It's a hospital, not a Hilton

There's a Facebook group called "It's a hospital... Not a Hilton." I used to check it with some regularity about a year ago but haven't really kept up with it. The thing is, it's a place for nurses (or other direct patient care personnel) to bitch about the craziest demands they've heard from their patients. I will admit that it's pretty funny and cathartic in a way to be able to vent about being treated poorly by the general public. I don't know of a nurse that hasn't had a patient be overly demanding or rude before, and few nurses that haven't had to deal with a violent patient. It can be mentally taxing enough to take care of those patients who are confused and argumentative because of dementia or delirium, but even more to take care of a patient who is otherwise in his right mind but seems to think that he has been assigned a new slave. However, I think I am over the constant complaining.

When I was in nursing school, I did a group project about Virginia Henderson, one of the historical figures of the nursing profession. We did a little skit in which I actually played Miss Henderson herself, the result of which was that my only real recollection of Miss Henderson's contribution to the nursing profession was her belief that nurses should "do for patients only what they cannot do for themselves" (I believe this was my only line in the skit, repeated ad nauseum). Most of the complaints that nurses seem to have about the expectations of their patients is that patients just expect too much. They are sick (or at least perceive they are); they want to be fed, they want to be bathed, and they want to be waited on. One of my favorite nursing lines is the one that goes something like "at what point in your hernia repair did they break your arms?" Virginia was right, of course; unless you actually did break your arms then you should be able to manage getting that fork to your mouth, and you should do it now because god know I'm not coming home with you. Annoying as this may be, however, this is an opportunity for patient (and family!) education, which is another big part of the role of the nurse.

Then there's the customer service aspect. Every freakin job these days is a customer service job, I don't care what it is you do. I spent many years in menial customer service jobs before I became a nurse, and after a while I learned that it was easier to just give people what they said they wanted (or at least give them the perception that that's what you were doing) than to waste time arguing about it. This made them happy, and got them away from me more quickly. If for some reason this didn't work, the fallback position is to apologize and compromise. All of these things were easier to do once I truly understood that these people did not know me and could therefore not be angry with me personally. In fact, this wasn't really about me at all. I tried to make you happy, really I did; if you are still not happy then you may never be.

So, if you come to my hospital and I am assigned to take care of you, I try to make you happy. If you have completely unreasonable demands then I apologize and try to compromise. I cannot produce miracles; if I could I would just cure you and then we would both be happy. So I do what I can, try to find a creative solution or bend the rules if need be. And if that doesn't work then I try to remember that I tried, that you don't know me, and try not to take it personally. I mean, I can't if I expect to be a nurse for much longer. But seriously, if you do come to my hospital, just be reasonable. It makes my job so much easier.

A touch of the AR

So, yeah, I'm a little AR. You know, anal-retentive? Which I think is a good thing in a nurse, right? Better than lasseiz-faire nurse ("just put that stool sample anywhere"). I am totally AR when it comes to charting, partly because of CYA (cover yer ass!) but also because I like having all the holes filled in. It just looks better when everything is in place. The charting we use where I work is a grid system, kind of like what an Excel page looks like. Pages are based on body systems, and there are a lot of add-in variables depending on what is going on with the patient (fluids, drains, skin problems/incisions, etc.). If there isn't a pre-made option, you can always create your own. The individual boxes are small and designed for 1-2 word descriptions (yes/no, wound type=incision, NS@ 100/hr, etc.), but you can comment on any box and explain yourself ad infinitum. Vital signs are fed into the system automatically, all that needs to be done is to click on the numbers to agree. I&Os are similarly quick to chart. The best part is that once you have saved your entries, the next time you click on that box your last saved entry pops up- if there are no changes you can just click "enter" to agree and shazam! Assessment charted. Which is why I don't understand why some nurses can't be bothered to chart.

Recently I got report from a day nurse who specifically mentioned several things that had happened over the course of the day. Nothing too exciting, but all things that were included in the orders as needing to be done. She goes home, I get started and log on the computer, pull up the chart and it's practically blank. Vital signs are mostly filled in (remember these are automatic), and I believe she had initial assessments charted, but other than that... what was she doing all day? Internet shopping? Helping with a code? So busy proving care she didn't have time to chart it?

We have charting guidelines we are expected to follow. Many are set by JHACO, the hospital accreditation board, some are facility guidelines, some are unit guidelines. In the ICU, our minimum vital sign charting parameter is every 2 hours, although almost everyone takes VS every hour as that is the default parameter for our monitors. Temps are taken every 4 hours (this is usually not automatic and is more frequently missed). We are expected to chart a full assessment every shift and update that assessment with any changes. We are also expected to provide personal care for our patients, feed them, turn them, ambulate them, and measure I&O down to the last milliliter. This is what nursing care is all about. Maybe this nurse did these things, maybe she didn't, but the saying around here (and probably every hospital) is "if it's not charted, it wasn't done." Two years down the road when the kids decide to sue because it wasn't grampa's time, there's going to be a chart review, and eventually someone will look at your shift and see your 12 hours basically unaccounted for. And in the unlikely event that you end up on the stand to defend your actions, you can try to tell the jury that you turned grampa every 2 hours like you're supposed to (if you even remember that night, let alone that guy), but the fact that you didn't write it down is going to make your statements about that and pretty much anything else you did or didn't do seem questionable. C. Y. A.

As an aside to the fellas, if I've not made this clear enough already, my charted assessment is very thorough, which is why I'm always over at the damn computer typing away (not, I repeat, NOT because I'm cruising Craigslist looking for secondhand toys for my kids. Or blogging.). One of the little boxes I'm filling in once a shift is "meatus assessment." That's right boys, I'm charting about your dick. Please, please don't give me a reason to go on ad infinitum.

CCRN

So I recently got certified in my "area of expertise," that being CCRN (Adult Critical Care Nurse- yes, I know the acronym doesn't match. Take it up with the AACN). My new certification is important to me because it makes me look like I know what I'm doing, plus I get to wear a snazzy gold "CCRN" pin on my name badge, but most importantly it earns me a $2000 bonus from my employer. I've been a critical care nurse for all of 2 years, and an RN for all of three. I guess that although I can add another set of letters behind my name, what I really feel like is a fraud. A fraud that tests well.

A friend of a friend on Facebook (not someone I'm friends with, but, oh nevermind) recently posted a status update stating not only that she had passed the CCRN test but that then went on to reveal her score in each content area, most of which were in the 90s or 100%. Let me tell you, I certainly shared with my Facebook friends the glad tidings of my passing; however, I chose to keep those 70% just barely passing scores to myself. I could go on and on about why I scored low (I was on maternity leave! Um... the test is hard!), but really, I got nothin', except that maybe I just need more experience.

Think back to when you were in school. Getting good grades seemed sooooo important, didn't it? Okay, maybe it didn't to you but it did to me. I was even on the dean's list (only my last semester, but hey that counts). I'd like to think it helped me get a job, but probably not. In my everyday work life? Who gives a crap. I make the same amount of money as those who barely skated by, and although I earned a BSN, make just a smidge more than those who have an associate's degree. We are all in one big happy nursing pool. I bring this up not to seem bitter because really, I'm not, but to point out that grades and intials aren't everything. Many of those "just barely passing" nurses are still fine nurses. And some of those dean's list nurses would make me leave AMA if I were the patient.

So I'm feeling a little conflicted about my CCRN. Like I stole my gold pin from someone more qualified. However, I'm going to go ahead and keep my $2000 bonus. And no, it did not get prorated down based on my passing score. 70% rules!

Flip Flopper

When you work the night shift, one of the big decisions is whether to stay on the night schedule on non-work days or to flip back to a day schedule. People do one or the other for various reasons; I choose to flip back to a day schedule (did I say choose? I meant am forced) by my family. As much as I'd like to sleep the day away, when my two year old gets up at 6am I am the one who is responsible for him (does this mean I don't let him run around the house for a little while while I lie in bed trying to sleep for just 5 more minutes? No). I do know of night shifters who manage to stay on a night schedule even though they have kids, but there is usually some other party available for childcare- a spouse, school... in my house, on weekdays anyhow, it's just me. Sure, my husband is home on the weekends, but just try sleeping when there is a baby crying off and on, a toddler running around shrieking, and the sporadic venture into the bedroom to retrieve just one more thing. At night, everybody sleeps. Well, not the baby so much, but that's another blog post entirely.

Different people have their methods, but mine is this: on days off, I get up early, I go to bed early(ish). On the first day I work, I get up as late as possible, which might be 9am if my husband is home or more typically 7am if it's just me. Commence toddler-exhausting activity. When my kids nap at noon, so do I- I try to get at least 2 hours in. This is not always possible. Once I get up, I get ready for for work & go. The following days I do sleep once I get home and get up around 7 hours later, except that after the last night in a row I usually try to get up around noon so I can try to get stuff done, which means that by 9pm I'm ready to pass out and... Voila! Back on day schedule.

Honestly, sometimes I think that if I had my choice I would spend all of my off time sleeping. Or at least most of it, with a few hours of waking time to work on whatever crafty project I had going. In some ways, I'm glad my kids force me to get up and get some sunlight in my life, even the heavily cloud-filtered sunlight we get here in the NW. There is something about waking early and having the whole day to accomplish, even if all that actually gets accomplished is feeding yourself and maybe cursory hygiene. Being a flip flopper isn't so bad now, is it?

The sitter patient

Okay, so I lied. It's midnight, but it's not so quiet. There's a fair amount of activity going on outside, outside being out in the hall. I'm stuck in my patient's room tonight. He's what we call a sitter patient, meaning: he needs a babysitter. And that sitter is me. I'm not sure if I am a better or worse choice for dealing with sitter patients since I have little kids at home. Taking care of a sitter patient is kind of like taking care of a two year old, except heavier, stronger, and with a lot more stuff attached to them. You know, important medical stuff that they just can't wait to rip off their body. I like to think that I have a slightly higher than average patience level for dealing with this type of patient because of my kids, but sometimes I think that maybe this patience is all used up by the time I get to work. Or vice versa.


Tonight my patient is a fairly pleasant gentleman who became delirious after a series of unfortunate events, starting with a fairly major surgery. Delirium is a pretty serious thing for hospitalized patients; studies have shown that there is a correlation between delirium and all sorts of negative patient outcomes. I understand this, but I have to tell you, this guy is crazy. Hallucinating, talking about (and insisting on) things that don't make sense, pulling at his feeding tube and his catheter. He got a big dose of a sleep aid at bedtime, but he still wakes up regularly to scratch his nose or pull his blood pressure cuff off. Now that most of the care has been done for him and it's time to sleep, my job pretty much just consists of sitting by the bed and telling him to stop and to go to sleep. I'll do this for 5 more hours.


The worst part of having a sitter patient for the evening is being stuck in the room. We're not allowed to have personal drinks in patient rooms so sometimes hours go by with no water, no bathroom break. Definitely no snacks. Sometimes patients will be trying to climb out of bed, over and over again, or otherwise attempting to (accidentally) injure themselves, making the job that much more trying. We can restrain patients if need be, but this is usually reserved for really out of control behavior as this usually just makes people mad. I'm a fan of the chemical restraint myself (hello sedatives!) but these are usually limited as they tend to make things worse for the patient in the long run. So here I sit. Who says nursing isn't glamorous?

The night nurse

I've been working overnights now for almost three years. When I first started nursing I thought I would hate the night shift and decided I would try to get on the day shift as soon as possible. My first job was on a surgical floor and the day shift was really busy, always running around to help patients out of bed, assisting with or giving baths, passing meds, passing more meds... and then the patients' families were always there, asking questions I had no answers to (hello, new nurse!), doctors were rounding... Seriously, it was all I could do just to keep up. When my orientation was over, I switched to the night shift, my new home. And... it was quiet. Sure, I was still running around like a crazy person, but sometime around 2 am there was this blissful period of quiet. Most of the patients were sleeping, the nurses were all charting, and the only noise was the tap, tap, tap of fingers on keyboards. I had time to look up the multitude of questions that had come up so far in the shift. I had time to finish my charting. I had time... to shop on the Internet. Now we're talking. Night shift it is then.


Nurses work the night shift for a number of reasons, some of which I have already mentioned. One of the primary reasons is money. Night shift almost always includes a differential of 10-25% on top of the base pay. Where I work night shift gets 10%. Weekends gets 25%. Night and weekend? You got it- 35% more money. I do like the money, but that's not my primary reason for night shift. Really, it's just... quiet. Now that I work in the ICU I take care of 1 or 2 patients a night. Unless something bad is happening, the goal is usually to maintain until the morning. No trips to imaging, no doctors coming by changing orders around, no families asking all those questions, just me and my (preferably) sleeping patient.


Since I started nursing, I've also started a family. I now have two little boys at home that are in my husband's capable hands while I'm at work. My youngest is still an infant, still breastfeeding as I write this, and it takes some effort on both ends to keep that up while I'm away. The hardest part is being away for so long- a 12 hour shift plus 8 hours at daycare so Mama can sleep plus commute time means I have approximately 2 hours with my boys on days I work. Fortunately, I only work 3 days a week and can make up for it the 4 other days I don't work. I think family reasons are another major reason nurses move to the day shift, but I don't know that I would really get any more time with them if my schedule was switched, seeing as how we'd all be sleeping. Or not sleeping. My poor husband.


So here I am, it's almost midnight. My patient is sleeping, and the only sound is the tap, tap, tap of the keyboard as I type this. Night shift rocks.