Final Thoughts From Nursing School

Today saw the end of my first experience in teaching a clinical group for a local community college.  I wanted to add on “clinical instructor” to my list of stuff I’m involved in, since it will help me in my education for my FNP certification, and in a way, it’s my way to “give back” to nursing, a profession that has been so good to me over the years.

I really enjoyed the opportunity to teach this group of seniors who had me as their last clinical instructor until they embark on the last five weeks of the semester.  At this college for the last five weeks, the students are assigned to a “mentorship”, in which they are paired with an experienced RN at some hospital in the area (and believe me, Pittsburgh has lots) who works one-on-one with them for a total 120 hours.  Basically, the student works the mentor’s schedule, does what she/he does, and pretty much acts as the primary nurse… at least that’s the goal.  Along the way, they have to write in and submit a weekly journal entry of their thoughts, successes, concerns, etc., and they have a weekly “roundtable” at the school in which they all get together by clinical group and discuss various issues pertinent to modern nursing and healthcare in general.

For my clinical group of seven students, they all passed their final exam, and all passed the clinical portion of the final main course (the clinical is pass/fail).  And pretty much everyone in this group was like me, choosing nursing as a second career.  They were all adult learners, and they all behaved as if it was “do or die” time for them… which indeed it was.  They were all conscientious, professional, and eager to learn.

For my “first” teaching experience, I made it a point to go above and beyond what was done to my clinical group way back when I was in their position, and decided to pull back the “veil” of the “ideals of nursing” and help them understand and get a taste of the “realities” of nursing.  Any nurse of any stripe will readily tell you that in nursing school, nursing seems to cut and dried, clean and sterile.  But once you hit the floor running as a new, scared Graduate Nurse (GN), the reality hits, and lots of those “ideals” tend to quickly fade to the reality of life on a busy hospital unit.  Some of those ideals are genuinely good, and need to be practised consistently, like using double-identifiers for patients when passing medications – every time, and washing your hands before and after each patient contact – every time.  But some ideals, while sound and good, aren’t necessarily practical in real life, for example gowning and gloving for an patient in isolation when all you are doing is popping your head in the door to ask the patient a question, and not having any contact with the patient or anything he/she is in contact with.  Don’t get me wrong, I thoroughly belive in using Universal and Standard Precautions, but even hospitals have picked up on the so-called “three-foot rule” of not requiring using isolation precautions if you’re not actually doing any direct patient care in the room or contacting anything the patient has touched, in other words, being outside of a theoretical three foot zone of the patient.  As my students will quickly learn, when you have an anywhere from 4-8 patient assignment, taking the time to gown and glove when all you’re doing is popping your head in to ask the patient how if the previously-administered pain medication was effective, is somewhat counterproductive.

Whew… long winded, huh?  Anyway, as my students embark on their 5-week mentorship phase and prepare for graduation and the very stirring “pinning ceremony”, I’ve pulled out some of my journal entries from back when I was in their shoes, and since I’ve given them all my contact information should they want to use me for a reference, some of them may undoubtedly visit my website and come across this blog (no, I’m not vain, am I?).  So, if anything helps them at all, go ahead and take it.  That’s what teaching and mentoring is all about, after all… coming along side a new, fresh nurse and guiding them in their practice so they can be the best nurses they can be.

God bless, and congratulations, guys!  You all deserve it, and I’m very proud of you all.  I know you’ll all make excellent nurses, and all in your own way, attain that “91%”!



Week One:  “Sink Or Swim”

Tiffany and I started out on the right foot, I think.  From the very outset, I pictured her as a younger, energetic, exuberant nurse with several years of experience and a head full of knowledge, just waiting for it to spill out on me.  I was nearly right.

She is young, 20 years my junior, but that doesn’t seem to faze her.  She was a grad from this hospital’s in-house nursing school, just under two years in her RN.  And she has more of a democratic style to her leadership, especially since she was a relatively new nurse herself, and I wasn’t the only student nurse she’d encountered since she passed her boards.  She seemed relaxed at delegating tasks to the students, and even allowed me to play the RN-mentor role with the in-house nursing school’s students assigned to our patients.

Our work together this week started out as I would have thought: taking a small portion of Tiffany’s 5-patient workload.  But when I finished the day giving my first-ever report as a nurse, I figured that things were going to get interesting.  The next day, I walked in to a “sink-or-swim” situation when Tiffany said, “two patients were just too easy for you.  You’re going to take my whole assignment.”  I could tell she was tossing me in the water, to see what I’d do with it.  I had to up the ante for myself, since Tiffany was clearly keen on delegating an amount of her authority to me.

The approach is considered “immersion”, and it’s the same concept I used on myself when I decided to work in healthcare as an aide while attending school.  In other words, if you really want to learn French, don’t pick up a French language book, live for 6 months in Paris.

Within a few short days, I was already picking up this hospital’s “lingo”, talking the appropriate talk to the other nurses, PT/OT departments, and the residents we needed to encounter.  I found I needed to listen thoroughly, concentrating on not only was being said, but what was written regarding my patients, and be able to translate that information in simple form to patients and family, and more professional form to the other disciplines with which we interacted.

So, will my one-on-one with an enthusiastic young nurse have me emulating that democratic leadership potential?  Stay tuned.


Week Two: “CLEAR!”

Something inside of me always wanted to yell that out.  I suppose the “ER” TV show subculture made it almost glamourous to shock the crap out of someone, all the while the adrenaline is pumping with the excitement of a do-or-die moment.  Perhaps this vision is simply leftover from my earlier days, as a young 17-year-old when I was struggling with the reality of leaving high school and debating between the passion of nursing school and “safe option” of another field, due primarily to the (seeming) social stigma of male nursing.  Looking back, my decision to sucker in to what was perceived about male nurses was plain stupid.

But coming back to my passion some twenty years later, hasn’t erased or diminished the reality shock potential of what will be after I get that shiny pin on my uniform.  It’s one thing to “practice” nursing practice in school, whilst you’re under the umbrella of the college and all your stupid decisions can be halted by a faculty member or a staff RN.  But when the ball gets firmly put in my hands, and there’s no direct backup, that’s when I think the stress of nursing will finally hit home.  I know that day’s coming soon.

And it’s not like I’m likely to escape any of the pressures that I see nurses face at this hospital.  As a teaching hospital, the staff is constantly surrounded by student nurses, student pharmacists, student doctors, and the list seems to continue on.  I think the ones with the biggest egos are the med students, who by and large have seemed to look down on the nurses as something inferior.  Maybe that’s just my impression as a student nurse, but perhaps that’s just one of the stresses that the “real nurses” (you know, the RN’s) have to deal with.  It seems to me, though, that the nursing staff seem to handle this ever-present invasion of student-whatevers with grace and charm… at least outside the break room.

Perhaps it’s called a “break” room because there, the staff can break down in front of each other, so that patients and visitors don’t see the effect of the pressures they’re under.  If nurses can check their personal lives at the door when they walk in, and not have to deal with personal issues at work, it’d almost be a perfect world.  But personal pressures are just one of many stresses nurses seem to shoulder.  Patient problems, incessant doctors who don’t seem to listen, doting families, unit managers yelling if overtime goes over a constantly-nebulous line… and to boot, the reality that occasionally, and one never seems to know when, we just might have our patients’ very lives in our hands… that’s all a lot to deal with, beyond the spouse or child calling with some issue or other, while you’re trying to work.

I like the fact that Tiffany keeps her sanity partially through pleasant thoughts of one day owning her own organic/health store.  For the most part, she tries to eat fresh and healthy, maintains a health-conscious lifestyle, and regularly “decompresses” even during work time.  Ah, if only I could emulate those habits.  Maybe when school is all done, I’ll have a clearer mind to de-stress in healthy ways like these.


Week Three:  “You Want Me To Do WHAT?”

There are some people I work with who I know will delegate “charming” jobs to me, and leave me hanging when I need an extra pair of hands.  These people are a major reason why I’m glad I won’t be working my current unit when I start as a GN.  It’s not that I don’t expect to encounter other such people in my career, it’s just I’ve had enough of delegation of “dirty jobs” to “the aide” borne more out of laziness than effective distribution of responsibility.

From a nurse’s perspective, however, delegation looks slightly different.  Since patient assignments are split during a day between those working 8-hour shifts and those working 12, there have been some occasions where prior patient experience and proximity are thrown out the window in favour of expedience and an apparent management phenomenon I can only describe as “spreading the misery.”

The nice thing about this hospital is that there’s always another student nurse floating around, part of a group who aren’t precepting yet.  So when Tiffany and I come in to work, the possibility exists that we’ll have a student to deal with.  And when we’ve been caught up in the misery-spreading, and we have an in-house nursing school student or two, the misery gets spread to them for the more “interesting” tasks.  They’re passing meds, doing patient care, and Tiffany wanted me specifically to double-check their work and shadow them.  So effectively, she delegated some of her responsibilities onto me, and I in turn delegated some onto the in-house nursing school students.

But rarely do I hear at this facility, a foul cry of “you want me to do what?”  For example, I could very easily have gotten myself, a repeat blood pressure on one patient this week who needed to be watched closely.  But I asked the aide covering our assigned patients to get the blood pressure, and without hesitation, he got it within the time I requested for him to repeat it.  There was no “why can’t you do it, you’re the student”, no “I’m too busy for that”.  This aide knew his job and knew it well, which freed my mind up on priorities of the shift, which included a fresh transfer from the ICU that became my first patient to see, someone scheduled for a test, who became my second, and the repeat blood pressure, who became my third.  The last three were “walkie-talkies”, one of whom was ready to discharge.  That patient was number four.

I think it’s the faster pace of a floor like this, with more rapid-fire admissions and discharges, acute patient care and med administration, that is helping me to understand how to quickly prioritise and turn, sometimes on a dime, to effectively manage the care my patients need.


Week Four:  “TRADITION!”

Someone famous once said, “the old ways are the best ways.”  It was Tevye in my favourite musical Fiddler On The Roof who kept singing the praises of “tradition” all the while that tradition was crumbling around him.  So it seems in medicine, and in particular, in nursing, that old ways, though having their proper place, sometimes need to give way to new “best practices” as our profession progresses.

But with change in the way we’ve done things, come changes in attitude, and conflict between members of what we always hope is a cohesive group.

Take for instance a recent development on this unit, which to some, seemed appallingly small potatoes, but to others (including the unit manager) was an issue that couldn’t be ignored.  It was several days ago when a patient was transferred from this unit to another unit, and according to that unit’s assessment, the patient was found to have deep impressions on both legs from knee-high TED hose placed improperly, and apparently not having been removed for days.  Now, anyone who’s had TED hose on for even one day knows enough of what it’s like to want them off at night.  So, when this issue worked its way through the nursing management, the edict came down that each shift must document TED hose usage on each patient, and when they went on and when they were taken off.  An excellent idea in theory, as it would give a clear indication of any skin issues related to TED hose usage and time on the patient.  But when the unit manager wrote that order on the whiteboard in the nurses’ lounge, some nurses were quick to whine about how that would be so tedious and that they’d quickly forget to chart that, since it’d never been tracked before.

I think to some of the staff who were whining, the issue wasn’t so much that they didn’t want to document additional data for the sake of effective patient care, it was more like they felt that it was an edict, and order handed down, and they had no ownership of the idea.

Perhaps that’s the root of conflict resolution and group communication… to realise that even when the group needs to follow a particular direction, the best way to approach the new concept is to help the group “take ownership”, or feel a part of the change; allow input and discussion about how exactly to implement the change and what positive qualities the change would bring to the group, rather than simply imposing the change on the group without any sense of “I was a part of that.”

My first degree was in communications, so these concepts of group “ownership” were well rooted.  The buzzword “change agent” came along many years later, I believe during the “dot-com” bubble era.  But the concept is the same.  Being able to effectively guide a group of people toward seeing change as a positive direction is definitely a persuasive skill.  Thank God for communications degrees.


Week Five:  “The ‘U’ Word”

Not every foul word in the English language has four letters.  Take for instance, the “u” word.  Management and administrations all over this country shudder when they think of or hear the word “union” because it invokes such painful feelings for them; negotiations, pay scales, grievances, and the occasional threat of a strike.

But why should it be that way, some would argue.  After all, especially in the last ten years or so, hospitals and other healthcare facilities have been trying to get nurses into more powerful positions.  They’ve encouraged nurses to complete their BSN’s, very often paying for the tuition along the way.  To counter the inter-discipline “power struggles” that sometimes exist between nursing, medicine, and other hospital-based disciplines, administrations have attempted to foster mutual communication between them, using such venues as roundtables, inter-disciplinary committees, and certifications.

Still, many nurses feel their voices aren’t heard, their plight as the first-line of patient care is under-appreciated, and that more is being piled onto them than they can handle and still provide safe, effective patient care.  Unions can, not always do, fill the need of speaking for nurses.

I came from a strong union background, and I married into one as well.  My father-in-law was an international union president for nearly 25 years.  Needless to say, then, I see a lot of merit in unions.  But as union membership and representation has declined over the last 20 years or so, I think the power a union represents has also been diminished.  This perception has not been helped by what I see as weak union administration.  My father-in-law was famous for saying “two heads are better than one – unless both of them are stupid.”  My feeling is that a union is only as strong its local administration.  Weak local presidents, those who have consistently given in to company bullying, who haven’t stood up for their members, and (especially) who have not had the intelligence to do their homework about the companies their members work for so they can negotiate contracts both knowledgeably and realistically, have done more to undermine the union movement than the Hiroshima bomb did to advance nuclear proliferation.

Certainly conglomeration in healthcare hasn’t helped. Unfortunately I’m currently “stuck” in the Pittsburgh, PA area… though my desire is to return to the sunny Delaware Valley and Philadelphia, where my heart is. Regardless, southwestern Pennsylvania has UPMC, a benevolent behemoth of a healthcare system, which appears poised to gobble up any number of “independent” hospitals and facilities in western Pennsylvania, including some who have had union representation for nurses and aides.  From what I have heard, this has resulted in the breaking of some unions and stagnation (at least short-term) of staff salaries.  For this and other reasons (which I’ll keep personal), I’ve dubbed UPMC the “Wal-Mart of healthcare” since in recent years, Wal-Mart has taken up the habit of moving into an area where smaller, independent stores were, and effectively running them out of business, while actively working among their employees to keep unions out of their stores.  Many nurses I’ve talked to in this area fear that adoption by the UPMC network may lower their personal satisfaction with their work environment.

Enter union representation… correct that… enter effective, strong, and intelligent union representation.  If the UPMC staff, or any hospital for that matter, with one voice, would stand up and unite under a common union umbrella, the anti-union sentiment among local healthcare delivery systems could effectively be de-clawed.  But it would take intelligent union leadership, not stupid people thinking that the union would help them get away with stupid decisions, and that they could get higher salaries every year.  Intelligent leaders (like my father-in-law, allow me to brag on him a moment) would have business sense and common sense, understand their company’s financial health, and understand what they can safely negotiate for, and when to stop.  After all, there’s no sense in negotiating your way out of a job, and the company out of business.

Nurses, as the cream between the cookie sides of the patient and the physician, need strong representation to have their voices heard, and to practice safe and effective care.  When the nurses have an understanding, compassionate administration above them, that’s well and good.  But when the administration above them is more concerned with the dollars the patient brings in than the care the patient receives, it’s time for a good, strong, and effective union.