Do Nursing Students Learn the Names of Medications Anymore?

VENTING HERE !!!  I’m frustrated with the general group of people I used to work with.  I love nursing, and am SO thankful I’m from the ‘old school’ of nursing. I still have my license even though I’m disabled, because it means something to me.  I worked hard for it. And it was my main identity for the 20+ years I was able to work.  We still had to do things that are done by machine now, but actually had to DO them ourselves (vitals, handwritten charting, doing our own orders, etc- no techs or CNAs in most hospital jobs when I started… on an acute neuro floor, I had 14 patients on the night shift). IV pumps weren’t used much- we had to count the drops with our wristwatch, and know when the bag was due to run out BEFORE it did, so we didn’t risk a line clotting off.  We didn’t have pulse ox monitors- so we had to look at skin color, and other symptoms, and then call the doc to see about getting ABGs done.   Older nurses get mocked, but we did a lot with much less mechanical help. When something breaks down, who knows how to improvise?   When I graduated, I had to test urine to determine how much insulin to give.  Blood sugar monitors were not common, and even in hospitals, an entire floor (neuro and OB/Nursery in my situation; NICU got their own) shared the monitor when they first came out.

But my major beef when I go to the doctor’s office now is the lack of understanding and interest in medication proficiency when the nurses review my meds with me.  It’s a huge part of their job- and yet pronunciation is abysmal, and knowing what the meds are for is worse.

I am constantly stunned at how few nurses I encounter are able to pronounce the names of medications, and know the generic names of brand drugs.  It’s appalling.   I graduated from an ADN/RN program in 1985, and in order to do so,  our entire class  (standard practice in all nursing schools I knew of back then) had to memorize brand and generic names of ALL meds our clinical patients were taking, the reason for the meds, usual doses, side effects, SPELLING, etc.- and hand write them on index cards, which were checked by our instructors- no boxed sets of cards from the bookstore. No apps.  An index card and pen, with a drug reference book was our ‘app’.

Take some pride, dear nursing students- and full-fledged nurses! Make yourselves sound like you have the education you paid for (generally too much, if you started with some big  school).  Don’t stumble over the names… learn how they’re pronounced. Ask.  Sound like you’re in command of any medication review, or at least go look it up later if you don’t have to give an unfamiliar med yourself- then look it up before.  For hospital and nursing home nurses, know your patient base, and get familiar with the most common meds.  Generic, brand, what they look like, etc.   I’ve caught the wrong meds in those bubble cards in nursing homes more than once, just by knowing what they normally look like.  And hospital pharmacies aren’t perfect…. know what you work with ! Sometimes it’s just a new supplier.   Don’t be afraid to call and clarify something, or send it back to the pharmacy to be double checked.  If you give the wrong med, it’s on YOU.  Nobody else.

I’m at medical appointments more often than I care to think about because of multiple disabling diagnoses, and a routine part of each appointment is reviewing my current medications.  I have to keep track of two types of insulin, and around 10 ‘scheduled’ prescriptions, and more OTC meds that I take routinely. Then there are the routine supplements and many PRN meds- prescription and OTC (that’s ‘over-the-counter’).  And I can pronounce all of them, in their generic and brand forms.  It’s not rocket science.  It’s medical literacy.   It’s also the JOB of any working nurse who has to review or give medications.  How do nurses make notes about new orders if they can’t spell the name of the meds?   When checking meds against MARS, how do they know FOR SURE they’re giving the right med, if they can’t pronounce or spell the names ?  Or do you just figure you can look it up later and hope for the best?   Never stop actively learning (not just hearing things passively).  😉

When talking to the hospital pharmacy, do you know the difference between Xanax and Zanaflex?  Do you know which one is tizanidine and which is alprazolam?   In an emergency, do you know which one can be reversed with Romazicon (flumazenil) ?  Or do you  need a few minutes to go check, as the patient’s respirations drop to the point of needing intubation, when knowledge of the meds (and knowing where they are in the crash cart or emergency box) could save time and unnecessary procedures ?  If not, you really are not competent to give or review medications.  If it’s a weird med, or something given for a condition that isn’t common where you work, then ask the patient.  They might not know- but you might learn something if you take a few minutes after work to look it up.  Patients can be huge resources with oddball meds.

Nobody can know every last medication out there- there are times when reference books (or apps… I liked actual books when I was working) are absolutely needed and a necessary part of being  competent and conscientious.   But the medications that are commonly prescribed for various conditions typical to your work environment  should be part of any nurse’s engrained memory.   If you work neuro, know the meds for epilepsy, Parkinsons, MS, CVAs, increased ICP, etc. If you work pediatrics, know the general ‘rules’ for Tylenol and ibuprofen, and the different code meds that should be posted in the patient room with their weight and appropriate doses.  If you work drug and alcohol rehab, know the meds needed for ODs, detoxing, and what symptoms to look for during withdrawal for the various categories of drugs.  You should be able to pick up on mistakes- including those given to you when taking or checking orders.  I’ve had to call doctors back, and verify doses, when they  just didn’t seem  right when I was checking orders.  Especially when working in pediatrics, geriatrics, and with patients with renal insufficiency or outright renal failure.

I learned the most about brand/generic information during the time I worked in nursing homes (so don’t squawk if you have to take a job in a nursing home- you will learn medications in such a way that you will be better in ANY nursing job you have later on).  I learned about the fragility of doses in pediatrics- and how to dilute meds to give the precision doses required of a 2kg newborn. I always double checked my calculations with another nurse, and the pharmacy (we had a pediatric pharmacist available at all times, which was wonderful- but not having that is not an excuse to double check doses).    And, never to give any dose to any patient if it just didn’t seem right.

In general med-surg nursing, I learned about how IV drugs should be given safely (so if you think that you’re wasting time in a med-surg job instead of your ‘dream position’, consider it what your nursing school didn’t teach you- after you have to complete an ‘internship’ that didn’t exist 30 years ago).  Don’t skip the saline flush before giving the IVP, even if you know it still has saline in the lock from the last flush- you don’t know for SURE it’s patent- things shift, and meds can HURT if they go into the tissues.  My dad complained about his IV site for 2 days when he was given nausea meds, and there was never a saline flush before the med- just after.  It wasn’t an overt ‘blow’, but it wasn’t patent in a normal way. He was treated like he was clueless about his own pain during the medication administration.  SAS(H) is still protocol in any place I’ve been (check your facility P&P Manual).  Don’t be lazy.  Meds that are pushed through infiltrated veins hurt (yeah, I said that before).  Take a couple of minutes to do it right.  It takes much less time to check patency than it does to clean up a patient and full bed change from the nausea med never getting a chance to work, and the patient puking his toenails up.  And some compassion? That will go a LONG way.

If we didn’t know the information that made us ‘floor ready’ by the time we were to graduate, we didn’t graduate. Period.  Very simple. Our orientation was ‘here are the narc keys, there’s the bathroom, here’s where you punch in, and good luck’- as the off-going nurse snickered. If I was lucky, the ADON was still around until about 6 p.m.- after that, I was the only R.N. educated person in the BUILDING of 150 nursing home residents (I had the skilled wing of 30 by myself for 3-11, and another 30 dementia patients if I worked a double on 11-7).    Three to four days tops for orientation  back in the 80s.  A couple of weeks in the 90s, and then ‘babysitting’ for 6 friggin’ weeks with a preceptor in the 2000s, because nobody trusted that someone with a license actually knew what the job required. Very sad.  I had a nice preceptor who ‘got it’ that the job there wasn’t my first rodeo- and it was nice to have someone paid just to be a resource for me (my main ‘needs’ were:  how to call a code, how to deal with the abuse cases and social services when a parent visited a kid who’d been on the news for being beaten or burned, and dealing with the general procedures for dealing with new orders, which docs are user-friendly, etc).   Very sad to see the need for internships; when nursing schools do their jobs, nurses graduate with enough knowledge to not need internships.  Most places have a skills checklist that has to be completed to a respectable degree before being turned loose, but those were pretty basic.   Nursing school used to teach us how to not kill someone on purpose- and be safe upon graduation.  Boards weeded out the rest. We still had things to learn, but we could take care of a patient without a babysitter.   Now  many schools are for-profit institutions that really don’t care about your education or if you did or didn’t learn something… it’s on you to be the best you can be.  Some schools are better than others- and some still care, but it seems that actually doing procedures has gone the way of the pterodactyl.

The entire six weeks I was inpatient for leukemia (on neutropenia precautions, so isolated), not one student nurse ever did anything but follow my assigned nurse around.  Most didn’t speak.   When did this happen?  We were giving meds the second week of class (with supervision) and added any procedure from catheters and NGs to IVs and wound care as soon as we got patients who needed them.  Hands on.  School should teach you that !

Technology is a great thing.  It’s great to be able to look up various disorders and meds, but it should never be a replacement for actual knowledge.  Passing boards in 1985 meant getting at least %60 of 1000 questions (ONE THOUSAND) correct (which I thought was horribly low- that’s a ‘D’ percentage-wise), during a two-day, four-part hand answered test (little boxes were filled in for computer scoring).  There was no ‘luck’ in getting 75 questions right, and then getting a license.  We had to get 600 or more questions right. It took about 3 months to get results.   And the next chance was 6 months away if you blew it.   Three tries, and back to school if you couldn’t figure it out by then.   The way it should be.  Competence… not laziness with looking something up, and then forgetting about it.  When someone is crashing, there’s no time for the internet or computers.  You need to MOVE, and do it right.  Knowing meds is a huge part of that.

Have you been the only nurse at a code on a neuro floor who knew to ask the doc running the code if he wanted a Foley inserted BEFORE giving mannitol?  (and why?). Then have him ask YOU what the dose should be?  Have you HAD to find an IV site in a vein as proximal to the heart as possible, to give adenosine to a 13-month old who went into SVT, and had crappy veins- and knew WHY it was important to get that vein so close to the heart?  Have you known how long D50 lasts after giving it for hypoglycemia (and that every patient is different, both in how fast their sugars come up- and drop, and how ‘low’ they can be and still take something orally instead?). Do you know that D50 is unpleasant, with a warm, ‘gotta pee now’ feeling?   Do you know that D50 will wear off before the cab gets there to take the patient home from the ER if you don’t give them some protein to stabilize their blood sugar?   If you work on a floor where someone can code, could be diabetic, have reactions to meds, etc., YOU need to know the possible meds you may need to help them, and anticipate what the doc may order. And anywhere you work, there is the possibility of someone having multiple medical conditions and medications.  All medication knowledge is valuable.

Do you know that the elderly can have paradoxical reactions to things like diphenhydramine? Or that they can even get delirium from meds like cimetidine?  Or that they are not great candidates for most psychotropics, because of reactions, as well as fall risks?   Do you know that benzodiazepines that are discontinued abruptly (in anyone who has taken them regularly, but with even smaller doses in the elderly) it can very likely lead to seizures?  Do you know what meds are benzodiazepines?

Maybe things are overall better than I’ve encountered, but with my own experience with more than one doctor’s office and more than one nurse, the medication knowledge is poor.  Nursing communication websites also talk about how nursing school glosses over a lot of things.   Get the pronunciation right.  Know how to spell meds, and what they’re for- even if just a ballpark idea.  READ your nursing medication reference books (or apps).  Know what to anticipate if you have a 12 week pregnant 15 year old with diabetes,  kidney failure,  and constipation after an appy… what will you do if you get an order for Milk of Magnesia from the doc on call, if you forget to mention that she has renal problems?  Will you question orders for NSAIDs if she has any type of  pain?

Newbies, NEVER let someone rush you into giving something that you have questions about.  New nurses who don’t ask questions are very scary beings.  I’ve worked in staff, charge, supervisory, and department head positions (with an ADN).  And my first question when I was in charge or supervising, when asking the current nurses about any newbies, was if they asked questions or not. IF they didn’t I was following them like white on rice.

Be proud of being a nurse.  Knowledge is power, and it will never be anything but a benefit. It will make you a more valuable employee.   And respected by your peers and supervisors. Patients also hope that you know at least as much as they do about most of their meds.  🙂

OK.  Done venting.  It’s 6:30 a.m. and I haven’t been to bed yet… I’ll come back and be my own grammar warden later on 😉

Dad Went To The Oncologist Today

Over the past few months, my 80-year old dad has been dealing with some health scares, starting with an egg-sized mass in his neck. Several weeks after it was found, he had surgery to remove it on November 30, 2012.  Surgery was considered very successful, as the surgeon was confident that the edges were all well encapsulated, and the mass had been completely removed. But they needed to figure out what had caused this thing. He hadn’t had any symptoms- it was found when he’d gone in for a routine exam to get his thyroid medicine refilled.  He had had two biopsies prior to surgery, and then the pathologist had the entire mass to dissect and tear up, and there was still no definitive answer as to the type of cancer this thing was. They knew it was an extremely low grade cancerous tumor that had actually replaced his thyroid tissue on the right side. They felt very certain that it wasn’t going to have any impact on his lifespan…but they still were not sure exactly what it was.  It had all of the characteristics of a ‘good’ cancer- but that’s about all they knew.

So, he was referred for a PET scan (fancy CT scan) and to an oncologist (who just happens to be the same oncologist I see- and like). I’ve gone to every appointment with dad (until today), since he’s not up on all of the medical terminology.  I’m quite comfortable with medical stuff, being an RN since 1985 and though I have been on disability since 2004, my own medical issues and cancer have kept me somewhat up to date on many things. And, I know how to use the search engines online 😀   I’ve been looking up everything that the docs have said, and I’ve been just as confused as dad.  I wanted to hear what the docs said, since dad calls me with questions, and I wanted to have the info as accurate as possible.  Sometimes dad’s translation of medical terms is a bit iffy !

At the first oncology appointment, the doc was very straightforward. They needed to rule out multiple myeloma. This is a cancer that dad has been terrified of since his mom died of it in a long, dreadful 9-month death back in 1979 at the age of 74.  I remember it fairly well (I was protected from some of the more sordid details- but I was 15 years old, and knew she was very sick), and knew she had been on dialysis 3 times a week during those months, had a horrible ‘quality’ of life, and had coded twice during dialysis.  Back then, they didn’t offer people hospice care like they do now. They went for the maximum treatment, even if they knew it was essentially pointless. Grandma went through hell, and dad remembers that very well.

At that first appointment with the oncologist, dad was told he’d need a bone marrow biopsy, as well as some other lab work.  Dad was offered the choice of doing the bone marrow biopsy then, or scheduling it for another day. I piped up and said he needed to do it then. He did NOT need to spend days worrying about it and imagining the procedure in his head (as he asked me about it, since I’ve had five of them).  The procedure does sound dreadful.  They drill a hole in the back of the pelvic bone to suck out bone marrow.  But, these days it’s much easier than the one I saw during nursing school.  That was the only thing that nearly dropped me to the floor in a dead faint during all of nursing school.  I don’t ‘do’ bone noise. But having them done, I learned that they aren’t that bad. I drove myself to and from three of them (the first two were done when I was in the hospital). So, dad got himself on the exam table, took some deep breaths, and had it done. He did extremely well, however, he didn’t really convince the nurse of his ability to drive home when he answered her with “well, I guess we’ll find out”.  Good one, dad.  We all felt so safe with that answer.

The oncologist also said during that first appointment that his PET scan did not show the usual ‘holes’ in the bones that someone who had multiple myeloma would likely have. And, dad hadn’t had any symptoms. This whole thing was sort of found by accident.  That was all good news. But, the bone marrow biopsy would say one way or another if he had multiple myeloma or any other bone cancer.  SO, after that appointment, there were about two weeks of waiting. He saw his surgeon last week and he felt that the results didn’t show MM- and could possibly be something so rare that he might write an article to be published on dad’s case.  There’s a possibility that this thing actually started as a couple of very slow growing cells transferred to him while he was still in his mother’s womb.  That sort of rare.

Today, I couldn’t go to the follow-up appointment to get the bone marrow biopsy and other lab work results.  I’ve got a nasty cold, and nobody in an oncology office with lousy immune systems needed my germs floating through the air.  Dad promised that he’d call me as soon as he got home, and he did. NO multiple myeloma. No chemo. No chance of that sort of agonizing death (though treatments and chemo are far different now than they were in 1979).  He does have to have some radiation, more as ‘housekeeping’ to be sure that if there are some stray cells they get nuked (the oncologist had mentioned the possibility of this at the first appointment). Dad will have some lines drawn on his neck so they know where to aim the radiation- so it will be visible that something is going on. Until now, I’ve been sworn to secrecy (well, that hasn’t actually been revoked).  But this is good news, and those radiation lines will be visible. People will know ‘something’ is going on.  And here’s the bottom line: dad is going to be OK.  This will not kill him.  🙂

As much as I love Texas and the 17 years I lived there, I’m so thankful to be here now for my dad.  I’m also thankful for the last 10 years that I’ve had to spend time with him. Though face-to-face contact is not as much as I’d like because of my own health issues, we do talk daily, even if he’s on vacation (well, those cruises and other international trips were some blips of time without daily contact, but I didn’t hear that any boats sunk, so I was fairly certain he was safe). When I am able, we do go out and do things together. And he’s always got my back. No matter what, I know that he’s always had my best interests  in mind, and now I want to be there for him to help with medical language translations, and just ‘be’ there.

Time is something that no one can ever get back.  Once it’s gone, that’s it.  I’m trying not to waste what time is left- and that is the kicker- nobody knows when it’s going to be over.  I know that one day he will be gone, and I dread that thought.  I’ve learned during these 10 years back here, as an adult, that he is, and always has been, much wiser than I ever gave him credit for (I think that’s pretty normal- when I moved to Texas, I was 22 years old and still had that post-adolescent ‘all parents are a bit dim’ outlook).  I’ve learned much more about what makes him him, and have so much more respect for him. Being adopted, I could have landed in a lot of places.  I’m SO thankful that I was ‘given’ to the dad I got. While no parent is ever perfect, he did an amazing job as a dad.

I thank God that he is MY dad.  And I’m glad he’s going to be here for a while longer 🙂

Nurses Aren’t Very Nice People

That was the search engine term on my blog site stats.

That’s the perception of nurses by more than a few people (including myself at times when I’ve been a patient).  I have some definite opinions about this, and most of it relates to the move towards a more ‘concierge’ industry with those blasted ‘customer satisfaction’ surveys that emphasize the trivial things (hot coffee, visitors happy, everybody cheerful and fit for a ‘Leave It To Beaver’ episode) and not whether or not the person got out of the hospital in better shape than he/she entered it. If people want customer service, they need to go to a spa. If they want professional healthcare, that sometimes isn’t all warm and fuzzy, they want nurses who know their jobs and do them in spite of the nastiness of some of the patients and inadequate training of the newer nurses from SOME schools (definitely not all of them, but I’ve heard many newbies talk about things they didn’t do in school… ‘old school nurses either did it or didn’t graduate).

I haven’t met many nurses who don’t genuinely want to give good care.  Now, there are those who go into it for the relative job security and decent base pay.  Nursing isn’t for those who have no compassion, and compassion isn’t teachable.  I apologize for those nurses. They don’t belong in the field.  But for most of the nurses I worked with over 20 years of being an RN, and for the additional 8 years that I’ve been in and out of hospitals as a patient (and seen a lot of good young nurses, and a lot of ‘do-nothing’ nursing students….not their fault- it’s how things are done in some schools), most really do want to do a good job.  That also may mean that having perfect coffee, enough chairs for visitors, and other ‘maid’ duties aren’t on their list of priorities.  If someone is going south in the next room, YOU may not be at the top of the list of people to please at that moment.  So sorry.

You may not realize the pressure put on nurses to make those satisfaction surveys glow, which demeans the professional aspect of BEING a nurse.  Raises and yearly evaluations include those stupid satisfaction surveys, so your coffee not being hot enough (which the nurse has nothing to do with- or may not know how you like your coffee as some inborn knowledge) becomes more important than whether or not you lived through your illness or injury.  Throw in some unprepared new nurses, a cranky doctor or ten, and your nurse may struggle to get through the day doing her JOB- not being your waitress.  Does she want you to be happy? Of course she does !  But someone down the hall who is trying to die twenty ways to Sunday comes first…and is stressful to care for.  Your nurse became a human long before she became a nurse, so cut her some slack.  Chances are she hasn’t peed once in the six times she’s hauled your butt to the bathroom.  She probably hasn’t eaten during an 8 hour shift while bringing you at least 2 meals, and maybe grabbed something in the breakroom during a 12-hour shift.  Yeah, you’re the patient, but the nurse can’t run on fumes with urine backing up into her brain.

What you don’t see are the nurses who have to wipe away tears when they leave your room because they know the diagnosis your doctor is going to tell you in the morning and it breaks her heart knowing that you’re going to leave a young widow with three kids under 10 years old, within the next year to year and a half.  You don’t see the nurse make six phone calls to find one person who will talk to her about getting some discharge planning help that social services, who is usually very good, can’t seem to get anywhere with because you don’t have the right insurance, and you need some specialized care (like alcohol rehab)…but the nurse knows some people in the business.  You don’t see the nurse who has spent the last three holidays at work without her kids or family because another  slacker called in. Again.  You don’t know that your nurse is being bullied by her boss because one time she said she couldn’t cover a second extra shift that week, and she’s just trying to keep it together long enough to find another job and keep a paycheck coming in.   Basically, your nurse is human, and has her own stuff to deal with- and you.  And five more along with you.  She knows that you are the center of your universe when you’re sick… but she has to watch out for all six of you.  And generally ignore herself. Yep- it’s the job.  But sometimes it gets old when there are just more people complaining.

SO before wondering if nurses are nice people, ask why they should be when they get crap from both ends of patients’ bodies, peed on, slapped, yelled at, belittled and demeaned, and complained to non-stop, and then search engine phrases sounding if all nurses are like Nurse Rachett from ‘One Flew Over The Cuckoo’s Nest’- when all she wants to do is sit down and talk to you about how the hospitalization is affecting you.  She WANTS to spend more time with you.  She wants your coffee perfect and all of your visitors there after visiting hours to be comfortable.  She wants you to get well and have a wonderful rest of your life- but unlike you, she has to deal with the reality of however many patients she has assigned to her, and the responsibility to keep you all in viable condition until  the next nurse shows up.   Even if you have an IV and multiple IV antibiotics going, and tubes in more than one orifice, fresh surgical wounds, and oxygen, YOU may be her easiest patient.

Make sure your needs are met, and hope for the ‘wants’- but understand that you aren’t the only one that your nurse is looking after.  She does care. She wants you happy. But she’s only human. ❤

To The Young Nurses…

…us ‘old school’ nurses don’t really hate you! At least this one doesn’t!  I miss being around students and new grads.  We’ve all been new, but things are different, and nursing school is VERY different than it used to be.  Back in the day, we didn’t graduate if we didn’t do all of the skills on the basic checklist. We either repeated the class, or got kicked out. Anything else we could do to get experience while we were still in school we volunteered for, whether it was our patient or not. Our instructors were the ones that followed us when we did anything for the first time (the hospital nurse had very little interaction with us – we weren’t her problem), and if it wasn’t up to her standards, she’d follow us until it was. Period.  When I’ve been in the hospital, I’ve had student nurses following my nurse. I was stunned by how little they were allowed to do, and the obvious absence of any instructor. I was willing to be a guinea pig! These hospitals get students from at least 5 nursing schools…and it was all the same, whether ADN or BSN.  The floor nurse not only got a patient assignment, she ended up with students to look after…not really fair. She didn’t sign up to be the substitute instructor.

That being said, I personally liked new nurses (still do, but I’m disabled, so no longer work with y’all).  Correction. I liked new nurses who remembered that they were new. Nursing school teaches you how not to kill someone on purpose- the rest comes with experience.  And that takes time, no matter how many books you read.  ‘Critical thinking’ isn’t something that is taught- it is something that is acquired. The basic skills are what get the job done.  It’s frustrating when schools expect the newbie’s employer to pick up the slack they left by not getting those skills taught.  I understand that not all schools are like that, but a LOT of them are. Much more than even 10 years ago.

I feel for nursing students and new grads. The hospitals have caught on. They don’t want to finish your education that you paid the school you went to to provide. They don’t want to fork over the money to have another nurse at your side for 3-6 months (orientation in 1985 was one week. Period. Can’t cut it? Hit the road).  I hear so many say ‘well, we have so much more technology now’.  Exactly !  We didn’t have machines, and still had to get the job done- so the excuses get old.  If you don’t know, you’ll get a lot more respect if you just say so, and don’t try and pass blame on to someone or something else.  But, in the meantime, you guys don’t get the hospital job you thought you were going to get.  Add in this economy, and you got a raw deal. The school still wants payment, and you get stuck making sandwiches at Subway to pay the rent and student loans.  (Nothing against Subway, but they don’t need nurses).

The whole nursing shortage thing is another problem. In some parts of the country, there is a bona fide shortage. In other parts, it’s more that people are overwhelmed by inadequate preparation, and can’t get the job done with the number of staff that fit into the budget (trust me, there are formulas for figuring out how many nurses the facility can afford and still stay open).  The nurse:patient ratio on an acute neuro floor in a community hospital in Austin, TX  (1986) was 1:14.  That’s right….fourteen fresh neuro patients (strokes, seizures, back surgeries, brain surgeries- after a short time in Neuro ICU, progressive neuromuscular disorders, meningitis, slow viruses, etc…mostly totally dependent patients with a multitude of tubes- PLUS any pediatric patient with a neuro problem since we didn’t have many dedicated pedi floors then) for one nurse on the night shift, and no CNA or ward clerk.  That is being short staffed- but we did it.  It wasn’t uncommon to have ET tubes in place without a vent, or nasotracheal tubes, trachs, feeding tubes, Foleys, IVs, and sometimes rectal tubes on most of the patients. Two or three of the fourteen might be ‘walkie-talkies’… So don’t tell us we had it so much easier, and don’t know how hard you have it when we’ve been working next to you (teaching you the ropes) – and were probably doing the same job before you started kindergarten. We didn’t know lower ratios.  One night it was me (out of school for about a year) and a CNA for 14 patients.  THAT was a bad night. The CNA was a nursing student, and extremely helpful. But she couldn’t chart, give meds, assess changes, or call docs. She was very good at letting me know what the next disaster was, so I could deal with it.  And that was appreciated. Everybody survived, but I was a wreck.

There weren’t IV pumps on anyone with fluids running (or antibiotics) unless they were at enormous risk for fluid overload- we counted drops while looking at the second hand of our watches.  We charted by hand. There weren’t any computers for a long time.  We checked blood sugars with urine dipsticks, and when blood sugar monitors arrived, we shared them with the entire 3rd floor- that included OB/Postpartum and Neuro.  I’m not sure why today’s younger nurses think that patients didn’t get as sick until the last few years. They did 🙂  Sometimes they were in ICU, but if they were still total care with stable vitals, we got them on the floor. Every. Damn. Day.  Total care is hardly a new concept.  Complaining about it has gotten much worse.

But I do sympathize that a lot of newbies haven’t been prepared for what is realistic.  Or how to manage time. Or do basic skills.  That isn’t your fault.  You got ripped off with your $20K/year education (should never pay that much- nobody cares what school you went to…. get an ADN, get a job, and get your employer to help with further tuition- it’s a general benefit in the vast majority of jobs I’ve had- especially if they demand a 4 year degree; not everybody does).  It’s not fair for you guys to get out of school and not have the skills you need.  Maybe that’s what happens when people go to nursing school just to be an instructor, and never really get real experience under their own belts before trying to teach others.  Check out the experience of the instructors you have. IF they haven’t spent at least 10 years doing what they teach, move on.  There is no end of learning once you’re out of school.  But not to have put in the time to really get a good representation of what’s out there cheats everyone.  Especially the patients their students will eventually care for.

Maybe this sounds harsh. Maybe it is. But I see/hear the same thing over and over.  Nursing isn’t a new profession.  Getting into it purely for the money is fairly new.  Yeah, it’s a pretty decent way to keep employed (especially if you’re willing to relocate to areas with real nursing shortages).  The pay isn’t bad.  The hours can be flexible (but newsflash: if you’re new, you get the crap hours).  I liked weekend nights so I always knew my days off, and the brass was at home 😀   With an ADN, I worked the floor, charge, supervisory positions, and administrative jobs for 20 years.  The whole ‘mandatory BSN’ thing was going on when I was in school in 1983.  It’s getting to be more of an issue in some parts of the country, and less so in others.  Where I spent the vast majority of my working years, I was able to work neuro, head injury rehab, med-surg, pediatrics, alcohol and drug rehab, adolescent psych, nursing homes (don’t knock it til you try it- it was my least fav thing in school, but I really enjoyed the old folks!), and MDS/Care Plans in nursing homes.  It was great to be able to move around when I got tired of something- but I never got tired of the interaction with patients.  If you don’t like being a waitress, babysitter, target for bodily fluids, getting beaten up with no recourse, family feud referee, or scapegoat for doctors, switch to something else.  You’re not that special to get out of ‘normal’ nursing tasks.  And, you’ll either survive and get good- or you’ll bail. But taking care of the majority of really neat people is worth it, IF you can deal with the lousy parts.

Nursing is something I really miss. I hate being on the patient end of things, and miss working with students and newbies.  I liked the fresh eyes and ideas.  But those with a superiority thing going on were just annoying.  I’ve had nurses with all of 3 years of experience go after me in a situation where my 15 years of doing the job came in really handy. One question: ‘have you ever felt like this before?’ gave me a lot more information than running around looking for heart monitors when they lady just needed to fart.  She had gas- not angina.  But the new nurse (3 years is still pretty new- it’s not uncommon to feel like a total dunce for 3-5 years- it’s a lot to get figured out) was sure that the woman was going to croak from a heart attack in a matter of seconds.  Uh huh. I told her she was welcome to call the doc herself (I was in charge, so made all MD calls, and assessments before those calls).  She declined. The lady was fine. I did put her on a monitor for a little while, and had it read by ICU nurses, and it was normal sinus.  I recognized that I hadn’t seen every cardiac event in the world- so was assessing her cardiac situation. All t-waves were going the right way. But ego and inexperience could have cost the patient stress, extra tests, and a lot of money.  IF the lady said she had felt that way in the past, just before she had open heart surgery, it would have been a totally different story. Alert the militia and sound the alarms !  But THINK!! Get the information! Do your own assessment. 🙂  And ask for help if you have questions.

When any supervisor would ask me how a new nurse was doing after they started, I had one huge criteria as to how much I trusted the newbie to be OK:  did he/she ask questions?  The quiet ones gave me the creeps, and I followed them like flies on roadkill.  I could deal with someone who asked 30 questions every night. I LIKED them ! I knew how they were thinking, and where their focus was!  I liked when a new nurse asked for help with something- even if they just wanted me to be there because they’d only done something once or twice before.  I was really OK with that.  They knew what they didn’t know, and that’s knowing a lot!  Time management and picking up the bigger picture come along with just doing it.

So if it seems like older nurses don’t like new grads, a lot of times it’s not really true. They don’t like how things have gone downhill with how nurses are educated and turned loose. Getting 75 questions right on boards isn’t impressive (our minimum was 600 out of 1000, over 2 days using a #2 pencil… a typical NCLEX question could involve a 15 year old pregnant girl in renal failure, with a hot appendix).  Yes, many of us need to listen more to what you’re all saying behind the actual comments and questions (i.e.-“I’m scared to death, help!”). We need to be more approachable (that is one of the best things any of my coworker LVNs ever said to me- I never made her feel stupid, so she felt she could ask me anything- we’re still friends).  But please remember, we’ve made it for decades!  We’ve had to go with the flow with all of the changes.  Many of us want to be useful to new nurses.  The whole thing about nurses eating their young is SO old… don’t even go there. It’s because you’re new, and SOME of you don’t know what you don’t know, and have gotten a shoddy education (no matter how expensive it was). You’re more work.  But be open. If you show respect, you’ll get it much more quickly.  🙂

I hope you will love nursing as much as I have. I miss working so much, and still keep my license active. I worked hard for it, and learned a lot by having it.  It gets better !

Why I Didn’t Die During Nursing School…

I was 19 years old when I started RN school.  And a very young nineteen.  I’d grown up in a conservative church, and was an only child.  I really wanted to be a nurse, and was determined to get through it, but I’m not sure how that actually ended up happening.  I was horribly shy when it came to dealing with the patients when I was a student.  My first semester of clinical classes began in September 1983.  A lot has changed since then…

My first several patients during clinicals were hemorrhoidectomy  patients.  There I was, never  having seen a naked person, and I had to look at their butts.  WAY into their butts.  Uh huh.  I’m sure nothing about me exuded confidence, so starting with the butt was probably a safe place to put me, but I was mortified, especially since most of them were men.  Butts and balls to a naive nineteen year old was almost the death of me.  I finally had a chat with my instructor (a very nice instructor, but she was also intimidating with her knowledge).   I needed a different view.

I asked if I could possibly have a different type of patient.  She said sure. No problem. So when I picked up my next assignment to prepare my careplan, I saw the words ‘esophageal varices’ in an elderly woman.  That meant that blood vessels in her esophagus had ‘blown’ and she’d likely been critically sick from blood loss.  I was sure my mere presence in the room would have her spewing forth all that kept her alive, and I’d kill her within minutes, even if indirectly.  I was terrified.  I asked my neighbor (a pediatric cardiologist) about said varices. He told me that it was possible she could bleed to death in minutes if they reopened.  Not helpful.  I got busy with my careplan,  and  every horrible thing I’d already heard or read was confirmed.  The woman was doomed.

The morning came for me to actually go talk to this lady (this was back  in the day when we did all care for the morning for our assigned patient- not following someone  else around while they did it).  I stood in the doorway trying not to pass out.  My instructor came up behind me and physically pushed me into the room, whispering “You actually have to talk to them”…. I was thinking ‘ just shoot me now’.

What I found was a very alert, sweet woman who was cooperative, and didn’t have any signs of getting ready to exsanguinate in front of me.  I said hello, and she didn’t die.  I did my nursing student assessment, and the woman didn’t seem to suffer any ill effects.  Huh.  So I’d been a bit more freaked out than necessary.  I had the same lady three different days. I even ended up washing and rolling her hair- which she loved.  Anybody who knows me is rolling over in hysterical laughter at the thought of me doing anything positive for someone’s hair. I can barely keep mine brushed.

The next horrifying event was bathing a comatose MAN.  I’d have to TOUCH him.  My instructor seemed to sense my incomprehensible stupidity (inexperience?) and was in the room during the whole process. I didn’t kill him either.  The familiar lightheadedness was with ME the whole time, but most importantly the patient didn’t get worse.  OK. Check that off the list.

On to the big stuff.  I had to give an enema. The ‘serious’  kind with the little soap packet and the big bag that got hung on an IV pole.  My instructor was in on this as well.  I got the soap into the bag, and was getting the water to the right temperature before I filled said bag. I had the clamp on, so nothing would leak before it was supposed to find its way into the lady’s back door.  I put the little packet of lube on the  business end of the tubing.  Gee, this was going well !

Then my instructor suggested it might be more comfortable for the patient  if I let the air out of the tubing before I brought it out to the patient.  Well, that sure seemed like a good idea- no point in giving the woman gas. SO, I unclamped the clamp on the tubing, and waited for the air to exit.  What I didn’t expect was the lube packet being shot across the room from the force of an entire length of tubing full of air.  It was like sniper training in its force and trajectory.  I don’t know where that packet ended up, but I know I was ready to die.  My instructor was very professional, but I think I remember a slight grin. The patient looked a bit nervous, along with slightly relieved to know that everything was being supervised, and this nineteen year old pre-rookie wasn’t being turned loose on anyone.  I got more lube, and the enema went in, and came out, just fine.

I got through my fundamentals class  without killing anyone.  THAT is why I didn’t die in nursing school.  Nobody got worse as a result of my care.  I started out with a negative confidence score, and got to the point where I didn’t anticipate disaster.  That was the biggest perk in getting through fundies.  I had a shot at becoming competent !  All nursing school really teaches is how not to kill someone on purpose.  The experience and finesse come later.  I was at least on track !  I’d gotten through the checklist of skills, and passed tests with solid grades (anything below %85 was a D; I was usually in the %90s).

In the 20 years I worked as an RN before becoming disabled, I got past the shyness fairly quickly.  I just didn’t have time for it.  I needed to get in, get information, give care, and get out.  On to the next patient.  Asking about the color and consistency of someone’s poop was as much a part of my day as parking the car.  I had entered an ‘intimate’ profession.  I had to know things about the patients that they didn’t tell anyone but their closest friends and relatives- and some things that they didn’t even (or especially) tell them.  I had the book knowledge, and I fairly quickly got through the ‘people skills’ that make nursing work.  Without them, there’s no chance at giving good care.  Without getting up in someone’s business, I couldn’t know what they needed.  That trumped my insecurities EVERY time.  🙂