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At what point in a new nurse’s orientation or career do they start to feel confident in themselves as a nurse and their skills?  The reason I am wondering is because I have a new graduate nurse who started a couple weeks ago and this is her main issue.

She has been on orientation for two full weeks now. Last week, she called me at home crying because she thought she was not doing well.  She said that she took care of two patients that day and was feeling overwhelmed.  She said she knew what she needed to do, but was constantly questioning herself.

I tried to explain to her that that was normal and that by comparing herself to her preceptor, who has several years of experience, she was only going to drive herself crazy.  I told her that I would be more concerned if she felt confident or overly confident at this point in her orientation. I even used my experience as a new grad as an example, explaining that I didn’t feel confident until at least nine months AFTER orientation ended, and even then I was just happy I didn’t kill somebody whenever I worked.

I had the nurse educator on the unit talk to her and explain it to her. I also talked with her preceptors and made sure they were helping to build her confidence. I asked one of my new grads who had just reached her one year mark to talk to her, too.

It’s difficult getting through to new nurses sometimes.  It’s been their dream for so long to be a nurse, and now that it’s a reality they realize they actually have people’s lives in their hands.

What I told her was true about being more concerned if she were over-confident.  I have seen too many new nurses fail because of their cockiness.  They end up facing the reality that they don’t know as much as they thought, or more likely doing something they think they know but really don’t and hurting a patient.

Mistakes are going to happen.  She’s going to make an error at some point in her career.  Being overly-cautious because of that fear is not going to change anything; in fact, I really feel it will make her even more likely to make a mistake.

How confident are you in your career?

The short answer is that nurses either make peace with the emotional demands of the job or find a different one. Mostly I have made my peace with it, but some days are harder than others, and those are the days when the “how” of coping really matters. I’ve had a few of those days lately, and they’ve made me think about what I do to keep the sadness of the floor, and the enervating work that regularly confronts death, from taking over my life.

A few months ago, a patient—a woman roughly my age, 44—was actively dying. When she was admitted with a diagnosis of leukemia a year before, she was energetic and bubbly. She had been a hairstylist, and once she started to lose her hair, she borrowed clippers to shave her head. When a rounding attending told her that being bald suited her, that she had a “nice-shaped head,” my patient thought this was hilarious, and her strong laugh was hard to resist.

Now, close to death and doped up on morphine, she could not chat with, listen to or even notice the people around her. Her husband and I talked, though. In the hallway outside her room, he looked at me, shaking his head. “I don’t know how you do it,” he said, imagining the toll the job took on me.

Two years ago, when I first started as an oncology nurse, I would pretend an emotional immunity in these conversations, a placid resilience, that I did not actually feel. Over time I admitted to myself that demurring was really only a way of lying about how the job taxes me. So this time I looked at my patient’s husband and thought about an honest response. “Well,” I said, “I have three kids, and they really do rejuvenate me.” The husband looked at me, surprised, and then nodded his head.

An explanation, however, is not an action—and to stay sane in this job, you have to act. As soon as I could, I called my husband. “Hey Arthur,” I said, “how about you pick me up when I get off work and we take the kids to Max & Erma’s?”

My son Conrad, who’s 13, and Miranda and Sophia, 10-year-old twins, really like the local Pittsburgh chain restaurant. But they know it’s not a place I would ordinarily choose, so they asked me, with that unselfconscious directness children have, why I suggested going. Once again, I thought about my answer. I often try to soften or even hide the hardest truths about my job. This time, though, the truth seemed like the best idea.

“A patient I like very much is dying from cancer and I was feeling sad about work,” I told them. “Seeing you guys makes me feel better, so I wanted us to go to a restaurant you really like.” All three of them sat silently for a few seconds, and then, like my patient’s husband, they all nodded.

The restaurant’s hum returned, along with the kids’ chatter. Miranda described the fifth grader who spent too long in the bathroom, Conrad bemoaned the librarian who could not control her class and Sophia complained about homework. The conversation was like a salve on my soul.

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Everyone needs to be able to confide in someone. Can you be trusted to keep another person’s information to yourself?

We hear so much these days about patient confidentiality, keeping medical records from being compromised, what constitutes “consent” to release information, and so forth. But can our own friends and associates count on us to keep their trusted information from becoming public knowledge?

To have earned the confidence of another person is a great honor indeed. It is difficult to find someone with whom one can share, and perhaps take counsel from, matters of a personal or professional nature. Most of us have experienced the fallout from gossip in the nurse’s station or at the lunch table. Information which has passed from one set of lips to several others is rarely the same as when it was first shared and can have very unpleasant consequences for the one who initially let slip whatever was given in confidence in the first place.

Previously I wrote an article on why nurses blog. In it I suggested one reason for blogging is the perceived anonymity which one hopes to achieve by using an avatar or user ID instead of one’s own name. As it is practically impossible to share “confidential” information on the Internet with anyone, it is more important to find someone with whom you can share your thoughts and problems without fear of exposure or betrayal.

There are times when being approachable is not only an honorable thing, it can also seriously impact another person’s life and limb. Particularly when one is dealing with teens and young adults who often desperately need to talk to someone outside of their own family or circle of friends.

Anyone who “accepts” the role of counselor, formally or informally, is subject to the same ethics as a priest, psychiatrist or therapist. There are only two occasions when a sacred trust can be broken: When there is knowledge of a crime or when there is a threat of danger to oneself or to others. In most cases, it is usually best to encourage the person to self-report the problem if no one else is in peril. Offer to go with them. Such honesty can go a long way toward someone keeping a job and getting whatever help is needed.

As nurses we have a professional responsibility to ensure patient safety. If we have knowledge that an error has been made which could potentially cause harm to someone, we have a duty to see that it is reported to the proper authority. This does NOT mean we go and gab about the person who made the error to the rest of the staff. He/she is probably upset enough from making a serious error in the first place. It is management’s job to address the problem with that person.

So, before you allow someone to confide in you, ask yourself if you can deal with whatever the secret is. If you can’t, encourage them to find someone else. Above all, do NOT use a person’s trust for any other reason than to help!

The human voice can never reach the distance that is covered by the still small voice of conscience (Mahatma Gandhi).

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May 6-12 is when nurses are nationally recognized for their efforts during Nurses Week. It’s a celebration of all things nursing. During that week, you have National Nurses Day, Student Nurses Day, and School Nurses Day to recognize the individual efforts of these “types” of nurses. The week ends on May 12, the birthday of the founder and mother of the nursing profession, Florence Nightingale.

Everybody with me?

Until recently, I’ve always enjoyed Nurses Week. I usually got a cool trinket or gift from my employer, and my fellow nurses would joke about the one time of the year we nurses actually are noticed.

These days, it seems the only time of the year we DO get recognized is now being watered-down (and maybe even flushed away) next to another nationally recognized week–National Hospital Week, which is also May 6-12 this year. The only difference I see from year to year is that the actual dates for Hospital Week can differ slightly, while Nurses Week always starts and ends on the same dates!

I guess maybe that’s my problem. Why must another week-long national celebration trample on the toes of our celebration?? (I kept getting circling results, so I gave up searching for some relevant history on National Hospital Week and the coinciding date.) Obviously, the celebration dates for National Nurses Week bear significance with one of its founding mothers.

In my opinion, nurses are getting shortchanged simply because most nurses work in hospitals, so it’s more convenient and cost-effective to celebrate both weeks jointly than to have two separate celebrations (it’s always about the money, you know).

Also, the health care personnel who are being recognized are equally shortchanged, because now they share their “week” with a much larger group of fellow health care professionals (nurses).

It’s become so common and convenient to lump them together that I found numerous articles that meshed this celebration into one singular event (I refrained from naming names here).

Deep breath.

Maybe I’m being selfish. Maybe I’m being obtuse. But the last time I checked, we nurses rarely, if ever, ask for recognition. And the one and only time the nation recognizes our sacrifices they decide to divvy up the recognition with another holiday?

What am I missing here?

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This is a (true) story about a Young, Brash, Cocky and Arrogant doctor, heretofore referred to as YBCA. Most of you know these types in your own practice. Very often they are their own worst enemy. This was one of those times:

Once upon a long and busy ICU shift, we had a patient who finally decided to go into a full-blown cardiac arrest. (Sometimes I get the idea that people do this for lack of anything else to do or just to aggravate us!)

Now, when a code is called in a teaching hospital, all of the residents come running in their various degrees of attire, desperately wanting to show off their newly acquired ACLS skills for the chief. Most are in scrubs with lab coats, but occasionally you get one who has just bought his/her first really nice suit…

On this particular day, the first to arrive was, you guessed it, our favorite YBCA. He showed up in a nice new three-piece Brooks Brothers suit complete with the “good” leather shoes and his class ring to complete the ensemble. (Do not discount the importance of the class ring. This MD has always been one to shove it into everyone’s face and say “Do you know what this is!?” Most people know what a ring is and he is NOT the Phantom!)

Looking very much like the Important New Urban Doctor, he immediately took up station at the side of the bed and began to give orders. Around the time his colleagues and the chief resident got there, it became necessary to “shock” the heart.

Now, we all know that someone yelling “CLEAR!” means that you get away from the bed.

Well, on this day our YBCA didn’t move–he was too busy lecturing the other interns on how the code was being run.

When run through a body, electricity does all sorts of interesting things. It can stop or start a body process, which is what you are trying to do with the heart. On this occasion, it triggered an involuntary URINATION on the person who was still standing with his leg touching the bed.

Yep, the yellow stream ran right down the pants leg of the new suit and into the “good” leather shoes. Right there in front of the chief, the nurses and everybody!

Nobody had to look at “the ring” that day…

I’ve got those yellowstain blues, those silly yellowstain blues (The Caine Mutiny, Columbia Pictures, 1954).

The truth? They’re both right.

Yes, our eyes do meet with affection—sometimes. And occasionally Tom will bring me a salad from the cafeteria so I can finish my charting.  I get to spend every day with someone I love, doing work that I love.

Since we are aware of each other’s needs, we are able to help each other. If my stack of charts gets too high, he’ll sign off my labs. If he’s running behind, I’ll see one of his patients. If something bad happens, a surgical complication or a miscarriage of an infertility patient, we can support each other.

At night when we sit on our porch with a cup of tension reliever tea, we can discuss interesting cases, new things we’ve learned or the latest research. It’s not boring as it might be with other couples because we’re in it together. Like anglers on a mountain stream, we compare notes, tell fish stories and empathize with each other’s successes and failures.

This is the good part of working together, but it has taken time to evolve. We’ve operated as a team our entire married life—30 years and counting. We met during our commune days, built log cabins together, planted fruit trees, started food co-ops and marched in peace demonstrations against the war in Vietnam. Eventually, Tom and I took turns going back to school. One of us worked while the other studied, back and forth. He became an EMT, then I became an LPN. He became a paramedic, then I became an RN. He worked as a medical assistant in an oncology unit while I studied midwifery. He went to medical school and did his residency while I taught maternal nursing and did deliveries in a university nurse-midwifery practice. During this time, we also had three kids and managed to pull off the usual things parents do: feed them, do their laundry, make it to PTA meetings.

When we started our private practice, the real challenges began. I was the administrator, but he was the medical director. I was in charge of the staff, but he was in charge of the nurses—and me! We had to be careful of each other’s feelings. No offhand remarks. The work was too intense. Patients’ lives were at stake. When the lines between colleague and spouse blur, distractions occur.

So I’ve learned to constantly remind myself not to interrupt my husband with domestic concerns. “Hey Tom, did you remember to go to the bank this morning?” I’m tempted to ask as I pass his desk.

I also show respect and not seek his advice on a patient as casually as I’d ask him to stop for a jug of milk home on his way home.

In front of patients, I always call my husband “Dr. Harman.” And I normally preface my questions with “May I consult with you” rather than “Hey, what do you think?” Likewise, he has to remind himself to treat me as considerately as he does the rest of the nurses.

Here’s an example that happened this morning.

“May I consult with you, Dr. Harman?” I notice he has frosting on his fingers and I frown. He’s supposed to be on a diet, but I resist my urge to comment.

“Sure. What’s up?”

I flip open Lilac Morgan’s yellow chart and run through her history. “This is a 57-year-old patient, overweight, hypertensive and having severe hot flashes. She smokes a pack of cigarettes a day and wants hormone replacement.” I’m ready for him to say No, she’s too high risk.

“Get blood work on her and if the results are okay, you can start her on something.”

Here’s the point. Would he answer a clinical question from another nurse or a nurse practitioner in the same casual manner? I don’t think so. He would sit down, listen attentively and then discuss the critical issues.

I give an inward growl, then toss my irritation aside. It’s not worth the hassle to go around mad. Progress, not perfection—isn’t that what they say?

There’s another thing. I know my husband so well, I’m always aware of his moods, even when he’s 40 feet down the hall. I can tell by the way he walks what kind of day he’s having. Jolly means he’ll stroll around the clinic, joking with the staff. Bored and he shuffles back to the kitchen to look for baked goodies. Hassled, he whips back and forth from exam room to exam room without a smile. Frustrated, he might snap my head off.

Like the nurse I am, when he’s having a bad day, I want to make him feel better, but I’ve come to understand that I have to let him be rather than asking all the time, “What’s wrong?” I try to respect his need for space and allow him to withdraw until he returns to his usual mellow self.

Because we work together, Tom and I tend to talk about our profession too much. I try to leave work at work, but still thoughts creep in. “Do you think we can give bonuses this winter?” I might ask as we’re getting ready for bed. We’ve learned that we have to call a halt to that and schedule a meeting for those kinds of conversations. Planning ahead has helped and, in fact, now we do the same thing with domestic concerns. I organize a sit-down, give warning of the topic, put a time limit on the discussion and include food—sushi, hot dogs or Kentucky Fried. Tom’s easy to please.

When all else fails, I remind myself what a competent, kind person I have for a partner—and tell him… “Tom,” I might say, “You are the best backup physician a midwife ever had.”

He smiles because he’s heard this from me a hundred times, but I think he still likes it.

Working with your husband is a delicate dance, more boogie than ballet. But then when you think of it, any marriage is. The lessons are the same, including the one you always hear: Leave time for romance. I’ll admit that I don’t always follow this advice. Fortunately, Tom is better than I am.

“Did I tell you about the 17-year-old I saw today with chlamydia?” I prattle on as I put my bare feet up on the porch rail and stare into the dark across our two acres of freshly cut lawn and surrounding woods. “She cried. I felt so bad. Her mother committed suicide when she was eight and she has a history of sexual abuse. On the other hand, she was having unprotected sex. I just hope she learned something….”

“Give it up, Pats.” That’s Tom. Fireflies flicker in the forsythia bushes. “Let’s think about the way the grass smells and how the tree frogs sing down by the lake.” He puts his hand tenderly on the back of my neck…I still get goose bumps….

On the Ball

It was 2 a.m. and the ICU doctors had gone home, leaving mostly residents—Trifoglio among them—to prowl the floor. A nurse approached Trifoglio and said she was concerned about a 17-year-old trauma patient on a ventilator. “‘This guy’s chest looks funny,’ she said. ‘His vital signs are all normal, but something seems weird.’” Trifoglio didn’t know much about medicine in those days, but she knew enough to have another second-year resident set his sandwich aside and take a chest X-ray. A barely visible line showed that the lung was on the verge of collapse. The residents and nurse ran to the patient’s bedside, and without a moment’s hesitation the nurse punctured the patient with a needle and filled his lung, averting disaster. “Twenty-five years later, I still remember her,” says Trifoglio. “If she had not been paying attention, we would have made the diagnosis on the postmortem X-ray.”

In the annals of medicine, doctors often get painted as heroes, but they know that it’s often nurses who save the day. Whether due to keen observational skills, experience or just an innate sense, RNs are frequently able to make diagnoses that doctors fail to catch. Several years ago, J. Randall Curtis, MD, a professor of medicine in the pulmonary and critical care division at the University of Washington Medical Center, had an AIDS patient in the ICU with acute hypoxic respiratory failure and bilateral opacities on his chest X-ray. “We were treating him for pneumocystis as well as bacterial and fungal pneumonia, but he wasn’t doing well and we were completely puzzled by his clinical picture,” remembers Curtis. “His bedside nurse came up to me after rounds and said, ‘You know, the color of his blood looks odd to me and his pO2 doesn’t match his O2 saturation. I think you should make sure he doesn’t have methemoglobinemia from the dapsone.’” The problem hadn’t occurred to the team of doctors, but the nurse knew it and was exactly right.

Going the Extra Mile

Most nurses are dedicated to their jobs. Yet for some, well, let’s just say there are those for whom “dedicated” is an understatement. Leslie Cordes, MD, sings the praises of Susan Walsh, one of those nurses who consistently goes above and beyond the call of duty and who happened to be in Haiti when the earthquake hit. According to Cordes, a pediatrician on the executive committee of the American Academy of Pediatrics’ Illinois chapter, who has also worked in Haiti, Walsh stepped up and capably led a team with very few resources to save countless disaster victims. “As leader of the team, Nurse Walsh took the medical knowledge she had and did what she had to do at a time of intense trauma. She also took the time to learn about the people of Haiti and their culture. I very much admire her.” (Walsh shares her account of the devastation in Haiti in her book Walking in Broken Shoes: A Nurse’s Account of Haiti and the Earthquake.)

There are many ways that nurses go the extra mile. Benjamin Ticho, MD, a pediatric ophthalmologist at The Eye Specialists Center in Oak Lawn, Ill., and a clinical associate professor at the University of Illinois at Chicago Eye & Ear Infirmary, points to Debra Skopec, the retinopathy of prematurity nursing coordinator at Advocate Christ Medical Center/Hope Children’s Hospital. “Recently we had a 25-week-gestation, high-risk preemie whose teenage mother had difficulty bringing her infant in for critical eye exams,” says Ticho. “Nurse Skopec arranged transportation to the hospital’s outpatient clinic and got the doctor to come over from surgery. Her determination to get the job done right has prevented problems, in this case lifelong visual loss, for umpteen patients for years.” Ticho also admires how Skopec has been a great mentor to younger colleagues and students. “She has consistently demonstrated the ‘best’ nursing qualities in all respects. I couldn’t do my job without her!”

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It’s one of those ‘under the breath’ hush-hush topics that is usually only discussed in the break room or behind closed doors. The dating scene mixing with the working scene. We all have come across it, heck some of us may have even tried it! Do you think cupid has a place at work?

I mean, it’s not like we don’t have lives outside of work (right?). OK, maybe some of us do? Okay, okay…maybe some of us try! The fact of the matter is, we spend a lot of time working side-by-side with the same people. And given the right set of circumstances, and the right set of interests, that really cool co-worker you love to work with could develop into something more.

We all know  and work with nurses who are in relationships with other health care professionals. *cough *cough* (I’m married to a nurse). Is it right? Is it wrong? Why? Why not?

What if things go wrong?

I, for one, have never had a workplace romance as a nurse. I had a few failed workplace dates in my previous pre-nursing life, though. And, well since they were failures it made the workplace a tad uncomfortable. I use the word tad loosely for anyone who has walked in those shoes before. Stress levels are bad enough at work, do you really think you need that ‘ex’ crossing your path multiple times during your day? They are referred to as an ‘ex’ for a reason. And at work there is no escape sometimes.

I would say this is the major reason for being careful when deciding if this date/ romance is something you want to explore with your co-worker. If it doesn’t work out, how are you two going to handle the end-game when you’re both at work. That cool working relationship will be gone – jus’ sayin’. It’s food for thought.

But then again, what if things go right??

Now on the flip side of that coin, my wife and I have worked side by side. I think a couple can have a great working relationship as long as they keep it professional and respectful. There is no need to be calling each other pet names during the shift. Seriously. Oh, and the PDA (public displays of affection) – yeah that’s a big no-no. Remember, keep it professional. You’re not at home or out at a restaurant, you’re at work.

Oh, then there is the whole delegation of authority issue. Unless you are both holding the same rank in the greater scheme of things, this will definitely become a sensitive subject both in and out of work. When you and your significant other are having a ‘disagreeing’ moment – how are you going to handle giving or taking orders from them? Hmm, just more food for thought.

Oh, and one last piece to this puzzle. The last time I checked most facilities have a policy that addresses this very thing. In most cases you can’t work in the same department, although there are exceptions. I think these policies are in place to safeguard from any of the above ‘difficulties’ I have mentioned. If you start that romance, is he/she worth leaving your department?

Does cupid have a place at work? Both scenarios are workable, but I think it boils down to what will change if cupid shows up (or disappears for that matter!). Can you live with those changes?

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I’ve previously mentioned that, as health care professionals, we are never really “off the clock.” Some health care professionals have discovered the hard way that being “unprofessional” can have dire consequences.

As a nurse, I’ve become socially gun-shy. Many of my coworkers have asked me on numerous occasions to join them in an array of social activities ranging from drinks at the local “watering hole” to attending parties or important events. I’ve continually declined their kind offers simply out of a fear of having too much fun.

Does that make any sense at all?!

The public has not been kind to many professionals who “let their hair down” and had a good time. Somehow the public equates our clinical skills and decision-making abilities with whether or not we act accordingly. A professional would never partake in loud or obnoxious behavior, nor would they consume alcohol of any kind. To do so would tarnish their reputation as a professional, right?

No one ever mentions that they are grown adults celebrating and enjoying the company of their family, friends and/or coworkers in a safe, non-threatening, non-violent and non-disruptive manner.

I’m willing to bet a few rotten apples have spoiled the bushel. Some extreme cases of carelessness, recklessness and juvenile behavior have raised the public’s concern.

In the end, I have spent a lot of time, effort and money to attain my professional position and degree. Am I wanting to go out and act like a fool? Or break the law? No.

Unfortunately, I’m still a tad bit defensive about interpretation. An innocent misinterpretation can be a very sharp sword. The mere presence of questioning one’s professional abilities simply because of what someone “thought” they saw is enough to damage a career.

Whether accurate or not, perception is reality. And with enough influence it can change other people’s perceptions.

I guess I’m not willing to risk all my hard work over a misinterpretation.

Am I being extreme? Or am I being conscientious? Anyone else brave enough to admit to sharing my fears?

Maybe I’m just getting old? (Insert sarcastic grin.)

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Ever heard of the “15-minute rule” within the academic ranks? I first heard of it as a college freshman during an introductory physics class. The professor was late–the class started at 1:00 pm and it was almost 10 minutes past the hour. I overheard a fellow classmate whispering to another classmate, “Five more minutes and we’re outta here!”

Of course, I had to know what they were referring to. They told me that the “cancellation courtesy” time was 15 minutes. If a professor did not show within that time frame, class was cancelled.

Whah??!!

Curiously enough, I heard this same urban legend throughout my college years. I cannot confirm or deny its validity, but it sure gave the newbie college students an excuse to ditch class, didn’t it?

So what does this have to do with nursing? I’m wondering if there is a “courtesy” time frame when awaiting a return phone call from a licensed provider who was contacted by pager?

Oh, you know what I’m referring to! You have an urgent (maybe even emergency) matter that needs addressing. You page the provider on call. And you wait for them to call you back…

Waiting…

…

Waiting…

…

Now, over the years I’ve heard many theories and contingency plans, but there is no documented standard the last time I checked (although I have heard of tentative protocols before). Some of the most aggressive nurses may wait five minutes if you’re lucky, while the more laid-back, nonchalant nurses have been known to place one page for the entire shift, whether or not they get a call back.

Is there such a thing as waiting too long? Or not waiting long enough?

It also seems to be dependent not only on the information you need to share, but also with whom you need to share it. With some providers you can get immediate calls back. Others claim the pager didn’t work, or that the full number didn’t go through. Walking on eggshells is a kind way to describe this debacle.

Then there is the sticky situation of no return call. What do you do when the situation needs addressing? Do you page them incessantly? Do you call them at home? Do you contact administration?

The reality is, each nurse has his or her own plan of attack. I know we all have our patients’ best interests in mind, and ultimately we will do whatever it takes to address our concerns–even if that means sending out a search party for the provider in question (by the way, that’s a true story!).

This is just another entry to add to the “things they don’t teach you in nursing school” list.

Care to weigh in?