Level One: Novice
Your charting is neat and thorough. In addition to checking all the boxes on your computerized chart, you add the occasional brief note when the patient’s condition changes or you’ve had to convey a panic test result to the doctor. You never, ever double-chart.

Level Two: Experienced Novice
You’ve gone beyond simple notes. Now you’re writing in Nurse Code, using phrases like “complex medical history” or “interesting patient” with some frequency. You’ve learned that trigger phrases like that can warn anybody reading your notes that some of your patients have been interesting, with challenging diagnoses.

Level Three: Losing Your Religion
You begin to use the word “states” more often, as in “Patient states he sees small purple hippopotami at the end of his bed.” Your notes contain references to yourself in the third person, such as “This nurse then removed the patient’s hands from around her neck.”

Level Four: After You’ve Been Audited
All the extra stuff disappears and you’re back to Level One charting, fearful that you’ll have to meet with your boss again. The word “editorialize” may or may not have been used during that meeting.

Level Five: Approaching Mastery
Nurse Code makes a reappearance, but in veiled ways. The word “see” suddenly becomes much more useful, as in “see allergy list, pages 7 through 60” or “see q5 minute vital sign records.”

Level Six: Mastery Unlocked
You no longer care about double-charting if the situation warrants it. You occasionally write novels, especially if you have one of Those Patients. If you do, no detail is too small to include: “Patient states he is allergic to oxygen. Patient noted to be breathing comfortably on room air.” You’ve learned how to add notes to flowsheets, and where and when you can safely say the words “interesting history.” Your boss no longer reads your notes, as the thrill is gone. The other nurses you work with, though, smile and wink at you when they pick up your patients.

Fuse, iStockPhoto | ThinkStock + Scrubs

This article is brought to you in partnership with the Air National Guard.

One of the most frequent questions I get from new nurses (or those about to be nurses) is “How do I choose a specialty?” Ten years ago, the advice to every graduating nurse was to not specialize too early in your career; instead, work on a general medical-surgical unit for a couple of years, then decide what you want to do.

I’ve never really bought into that advice, and I buy into it even less now. For one thing, med-surg is its own specialty. For another, the majority of hospitals, research centers and clinics want to be able to train (or fine-tune, in the case of experienced nurses) their nurses in their own ways. Nowadays (says Grandma Jo, sucking on her dentures), new nurses are expected to start out in a specialty, switching later if they want.

How do you figure out where you belong? And, more importantly, how do you figure out if your chosen specialty isn’t the best fit?

Let’s take that second question first. If it doesn’t excite you to think about all the cool stuff you’re going to learn every day when you get to work, if you don’t perk up your ears when some doctor starts lecturing his interns on a tricky case, if you dread having to re-up a certification, you’re in the wrong place. Just because you earn money doing something doesn’t mean you can’t get joy out of it. Heck, if you’re spending 36 hours a week doing that thing, it had better make you happier, or at least not make you more unhappy.

In that vein, then, think about what excited you most in school clinicals. That probably won’t be the area in which you felt most comfortable; instead, it’ll be the one that had you tipping your head to the side and engaging new parts of your brain. Think of the most interesting problems you had to solve—that’s a good clue to where you might belong.

Remember which nurses and doctors your personality meshed best with. ICU nurses tend to be OCD, while rehab nurses are some of the most patient people ever. Like-minded people gravitate to certain areas of medicine and nursing for a reason.

Finally, list your own strengths and weaknesses. If anxious adults put you on edge, stay away from the neonatal ICU. If you like seeing the same patients every day for weeks and getting to know them, don’t work in a day surgery center—look for a job in rehab.

If you love getting an adrenaline rush and doing something different every day, consider becoming an Air National Guard nurse, where you could care for patients being airlifted out of disaster-stricken areas or save lives in a field hospital in the aftermath of a hurricane. The Air National Guard also affords the ability for nurses to choose from many different nursing specialties which could be just the path to take for a nurse who’s yet “undecided.”

Being open to the possibilities can prove handy in the long run. Just ask the neuroscience-certified nurse I work with who used to run a podiatry clinic!

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Are you ready to hit the floors as a new graduate nurse? Take this quiz to find out. It’s not as tough as the NCLEX, but it’s equally important you score well—for the sake of your future!

 
Nursing Scenario #1: You enter the breakroom to find that a grateful family has sent several trays of deli sandwiches, bags of chips and assorted desserts to the staff. You:
a. Lean out the door of the breakroom and holler the news to your colleagues.
b. Stuff as many sandwiches as you can into your mouth at once, damn the risk of choking.
c. Sneak out a plate of your favorites before passing the word that there’s food around.

Nursing Scenario #2: There’s a crowd of people in various stages of agitation between you and the time clock at the end of your shift. You:
a. Rush forward to see what the trouble is.
b. Push your way through the group, muttering, “Excuse me… Pardon me…”
c. Take an alternate route downstairs and punch out in the basement.

Nursing Scenario #3: A patient has had an Unfortunate Series of Events that has culminated in his bathroom being covered with an Unfortunate Series of Explosions. You:
a. Pretend it never happened, then call Housekeeping.
b. Clean it all up yourself, reminding yourself that this is why you entered nursing.
c. Make a list of people who owe you and call them.

Nursing Scenario #4: You return home after a long, messy day at work. You:
a. Fix dinner and play with the kids.
b. Hop online and lose yourself in a multiplayer game or Facebook.
c. Strip naked in the front yard and douse yourself with all-purpose cleaner, then come inside and set your scrubs ablaze while you mix a martini.

Nursing Scenario #5: A long-lost friend buttonholes you at a party. When they ask what you do, you say, “I’m a nurse.” They immediately begin telling you about their latest health problems. You:
a. Sigh inwardly and forget mingling for the rest of the night.
b. Hand over the name of a good general practitioner.
c. Excuse yourself by telling them that you’re an expert in neurothrapolinguistics, fromniddy blappotism or diabetic whangsols, and head for the beer cooler.

ANSWERS
If you answered mostly A’s, you’re a sweet, naive person with a really long few years ahead of you.

If you answered mostly B’s, you’re nearly a nurse right now.

If you answered mostly C’s, you’re cheating. You’ve been a nurse for at least a year already.

Good luck, graduates! All joking aside, I am excited and looking forward to working with you.

Florence Nightingale | WikiCommons + Scrubs

We’ve all heard the stories of ol’ Floss The Boss in the Crimean War. Most of us have read Notes on Nursing, most of us have taken the Nightingale Pledge and we all know Florence was the founder of modern nursing education.

But who among us knows that she spent the last 50-odd years of her life mostly confined to bed? While she was sick with what was probably brucellosis and a case of spondylitis, she was reforming hospital design and further contributing to nursing education. All of that from a heavily decorated Victorian bedroom scattered (I’m sure) with innumerable side tables and knickknacks.

It’s not like she wasn’t physically strong, at least as a younger woman. Nursing is no picnic now, and nursing in war zones and poorhouses in the 1850s and 1860s demanded the physical and mental strength that the soldiers of the time had—plus, nurses did it all in heavy, confining clothing. So why did she spend a half century in her bedroom, intermittently ill, while at the same time managing to change the course of nursing both as a career and as a science?

Flo was born into an upper-middle-class family in 1820. The peak of her career came during those years when social mores dictated that women’s highest calling was the home and family.

Women who worked outside the home, unless it was in distributing thin soup and moralistic pamphlets to the Deserving Poor, simply didn’t exist in her time, class and place. Further, she never married—which means that the expectation would’ve been that she’d spend time taking care of other members of her family until the day she either died or retired to a rocking chair in the corner.

What’s a rich, ambitious woman to do when faced with the prospects of: a) being a nurse for her older family members (or, at best, a genteel companion); b) getting married and devoting herself to the care of a husband, household and family; or c) being ostracized for her ambition, thus throwing up obstacles to what she really wants to accomplish?

Florence took to her bed. From there, she was allowed almost unheard-of freedom in terms of intellectual and political influence. She published, raised funds, refined nursing theories she’d first thought of in the Crimean and generally proceeded to do nursing like a boss for 53 years. She took the Victorian notions of women’s delicacy and tendency toward illness—remember, this was the heyday of the wandering uterus—and turned them on their heads, ensuring that people left her alone and let her work.

Let’s raise a glass to Florence Nightingale this week, and not just because she moved our profession into the modern day. Let’s toast her as an example of what can be done if you use the rules to your advantage by sticking to the letter, if not perhaps the spirit, of the law. Personally, I plan to raise my glass from the cushy comfort of my own couch.

WaveBreak Media | ThinkStock + Scrubs

Your resume was perfect, you sailed through the interview and now you’ve got a job offer in hand. Hooray! But before you blurt out “Yes!” to the first offer that comes your way, make sure you stop and look around—is this workplace the right one for you?

Here, I’d like to list some of the things that I now look for when I’m trying to decide whether or not to take a gig.

First, how’s the culture on the unit? If the folks on your prospective floor are smiling, working together, collaborating rather than competing, that’s an excellent sign of a healthy workplace. Everybody has off days, so it’s worth it to do some down-low reconnaissance to see what the usual mood of the unit is.

Second, what’s management like? Ask people where you want to work how often they see or hear from their CNO or DON. Ask people what happens if they’re short-staffed. Does the manager stick around to help out? Do people volunteer to work extra? If there are problems on the unit, whether they’re technological or personnel problems, how are those handled? How often do the nurses get props and compliments?

Third, what’s staffing like overall at the facility? A well-staffed surgical CCU means nothing if the stepdown units are constantly overflowing. How often is mandatory overtime required? How many agency nurses are on your unit at one time? In the facility overall at one time? How often do nurses renew their contracts? Do they stick around or do they go elsewhere as soon as they can?

Fourth, what’s the benefit package like? Are there incentives for longevity? Does the institution reimburse nurses for licensing or specialty-certification costs? How does management approach educational opportunities? If you’re interested in continuing your education with a BSN or an MSN, ask about reimbursements for that. A pal of mine recently got a sweet gig in an ICU, and the hospital is paying for her PhD as well.

Fifth, and finally, look around at the way people interact with the folks they work with who aren’t their clinical colleagues. Simple politeness, friendships that cross departmental lines and plain old respect all go a very long way toward making a place a good place to work.

You probably won’t find everything on this list in one place unless you decide to work for a schwanky private hospital. It’s worth your time to check online message boards to see what other nurses say about your prospective employer—but always remember that the disgruntled yell louder than the happy. And good luck. Nightmare stories are everywhere, but most people, provided they’re not either perfectionists or jerks, can find a comfortable place to work and learn.

iStockPhoto | ThinkStock + Scrubs

Happy Nurses Week, nurses!

SEE OUR FULL NURSES WEEK 2013 ROUND UP HERE.

Guys, I know your jobs are hard ones. You get all of the kicks and none of the kisses, and you’re responsible for maintaining the smooth operation of hospitals in the face of an agitated mob of nurses and doctors, many of whom can’t remember the last time their feet didn’t hurt.

Nurses Week is one of the few times throughout the year that you can show us all how much you depend on us. I have a few ideas for making this Nurses Week not only memorable, but really meaningful. Read on.

I do not need another lanyard, ID holder or tote bag with the hospital’s name on it. Instead, consider handing out pens. You can get ’em cheap in bulk, and those gel ones are great to chart with. If you’re really wanting to put your imprint on something, why not those little foldable umbrellas? We could keep ’em in our lockers for when it starts to rain 10 minutes before we get off work. Itty-bitty flashlights are more useful than you can imagine and actually fit on a keychain.

Nor do I need, Heaven knows, another freaking donut or cinnamon roll. You guys insist on passing out food every year during The Week, and it’s always sugary stuff and sodas. This year, could we have a plate of sandwiches or a couple of cheap pizzas? How ’bout some of those breakfast burritos the cafeteria makes, delivered with decent coffee some morning? That sort of little touch would be especially welcome late at night and on weekends, when, at many hospitals, nothing’s open but the vending machines.

Finally, I would like to hear more than once a decade that I’m doing a good job. The recent economic sludgefest took a lot of money out of your endowments, I know. Telling me that I’ve done well in the face of whatever odds costs nothing, and it’s something I don’t hear all that often. If you can’t think of something I’ve knocked out of the ballpark lately, at least compliment my sense of humor or my intelligence.

Yeah, all of these suggestions will take a little more time and thought than I’ve seen you put into Nurses Week for the last few years. It will be worth it, I promise—there will be one year when your nurses won’t snort, roll their eyes and toss your lanyard in the trash. Please consider treating your yearly thank-you as more than an afterthought.

springerpub.com

Nurses in popular culture have gotten a bad rap in the last 40 years or so. When a nurse on a soap opera (Bobbie on General Hospital) is a shining example of professionalism and skill, you know you’re in trouble.

I only discovered Cherry Ames a few years ago, after being a nurse for a while, and I was instantly smitten. In the first four books of the series, Cherry goes from being a new nursing student to running an army hospital in the Pacific theater. Her career trajectory is more believable when you learn that the U.S. government spent millions of dollars during the Second World War in training and mobilizing nurses, and that a bill to draft nurses into military service failed by only one vote in Congress.

Cherry seems much more real than her contemporaries like Nancy Drew. Yes, she’s solving mysteries and doing heroic things, but she also gets scared. She screws up and gets punished. She’s always late, there are people she doesn’t like and who don’t like her back, and at one point, she almost misses moving off of probation due to a clerical error at her school. (That last point made me laugh out loud in recognition: It seems nursing school hasn’t changed much since the 1940s.)

The most interesting thing for me, the WWII history buff, was Cherry’s experience in the service. The Pacific side of the war stretched Allied forces thin, partly because the Japanese were such determined fighters, but also because conditions were so bad. Malaria, skin infections and parasites were huge problems for soldiers and nurses alike. Keeping food edible and finding potable water were also constant struggles. Helen Wells, the author of the first books, sanitized things a bit for her younger readers, but it’s interesting to compare the experiences of the fictional nurses’ corps with the real experiences detailed in books like We Band of Angels.

Best of all is Cherry’s training to be a flight nurse in the fifth book in the series. Imagine what it must have been like to take care of critically injured men in a C-47, with minimal to no pressurization in the cabin, with no red cross painted on the plane and with enemy planes seeing a sitting duck. C-47s had to fly low and slow, as going too high would’ve caused irreversible damage to brain-injured patients or those with chest wounds. They weren’t allowed red crosses because they hauled equipment and supplies as well as patients. Even though it was a young adult novel written years before I was born, that book had me gritting my teeth in suspense.

I’m a Cherry Ames nerd and proud of it. The series slumps a bit in the middle, when Cherry goes off to do things like work at a ski resort, but the first books are treasures. Modern medicine’s come a long way, as have the privileges and practice standards of nursing. Reading the Ames books makes you appreciate that, as well as love the simplicity of the way things used to be.

Plus, she had that cool cape. I’m still looking for a cape.

Thinkstock | Photodisc

You know those medical shows? The ones with the handsome doctors, beautiful residents, snarky-yet-warmhearted unit secretaries and endless drama? Don’t you just love them?

Yeah, me neither. I used to watch “McDreamy’s Adventures in Malpracticeland,” but I always ended up throwing my wine bottle at the television about halfway through, which was detrimental both to my television-purchasing budget and my wine consumption.

So when the fine folks here at Scrubs asked me what I’d do differently if I were producing a hit show about a hospital, I jumped at the chance to finally make my dream cast list public.

Cast for Sunnydale: Healthcare for the Hellmouth:

Our heroine would be a petite, blond charge nurse with a reputation for slaying arrogant administrators and doctors. She would be independent, intelligent, sharp-tongued and able to face even the biggest bedpan disaster with aplomb.

Her immediate group of friends would consist of a sweet, slightly clueless new nurse with a talent for unscrewing tightly connected IV hubs; an older, cynical patient-care aide with a nifty accent and shelves full of antique nursing adventure novels; and a sarcastic charge nurse with a heart of gold. In Season 3, the charge nurse would finally be recognized and lauded for saving the heroine’s bacon at least once during every episode. This would be the only character remotely like their real-life counterpart.

Minor characters would be the noble, selfless doctor; the obnoxious-but-brilliant doctor; the nursing colleague who can never be found and is usually charting in a bathroom stall; the well-intentioned but bumbling nurse or doctor who provides comic relief; and a couple of guys with undefined jobs who are just there for eye candy.

The villains would have to be a shadowy, ill-defined group of surveyors and hospital administrators who, through the use of a series of rapidly-killed-off cat’s-paws and plans that defy logic, attempt to keep our heroine and her friends from getting lunch or giving report on time. Where most dramas have explosions and gunfire, this one would have true-to-life scenarios involving stuck elevators, beds that won’t go down and slow-moving floor polishers.

Hollywood, you call me!

THINKSTOCK

Curious which blogs fellow nurses are reading? I know I am. Here’s a list of blogs that I follow and why I love them. Share yours in the comments!

GruntDoc (gruntdoc.com)
He’s a fellow Texan and an emergency room doctor. Be sure to read the wasabi story and check out his latest merge of Press Ganey and the pain scale.

Midwife for the End-of-Life (deathmaiden.blogspot.com)
Sadly, she hasn’t updated since August, but there’s a lot of good, re-readable stuff here about being a hospice nurse.

Codeblog (codeblog.com)
The grandmother of the nurse blog. Funny, irreverent, respectful of the profession, well-written.

What Should We Call Nursing (whatshouldwecallnursing.tumblr.com)
A Tumblr devoted to exploring the world of nursing through GIFs. Laugh-till-you-cry material.

Are You Having Any Pain? (areyouhavinganypain.tumblr.com)
Another GIF blog, this time from a nurse in an inner-city hospital.

Enjoy, y’all! Remember, that greyhound saw the canary on February 2, or whatever that was, so spring will come early this year!

Thinkstock | istockphoto

How can you tell a newbie nurse from a seasoned professional? Appearances can be similar, and feeding ranges tend to overlap. Nursing theorists divide nurses into categories from novice to expert, but these theorists overlook such identifying characteristics as plumage, calls and agonal displays. Here’s a nurse-watcher’s field guide—get your binoculars!

Type 1 – Newbie Nurse:
Plumage is bright and unwrinkled. Look for telltale signs of recently purchased scrubs, such as packing creases and ironing marks. Stethoscopes are clean and labeled. Flight tends to be fast, yet wavering, with much swooping and doubling back for things forgotten in the utility room. Call is a brisk, piping “Can I help you? Can I help you?” Agonal display is rare, but involves the slapping of the hand against the forehead, usually on the way home from work. Feeding times and migratory patterns are not well established for this stage.

Type 2 – Cheerful Competent:
The Cheerful Competent is, physically, little different from the Newbie. Plumage may be slightly duller, while pockets have begun to sprout loose threads and stretch marks. Flight, while still disorganized, is straighter and more direct. Call is lower-pitched, a lingering “Lift help lift help lift help too-woo.” Migratory routes are well established, with coffee machines visited three to four times a day. Agonal display is the rubbing of feet, but this is rarely done where even the most dedicated observer can see.

Type 3 – Midcareer Muddle:
Midcareer Muddles have reached the stage in the nursing life cycle when nesting and feeding patterns may change radically. Plumage color can switch among various shades of blue or tan without warning. Dark marks appear on the face, below a slightly duller eye. Flight is straight and soaring, with an in-flight call of “WhatdidIdooooo WhatdidIdooo.” Midcareer Muddles often congregate at local watering holes in the company of other Muddles.

Type 4 – Exhausted Expert:
The end stage of the life cycle of the nurse can be quite drawn out, with little difference apparent between light and dark morphs. Dark marks under the eye become more pronounced, plumage is in varying shades of the dominant color, and crests and mating display become much more subdued. The Expert is difficult to spot outside of captivity, as plumage may be shed at any time for something more comfortable and less hospital-smelling. Migratory patterns are regular, as are feeding patterns. The observer is warned that severe injuries have been reported to nurse-watchers in the field who have inadvertently stepped between an Expert and a source of food or a bathroom. Call, at rest, is an upward-inflected “What the heck what the heck what the heck.” The prudent nurse-watcher is reminded to use caution in observing this species. Behavior can be unpredictable, especially at the end of a shift. Remain concealed, and carry granola bars in case of the need for a quick getaway.