wakes up and realizes that some things are good, some are bad and not everything is perfect. Or Burnout the nurse quits the job and goes to another job (to enjoy another honeymoon!) or maybe leaves bedside nursing altogether.

and resolution. where the nurse develops a sense of perspective and is able to contribute effectively.

The Care Plan for the Nurse?

The key is to assess yourself and those around you, and adopt some specific interventions.

the honeymoon? keep the new nurse grounded in reality. No, it’s not as perfect as you think

crash and burn? similar to above. No, it’s not as bad as you think. Hang in there and keep working at it!

recovery? find new ways to be productive now that the new nurse has been around the block.

and resolution? find joy and happiness in leading your life, with nursing being just a part of it…

Water over the dam

There’s been a lot of work on related topics since 1975. For example, the whole “codependence” thing came and went – the more codependent the nurse is, the more likely they are to experience burnout.  Closely related to this is the idea of OCD, and I gave my two cents on this in a prior blog. We have had periods of cost-cutting when a new wave of managers rejected efforts to nurture and  mentor new nurses through their role transition issues. Sometimes it feels like all the negative and positive trends are now stewing in the same pot…..

The Bottom Line

Probably the most important lesson is that you may go through these phases by yourself, but you are never alone. Use your peer-group resources. Each nurse has to start by assessing themselves as to where they lie on the four-phase continuum. Keep your sense of humor, and keep your self open to sharing with others.

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Part 4 – the Nurse’s Brain – joining the borg!

Nurse Brain

Florence once said that to own a pen was more iimportant than to know how a stethoscope worked.There were three parts to the discussion about the Nurse’s Brain so far, and buried in the discussion after one of the entries was a question from an experienced nurse:

Joe,  I do like your brain and it looks like a good way to teach students. However, we have a ten minute overview report followed by bedside report, then it is go go go. Do you have a preprinted template your new nurses can just fill in? I’m not sure when a floor nurse would have time to make a detailed outline for the day.

That was  a great question which deserves to be addressed in a separate blog altogether. As I have said, a brain is a way to organize data, and if your happen to be at a hospital which has a good informatics system, there must be a way to set this up so that much of the stuff gets a nurse-friendly printout. Any number of templates will do…. in my blogroll is a site where you can find a collection of such things.

Answer – join the “borg!”

In the meantime, here is my answer:

One option is for the nurses to get there a bit early and scout these things out.

But here is another way to use it: In the 1980s I was nurse-manager of an ICU/CCU in a community hospital in rural Maine. At that place, all the nurses used a brain, it was a four bed unit with a lot of CCU ( this was in the olden days,  prior to TPA and the modern era of thrombolysis, that tells you how old I am….). The team there had adopted a twist to the system (prior to the time I ever got there) which was very helpful.

One of the duties of the off going nurse was to construct a nurse’s brain for the upcoming shift of next nurse, one for each patient. Obviously it would be subject to change, but it was a good way to start. It consisted of a handwritten summary of assessments, labs, IVs, treatments, etc  and it was used along with the Kardex and chart, during report.

When the system worked (most of the time) it was terrific. (of course, there were times when the plan changed dramatically the next time somebody went into the room, but that is another story…)

You might consider adopting some system such as this. It’s way to get the staff involved into the subject of what we nowadays refer to as “handoffs” and accountability.

Oh, and by the way….

Some people will be scratching their head, asking “What is the borg?”

Any fan of Star Trek will tell you. There was a planet in Star Trek where every person was hooked directly into the main computer so that they completely lost the ability to have an individual thought, but on the other hand, each person shared the collective wisdom of a billion humanoids…..

The end result of using a Nurses Brain is effective teamwork and preparation. Here on planet earth there are different models of achievement. If you can adopt a Nurse’s Brain, you will be just like the person in this video. trust me!

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If you, as a nursing student, MUST learn EKGs…..

want to learn what’s really important in nursing? it’s not what you think… I don’t often get to the point of revealing my deepest secrets to the world, it takes a lot  to actually put these things in print.  For example, even though I know the name, hand gesture and usage of the  One Universal Surgical Implement, when I was initiated into the cult I was sworn to secrecy that I will only reveal it to those cognoscenti that show themselves capable of handling such knowledge…..

Responsibility always comes with knowledge.

Remember that. Before i would ever reveal anything, you must prove yourself worthy. And of course, the first step is to buy and read my book about Nepal. It’s the kind of book you can give to the nurse in your life for Nurses Day or for graduation from nursing school.

Anyway, there were too many protests to last last blog

They call this “push-back” – readers who said they just needed to be ekg-certified….. O to be young again!

The Six Rhythms

There actually only six you need to know. trust me. This Pearl of Wisdom has been enshrined in the American Heart Association Manual for twenty years, but somehow people gloss over it and say, it can’t possibly be so simple….

Link to a website

In Nepal I met Jason Waechter, an MD from Canada who was working with Patan Hospital.

He was wicked cool.

has all kinds of great stuff about critical care on his website.

I particularly recommend the handout on basic ekg.

also – I have a two-page handout on rhythm strip analysis which I will share.

To get the two-page handout,

subscribe to the blog,

share with all your friends, and

send me an email. joeniemczura@gmail.com

ten-four, over and out in Honolulu today…..

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What if every nurse did this today? Major TIP for today

Want to make a good impression at you nursing workplace? I have worked in hospitals all my adult life, and I am about to impart a secret that will help you get ahead, every time.  When you use it, let me know how you make out. All I ask in return is that you share this blog with as many friends as you can, and consider adding as a subscriber. For an added bonus, look at the fan page for my book about Hospital Care in Nepal. 500 photos, some videos and commentary on health care in Low Income Countries.

There is a secret group of employees at your hospital

They are unseen, and often unrecognized, but you can’t do your job without them.  It’s the housekeeping staff.

Once I had a student group at a Catholic Hospital in the Northeast. I like and respect Catholic healthcare ( yes, I am Catholic myself and I do go to church. Yesterday’s sermon was about Abraham and his obedience to God. we were all happy that Abraham’s son got off the hook, even though it was last-minute if you ask me).

But I digress – back to the Catholic Hospital

The C.E.O. of the place was a Catholic nun. Wonderful person. Truly. She had this amazing ability to appear on the ward at odd times just whenever there was some sort of conflict happening with a patient or family. It was like magic. Uncanny.

I discovered it by accident

Turns out that the housekeeping staff all had cell phones and she’d given them her cell number. The housekeepers there were all longtime employees – we are talking thirty years or more in some cases. The CEO would host them  for breakfast now and again. The CEO always had a good word for me, because I had long ago adopted a policy to be nice to housekeeping. There was one who was Polish-American  and I sang her my favorite Polish Christmas Carol.

Now – I have never seen such an effective under-the-radar surveillance system at any other place. But whether this kind of informal network exists or not, you can do your self a favor by adopting one simple practice. Learn each housekeeper’s name, say hello to them every day, and be friendly.

That’s all you need to do. that’s the tip for the day. I think especially for a new nurse, a hospital setting is overwhelming and there are so many people to figure out, that it is easy to retreat into a small shell and only interface with people who are above you in the food chain somehow.

try it for a week, and let me know how you make out….

and yes, if you are applying for a job, be kind to every person along the way, including such persons as the receptionist in the Human Resources Office. Even if they do not have the CEO’s cell phone number…..

 

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How to avoid the Nursing Work Culture From Hell

please subscribe to this blog. click the button at right. If you agree with this post, please share as widely as possible. together, we can work to improve the daily worklife of every nurse and every nursing student.

Culture at the workplace?

A workplace becomes a surrogate family for the people who spend time there. When people spend so much time together, the personalities come out. A group will adopt a set of informal rules that guide each day. This becomes “workplace culture.”

If you have been a nurse for any length of time, you develop a sixth sense for this. The minute you walk on to the patient care area, you get a vibe of what it’s like there.  It may be calm and peaceful, it may be chaos, it can be happy or tense. It can be this way independently of how much nursing care the patients require. When you interview for a nursing job, be advised: the best managers know about workplace culture, and they are looking to add staff who will value it and honor it. A theme of this blog has been to encourage new nurses to live up to their caring potential, and it includes caring for those around them as well as for the patients.

Urban Community Hospital – a “war story”

My first nursing job was not a place for teamwork. It was an “urban community hospital”  and chronically understaffed. Each shift was a contest to see whether you could get through all the work yourself, and the assignment was heavy. It was a trauma ward, lots of gunshot wounds and stabbings and victims of beatings, along with a population of heroin addicts and homeless persons. Lots of crime victims. The staff consisted of a head nurse who had worked there since the dawn of time, and each spring there was a fresh crop of new graduate RNs. The hospital would hire a batch of new grads all at once, they would stay a year, then leave once they got “the golden year” of hospital experience. Or at least they were planning to leave then; most left my particular unit before hand, chewed up by the system of unsupportive coworkers. The crew of nurses aides were all older than the young RNs.

Walking Rounds

We did “walking rounds” there, change-of-shift report consisted of a procession of sorts, all the nurses in a group  following the kardex from bed to bed like it was the Bible at the beginning of Mass. The circus was led by the head nurse, same age as my mother. She generally arrived each morning with an attitude, and would heavily criticise the night nurse, pouncing on any inconsistency she found between the way the patient looked and what was written in the kardex; or how the story was presented.  Very theatrical. As report was read, she would examine each patient (“you said the IV was NS w 40 of K, why is it I see a bag of LR hanging?”) This included getting on her hands and knees to look under the bed, on occasion, as well as barbed sarcasm. Every day.  One day she chased a rat out of the ward, to the cheers of the rest of us…. but that is a whole nother story ( it was a very large and well fed rat). Yes, she was teaching us how to have standards and to follow them; but nowadays we would call her approach “horizontal violence’ or “verbal abuse” or “eating the young.”  That was the way it was in that time and place.

These days there is a national movement toward something called “Magnet Culture” – hopefully to eradicate that sort of approach. UPDATE: a former student emailed me after reading this, to alert me to some excellent work published by Sigma Theta Tau about Bullying in the Nursing Workplace.

New RN working nights

I was on eight-hour shifts, a day night rotation and soon found myself working nights about eighty percent of the time – the only time I was on days was on the head nurse’s weekend off.  The day I passed my Boards I was Charge RN whenever I showed up from then on. That was how I spent my first year as an RN. Since I was on nights so much, it meant that I got to be the person going through the gauntlet every morning. And yes, I did well at it – better than the others. In those days I could be just as sarcastic and unforgiving as others. I would spit it right back at the head nurse, to the astonishment of other first-year RNs on the crew.

I no longer treat others that way.

The usual night staffing was two RNs for up to thirty patients, and even then, I went out of my way to help the other RN be ready, which was appreciated. I promised myself I would never be the kind of nurse manager  that I was now working for, and that if I ever had anything to do with it, I would be kind and respectful.

In other words, it was the Work Culture from Hell. Got the picture? I can go on and on – you got me started, but like a bad dream, I need to wake up and remember that this degree of dysfunction is not the way to go through life. Let’s focus on positive ways to interact, here.

Teaching workgroup culture. learn it and live it.

What I do now is to incorporate healthy work behaviors into nursing school. Nursing school is not simply to learn about patient care; it’s to learn the way a professional person acts and thinks. Sometimes in the Fundamentals lab, a student acts as though the only thing they are there to accomplish  is to learn how to perform a specific skill according to the checklist. They don’t care whether others also learn, and don’t help their classmates or spend time coaching somebody slower to grasp the concept. Somehow there is a subset of students who think it’s okay to be a jerk to those around them while they focus on their own learning needs. This may work for Jack Sparrow, but will not lead to success in a hospital workplace.

This tells me that such a student has a learning opportunity.  Focusing on yourself is not the way to go through life. You are missing a major part of the ride.

(Note: a few years back I developed a one-page handout for how to act in the nursing school lab which I will send to anybody who emails me and asks for it)

How to Succeed as a team

Want to develop the habits of a helpful work group culture? here are some ideas. They are not a “Code” – more like Guidelines.

In both lab and clinical: Your work is not finished until the work of everybody is finished. Nobody sits down until everybody is able to sit down. If one person is getting swamped, we pitch in and help them. In the lab, it’s the students and faculty together, who tidy up and make the lab ready for the next group of students. Don’t rely on somebody else to clean up after you.

In the clinical setting: learn about  each other’s patients. Depending on how morning report is handled, this can be a challenge. If it’s a group report that’s easy; but if it is nurse-to-nurse report, you have to go out of your way to do this.  Find a way to check in with the other staff nurses (or the other students) after an hour or so.

Nobody lifts or transfers any patient by themselves.  There is a strong evidence-base out there regarding nurses and prevention of back injuries, so we have an important reason for this. Some wards have many “heavy” patients, and this attitude makes a big difference. But it’s also a chance to create and strengthen relationships among the staff.

say thank you. this goes a long way. there’s an old saying that “People may forget what you did or said but they won’t forget how you made them feel.” think about it.

use names. there is a parade of people through every hospital area every day. Learn who they are, and use their name in conversation.  You don’t have to go to Happy Hour with them or learn their kids’ names, but why not humanize the workplace? this includes housekeeping, the docs – everyone.

name tags. Ever been in a college class where the professor never learned your name, even by the end of the semester?  At my nursing school, we teach the same course to a different cohort each semester, there are fiftysix or sixty new names to learn. On the first day I always set up a system of using name tags, keeping them at the lab. The students collect at the end of each session. We call each of the students by name. They are not allowed to melt into the woodwork, which is often a surprise for the students.

just like a basketball team
Huddle. this picture was taken in Nepal, but any of my students will recognize this gesture. When I wave my hand at waist  level, they know that I want them to approach. I never have to raise my voice when calling them over. (and yes, they know i will not bite…) At lab and clinical practice,  I call a huddle every now and again. soon the students learn to call their own huddles without me.  Communication is a big part of teamwork. We use the time to share and to plan out our work and get ideas.

The Bottom Line about workgroups

The fact is, we all have a choice to create a healthy work culture, or not. which will you choose?

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Should a new nurse go to graduate school right away if they can’t get a staff nurse job?

Funny you should ask… I will answer in a minute, but before you read on, please take a look at my book about hospital care in a Low Income Country. My book won’t help you get a nursing job, but it will remind you of the value of nursing.  And why not go the right of the screen, and click oon the little box that says “sign me up” ?????

It’s a tight economy for nurses

The job market has changed from just two or three years ago. This past month, three different new graduates told me they were worried about their prospects of getting  a staff nurse job. Each of the three asked me the same question.

“If I can’t get a nursing job right away, should I go to graduate school?”

And

“What track should I take? Is it better to be a nurse practitioner or a nursing administrator?”

The pros:

You will have more credentials.

You will be doing something productive.

In the long run, you can get it over with before you have other responsibilities.

The cons:

Running up more debt in student loans.

Not having enough experience to draw upon.

Still having job search trouble after graduating.

As always, the answer that fits you depends on your circumstance. If you are young and your parents will still foot the bill this is different from being say, thirty and with two kids.

My story

For me personally, I went to grad school after being an RN for a year, worked in ICU while in school, and then took a management job for ten years after grad school. I knew I wanted to teach eventually, and the MS degree was always in the back pocket, just in case. By the time I made the move, I had two kids and a house and a mortgage; I was living in rural Maine far from the nearest graduate program. Having the credential allowed me to make a career change within the nursing profession that would have eluded me if I needed to go back to school right then. So, the timing was auspicious.

I did my grad school in a “Clinical Specialist” track, what would now be lumped in with other ARNPs. There was a window of opportunity in the nineties, when the ARNP standards were revised during which I could have become an NP with nine more post-Master’s credits, but I decided not to at the time. The classes would have been 65 miles away; it would have cost $2500; I would have needed to do a clinical placement in an MD office practice. Finding the MD sponsor would not have been a problem, but I always did ICU and the thought of looking at otitis all day or dealing with management of HPTN, was not appealing. Those things are important but in my heart of hearts I wanted to be doing hospital-based acute care.

Call me a traditionalist.

How many NPs do we need?

For awhile there, the federal government was subsidizing the expansion of NP programs around the USA. There are statistics to say we need these primary care providers, but I wonder. When layoffs and restructurings happen in the health care industry, reductions in clinic staff always seem to involve the NPs before the doctors. I just don’t think the underlying reimbursement structure is well-established enough. And if you are a family NP? There are fewer kids nowadays and family care includes a lot of clients who lack insurance. This has been true for decades. Even in the 1980s, both of the two pediatricians in town had less take home pay than I did as ICU manager of the local hospital (they had office overhead, employees, etc).

What does an ARNP do all day?

A friend of mine in Maine is a women’s health APRN. She spends her whole work day doing contraceptive counseling, pelvic exams, and fitting diaphragms, IUDs and depo-provera inserts. She loves what she does. Simply gushes with enthusiasm. I don’t want to deny the importance of women’s health – it is critical. But would I want to do that? No way.

There is significant Continuing Education required to be an ARNP – to maintain certification takes 80 hours per year (varies from state to state).  this is a sizeable investment of time and money. Yes, we need to stay current in our field. But this is time spent away from patient care activities.

How to fix the nursing job market

In My Humble Opinion, we need to fix the gridlock in Washington DC before the health care situation will be improved. We have a series of paradoxes: lots of patients; lots of need; a huge cohort of older nurses preparing to retire in the next few years; and a larger supply of newer ( younger) nurses waiting in the wings. But jobs in health care are being held hostage by Congress. We need to get some grownups in charge back in the Capitol Building.

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Part One “Getting Your Foot in the Door” for a nursing job

Jan 19th 2012 Update: link to a good blog on The Hidden Job Market, which is another angle on foot in the door…

Foot in the door

This is one in a series of blog entries written for young nurses. Take a look at the previous blogs about resumes, what to put in a cover letter, how social networking can hurt or help you, and ways to look at your portfolio. If you are a nursing student, you can start now to think about these things. Please share with others.

While you are at it, go to Amazon and buy the book I wrote about Global Health Nursing. It won’t help you in your job search but it will give you a window into a very different kind of nursing and it will help you remember the best reasons you chose nursing in the first place ( I hope).

The basis of the foot in the door strategy is simple:

A) In school: If the organization where you want to work hires ward clerks, nurses aides, billing clerks, etc, get a job there while you are still a student.

B) as part of school: If you want to work on a specific unit of a hospital, try to do clinical there through your school.

And

C) after graduating from school: If your target is a hospital which is not hiring for RN positions, apply for a job as a nurse’s aide or computer tech or anything, so you can become an internal applicant as opposed to an external applicant. Many large organizations will offer positions from within, first.

Let’s take these one at a time.

A) working part time while in school.

Nowadays it’s less usual to be a nursing student who does not work in some part-time job, somewhere, I’ve had students who worked as servers, telemetry techs, billing clerks and even as hula dancers at the big hotels on Waikiki.

You might as well be working in a hospital. Don’t underestimate the job of being a ward clerk. A ward Clerk will become familiar with the systems by which the hospital actually runs;  A clerk  gets into the chart everyday; and a clerk has a daily opportunity to become literate on computer systems such as EPIC or MediPro.

Here is a Pearl of Wisdom: Many of the older RNs nowadays don’t have the computer skills for EPIC are reticent about learning on the computer. The more you become proficient at EPIC or some other system, the more you can use this as a sales point for your resume. You are in the tech generation!

If it’s a nurses aide position, most hospitals will only hire you if you already have the Fundamentals course and some clinical under your belt, and often the state will require documentation that you have enough training to be equivalent. This varies state-by-state.

B) through school, as part of clinical, especially during the last semester

Future employment advice if you are doing clinical at a place you want to work later.

General advice: don’t only focus on the patient.

Oh, you need to do excellent patient care. You need to prepare well, be organized using a “nurse’s brain” and you need to be “on it” every day that you are there, using critical thinking and applying what you learned in class. But you also can benefit by adding some extras. You’d be surprised how students miss the little things: learning the names of the ward staff, (then following through by using people’s names when you talk with them), being polite to the housekeeping staff, (you can’t do your work without them!) and relating to the ward staff like future colleagues. On many hospital floors, the staff is already looking at you to evaluate your potential. Hate to put pressure on you, but it’s true. They are taking notes.

Specific advice for seniors:

Most schools nowadays incorporate a senior practicum, in which you are no longer in a clinical group, but are assigned to work one-on-one with a preceptor.

You don’t always get assigned to the floor you want, but that’s not the end of the world. There is strategy to apply here. For example, at one of our medical centers the Medical-ICU is considered to be the among the best placements; but they have never hired a new graduate and there is a waiting list of experienced RNs who wan to work there. So – you can get ICU clinical but it won’t lead to a job there.

If you don’t get placed in ER or ICU, it’s NOT the end of the world. My usual advice is actually to work on a Medical-Surgical ward, because the skills of organizing your day, setting priorities and making decisions about psychosocial issues are ones which apply to any setting. A few years back we had a student whose goal was to be a CRNA and he did his senior semester practicum in the O.R.  He enjoyed it, but it didn’t really help him learn the assessment skills he needed – he focused mainly on the surgery and on sterile technique. Right after graduation he got an ICU job, but did not do well there; I think he would have done better if he’d done medical surgical and gotten solid organizational skills. The O.R. seemed good superficially but turned out not to be a good “fit.”  Having a placement that meets your needs now is actually more beneficial than getting the dream placement if you can’t make the most of it. Have a heart to heart with the clinical placement coordinator as to what you really need, not just what you want.

The preceptor is critical. You need to know that when it comes time to apply for work there after graduation, about fifty per cent of the input as to whether you should be hired, comes from the preceptor. Recommendations, the interview, the cover letter? Nowhere near as important. When you apply to that hospital for a nursing job, highlight the name of your preceptor in the cover letter.

Read up on how to have a good relationship with your preceptor.  There are some great articles about your relationship with your preceptor on the Web.

The next thing is to consider work behaviors, and for that I have a story. Two years ago one of our senior  students took an ER job right out of school at the hospital where he’d done his senior practicum. This was a “success.” I asked him about it and he said:

“I took your advice”

Oh? ( couldn’t remember which advice he meant, I give lots of advice. What I am writing here is something I have preached for years, but don’t ask me to recall every single thing.)

“Yeah, I knew I needed to impress them with not just my nursing knowledge, but my work ethic. So, I never sat down when I was there. If there was something going on, I offered to help, but in the quiet times I did stuff like defrost the refrigerator, clean the nurse’s station counter with rubbing alcohol, and tidy things up. I didn’t brag about it, but everyone sure noticed.”

So what he was saying was, he was neat and cleaned up after himself, in addition to using checklists and following protocols. He was the kind of guy who showed up to lecture class or lab with a to do list, and I bet if I spoke to his mom he also made his bed at home and helped with the dishes and chores. ( I never did speak with his mom, this is a guess.).

Even if you don’t have your foot in the door, ask yourself whether you have this kind of attitude at which ever job you now have?

Tomorrow:

Situation C – getting an aide job *after* nursing school.

This blog is 1,316 words – long enough to digest in one day; I will break it in 2 pieces. The last part of foot-in-the-door is when a hospital has enough RNs but will consider hiring you as a nurse’s aide even though you have a BS and pass NCLEX.

Til then, share this with every nursing student you know, and Stay tuned!

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