Lost my temper at work :-(

One of our night time charge nurses just recently quit and in the mean time they're having random ICU nurses float out to cover the role. One in particular, M, has been charge two times when I was working on step down and both times he has very sarcastically, publicly, and nastily questioned my acuity assignments. He has this way about him that is sort of sarcastic joking --- like guys like to rib each other -- but has enough of an edge to it that really doesn't feel good. And I don't think it's appropriate in the work place.

The team I had last night was rough. I've had them two nights in a row and the first night was even busier. I only rated one of them as high acuity (there are options of low, medium, and high, with about 10-12 different levels of each of those based on criteria). The criteria for acuity levels are different on step down versus med surg versus ICU. So this temporary charge is probably not as familiar with the acuity levels for step down as he is for ICU -- but he does occasionally float out to step down when the census is high; all the ICU nurses do.

The criteria for which acuity and # you assign the patients are pretty straightforward. Things like isolation precautions, frequency of interventions, whether or not those interventions are effective, hemodynamic instability, active arrhythmia management, etc contribute to the rating.

So for my team last night I think I rated them as a medium, a lower level high, and a high. For various reasons, all following the prescribed acuity scale for step down.

And this same temporary charge nurse starts mouthing off at me about rating two of my patients high. Goes on about "well they might be high acuity for you, but for me they would be low," and basically making fun of me and questioning my judgment in front of two other nurses. At first I kept my cool. I said it was pretty straightforward what merited the acuity rating for each of my patients. I pointed out that I probably knew them better after spending two 12 hours shifts with them than he did after getting a *very* brief charge-to-charge shift report. He kept pushing and pushing, and I snapped and said, "F*** you." Up until that point it was unclear whether he was being a joking jerk (ribbing me) or serious, but it was starting to feel pretty serious. At this he was surprised, "Did you just say 'fuck you'?!"

I never swear at work. On night shift many nurses do. I'm mostly quiet and focused on the patients. This really struck a nerve with me (probably based on previous experiences at my old hospital) and I lost my temper. I'm really kind of mortified that I did. I hope this doesn't go any further. The other two nurses that he was poking fun at me in front of supported me, and also supported the concept that it is the bedside nurse who knows the patient best in terms of assigning acuity.

The day shift nurse that I handed off to yesterday morning told me at the end of the day that it was the worst team that she had ever had. It's *not* *just* *me*. She requested that one of the two most time-consuming be redistributed to another nurse, and ended up getting a whole new team today instead. (We split my team up for today's receiving nurse).

I feel sick to my stomach over the whole thing.

Have any other nurses had difficulty with charges questioning your acuity ratings?

So, I'm a nurse now...

I got busy and let this blog fall by the wayside during nursing school. I think that might be a fairly common pattern for those trying to blog their ways through school!

I graduated from my associates of nursing program in May of 2014, had my license by July, and started my first nursing job on a mixed med-surg/tele floor in August 2014. I worked there for a year and a half (first half nights, second half days), and then requested a facility transfer to a hospital closer to where I live. I now work night shift on a step down unit---have only been there 3 months. I like my crew. I'm hoping to switch back to days eventually, although the pace of nights is pleasant.

At one point I applied for a labor and delivery position at the same hospital. I was pretty excited about it, thinking it would be a key in for eventual move toward NICU. My interviewers realized that too, because I'd been talking to a bunch of people, and they decided to go with someone whose dream was actually L&D. Fair enough. I'm now glad I didn't go that direction. I still think I'd like to work in the NICU at some point, but maybe as part of the float pool at first (get my NRP and STABLE certifications).

I have been working on an online program for my BSN. Two semesters down, and I have one more class to complete before the degree will be done. I've already switched over to the bridge program for a masters of education in nursing. I think I want to teach nursing at the local community college down the road. It will probably take several years to get there, although I could have my M.S. within the next year and a half if I keep up at my current pace.

There were definitely some struggles in my first year of nursing. I'm not going to dwell on them now. Mostly not in the actual care of patients! I may get into them later.

For now, I'm happy to have a stable job near home with coworkers I like and a three-12's schedule that allows for a fair amount of time off.

energy slump!

I have sort of been dragging my feet on everything for the last couple of weeks. I can blame part of it on having had bronchitis, and it's lingering effects. But part of it, I think, is just due to getting a lower grade than I expected to get on my midterm clinical eval and letting it get me down. A B+ is a fine grade, but I had it in my mind that my semester was going so well that I deserved an A. Woe is me. Not.

Asking around to my classmates, I haven't yet come across anyone who got an A on their midterm eval, not even an A-. And a general theme in the feedback is that we need to exhibit more confidence in the clinical setting.

That feedback and grade, unfortunately, I let have the opposite effect on my confidence. I skulked into clinical feeling worse about myself, and self conscious, and wondering what it was I had been doing that made me seem not confident (because up until that point, I had felt confident!).

I think a big part of doing well in nursing school clinical is letting go of the anxiety about being judged, and just diving in. I hope that by next Monday, when I go back, I won't be feeling sick anymore, and I can really bounce back and go full steam ahead.

Oh, but this is all just review for you, isn't it?

I kind of love and kind of hate that some of my teachers have so much confidence in me sometimes, or assume that the content is easy for me. They think, oh, she's got a biology degree already, this content is effortless for her!

But stop and think about that for a minute. How many undergraduate biology courses do you know of where they go over acute interventions for increased intracranial pressure? How about the specifics of traction setups? Or different methods of modifying the bowel after a portion of it has been removed?

Yes, I have probably a better understanding of some of the anatomy and physiology of mammals than some of my classmates. And I'm a good critical thinker. But I'm still working HARD!!!

My training in marine biology is not so much helping me with patient care, I promise. If anything, the greatest benefit of having a couple degrees behind me already is that I know how to be a good student; I know how to study well, and I'm not as shy about asking the questions I need to ask.

"RN = Real Nurse"

Today I felt like a real nurse more than ever.

I was on outrotation to ICU yesterday, and asked permission to stay again today. It was really worth it. My more difficult patient, I already knew the nuances of all his equipment & tubes & wires, and was familiar with his MO and particular breed of family drama. My second patient, I knew a lot about her condition from my own health experiences & so felt comfortable managing the interactions, education, medications. It was only my second day in that unit, so I didn't know where everything was, but I knew enough to get by. I was able to do & chart full shift assessments on each, and do a lot of the maintenance stuff all day long as well as both med passes.  I got some positive feedback from the staff nurse, who happened to be charge nurse, early in the shift, which made me feel more confident. She complimented me on my charting.

I feel like everything is starting to come together. Our next two skills on the horizon...IV push and IV starts, I think will really put things over the top. IV push is going to be a game changer in terms of time management, but the next time I go back to clinical I will be switching to DOU (from mostly med surg) and taking one patient for the first day, which will help me get my footing.

Excited! Exhausted. But mostly excited!

Clinical After-Burn

I seem to do a lot of after-processing after clinical and internship. Thinking about the patients I had that day, what their symptoms were and how they led to a diagnosis. How I interacted with them and other members of the healthcare team, and what went well and what didn't. Picturing procedures that I did or saw in my mind's eye.

I think it's a good thing...like how you keep burning calories for a little while after vigorous exercise, even after you've stopped. Getting more bang for your buck. (So long as it doesn't interfere with sleep, which it usually doesn't).

But sometimes there is something that puzzles me, and I get stuck on it, and really without more information I can't reach a plausible conclusion and it BUGS me. Like yesterday. A middle aged woman came into the ED because another HCP noticed that one pupil was larger than the other. They were both still responsive to light. She hadn't been exposed to any chemicals or medications that she was aware of. She had no neurological symptoms, had not hit her head. Her scans were negative for any sort of abnormality...no brain bleed, no hematoma, no tumors. She didn't really even have any symptoms related to the eye being dilated; wouldn't have noticed herself if the chiropractor hadn't pointed it out to her. Her blood pressure was a little high, for her, but seemed hospital-stress related. Over the time she was there, her pupil slowly returned to close to the size of the other one (it started at about 4mm vs 2mm in the other one).

The doctor didn't know what had caused it, and basically told her she might follow up with an opthamologist, but that he thought she must have accidentally rubbed something in her eye (she couldn't think of anything she might have been exposed to). I ran this by my neuro teacher, and she didn't know. She googled a little bit, and ran it through her own experiences and brain circuitry, and finally just told me I needed to let it go! I hear that a lot from my teachers.

Mid-sleep panic

I spent many hours yesterday making my flashcards and reviewing lecture and reading material. Right up until bed time, in fact.. of course, I did listen to a book on tape of something entirely fictional and fluffy in between studying and really falling asleep, but I think the nursing material was still on my mind.

I remember waking up a couple of times in the middle of the night and feeling panicky with thoughts of, "I'm not going to be able to do this, I'm not good enough, I can't memorize it all, I won't get a job..."

I was able to tell myself that the middle of the night is not the right time to be considering these things, and fall back asleep. And I feel..well..pretty good about my path and future by the light of day.

I'm doing well in my classes, clinical is going very nicely this term, and I feel very supported and liked by my teachers and most of my classmates and the staff nurses I've worked with. I don't know why I'm filled with so much self doubt sometimes.