Hindsight's 20/20

Tomorrow I start my final term of nursing school, and I'm having one of those days where I'm completely lacking in motivation. If I can summarize the one major thing I've learned throughout this process, it's how to deal with disappointment! When I embarked on this journey, I had the most rock-solid, well-thought-out plan, and there was no stopping me. In 2007 when I began taking my prerequisite courses, the economy will still giving the appearance of decent health and my husband's job was thriving. I got accepted into a bachelor's program but opted for the local community college program, wanting to avoid the almost $40,000 price tag of the larger school. Besides, everyone knew that Chemeketa's associate degree program was the best in the state! And once I got hired at the hospital, my employer would repay my student loans and provide the cash for me to continue my education and get that highly sought-after BSN.

Fast forward to the present, where all sorts of unexpected roadblocks have been thrown up and my wonderful plan has screeched to almost a standstill. First, the economy tanked and all those nurses that were supposed to retire decided not to. (Not that I blame them.) Hospitals instituted hiring freezes and for the first time in years, there isn't a huge demand for nurses. Second, Salem Hospital, where I intended to work, is in the process of achieving "Magnet status," which implies a higher standard of care; as part of this process, they are required to hire a specific percentage of bachelor's trained nurses. Given the crappy economy, they are pretty much ONLY hiring bachelor's nurses, which means that getting a job is going to be incredibly difficult for me. So with no job, there's no generous employer to repay my student loans, which means I get to repay them while NOT working. It's hard not to feel a little silly at this point, having worked so dang hard for an associate's degree that upon graduation, will actually work against me. Great plan! It's also hard not to imagine where I could have been career-wise had I not decided to quit and go back to school. And now I'm seeing job postings for technical writers and it is oh-so-tempting to just apply and pretend that this little adventure never happened.

So, looking back, would I have done things differently? My canned answer is "No! Of course not! Eventually having a RN license is going to be a huge benefit!" But my realistic answer is, "Yes, probably." Knowing what I know now about associate degree nursing falling out of favor, I probably wouldn't have attemped this at all. I have a friend who opted for the excelerated bachelor's route and is now working as a nurse, trying to repay $500-600 per month in student loans. If I wanted to sink myself with debt, I would have gone to medical school!! Anyway, the fact of the matter is, I can't go back in time and choose a different route and now have to deal with the decisions I've made. And right there... THAT is the best lesson ever! I can't change my circumstances, only my attitude, and that tends to vary on a weekly basis. But don't worry, I'm going to make it through this because I have no choice but to keep moving foward and be as flexible and optimistic as I can. I'm sure that somehow I will find a job and someday this will have all been worth it. Hopefully I'll look back at my feelings now and laugh, remembering how worried/disappointed/pathetic I felt. And thankfully, I have learned that I can make do on a lot less than I had ever thought possible, so even if I don't find a job for a few months (years?), we'll survive.

The downward spiral

Hello mediocrity! Nursing school is officially kicking my butt. I know I've said this 50 times before, but I am working harder to earn this 2-year degree than I did to get my bachelor's! Or maybe it's a different kind of learning? I don't know... all I can say is that I've never had so many blows to my self esteem all at once. I'm tired of feeling inadequate!!! I just want to be on top of my game again. Obviously I have to take things one day at a time and appreciate the little victories, but the last week was pretty rough. I had my one comprehensive skills check-off for the term and FAILED it. Nice! I got really nervous because I was in the very first group of three to go right at 8 AM sharp, and it was like being at a piano recital when I was a kid... I got in the room with the instructor and her clip-board, sitting there all silent and just waiting for me to slip up, and OF COURSE my mind went totally blank! I got through 95% it without any major hiccups, but then at the end while hanging an IV medication, I had a moment of stress-induced psychosis and somehow convinced myself that a 100 ml bag of azithromycin running over 1 hour should be set at 200 ml/hr on the pump. Hello! I think I'm so used to doing math that I couldn't fathom it being so easy. The look of pity on the instructor's face was almost too much to bear, and for the first time during this program, I almost cried. Failing a check-off doesn't actually do anything to my grade (gotta love community colleges!) and I am only required to go back and redo the one portion where I made a mistake, but it was so devastating! I mean, I KNOW how to do that stuff and it is embarrassing to make such a simple mistake just because of nerves!

What I've learned from this is pretty huge though: life goes on after failure. I went back today and redid the check-off in five minutes and passed. And that was that! Why did I waste so much time feeling bad over this? In the end it was pretty much nothing. I think nursing school will finally cure me of being a perfectionist, because being perfect is simply not possible in this environment. I tend to want everything clean and flawless, but I guess in the end I'd rather make mistakes now, learn from them, and be a better nurse in the field, rather than get through school without a single problem, then fall flat on my face in the real world. I've been so terrified of messing up and I discovered that it's really not so bad! I certainly remember things better when I learn the hard way, so I'm choosing to be grateful for these experiences. It's hard not to feel defeated sometimes, but what I'm starting to appreciate is that fact that tomorrow is a new day, full of chances to redeem myself!

Doing more with less

Wow! This year is so different! I think I made a mistake last year and assumed that the way I was learning to do things was the way nurses do it, when really it was the way that 1st-year nursing students do it. Last year the focus was really broad and we had to thoroughly research diagnoses, drugs, and pathophysiology. I got really good at covering all angles and considering all possibilities, and now I have to change my focus! This year we are supposed to incorporate the gobs of information we learned last year and filter it down into what's most important NOW. The instructor's always ask, "Why is this patient in need of nursing care TODAY? What do you need to worry about at this exact moment in time?" It totally makes sense, but when you are so used to a broad focus, it's hard to narrow it down. It's not second-nature yet. Each instructor has had some fun analogies about the transition from first to second year... here are my favorites:

• Second year is time for you to "fly the nest" and learn to think on your own. You may fall a few times and that's natural. But by graduation, you WILL be flying!
• During first year, you learn how to do a lot with a box of eight crayons. Second year, you get to work with a box of 64 crayons, but you need to know which crayons to choose!
• During first year, you were taught to create the "entire buffet." But second year, you need to be able to look at the buffet table and know which items to select.

Clinical is still stressful, but the most refreshing change is that we aren't micromanaged to the extent that we were last year. We have so much more freedom! Last year we were supposed to adhere to a strict policy of "three checks" for each medication administered, and if you missed a check, you risked being written up. This year, the instructors are telling us to not let multiple med checks become a crutch and a hang-up. The new advice is, "Trust yourself!" I'm so much happier in this environment because I feel like I can do my work faster without worrying so much about arbitrary details. (But I totally see why this system was a necessity last year, don't get me wrong.)

The same philosophy is applied to our patient preparation requirements before clinical. Last year we all trooped to the hospital the day before clinical and spent a good hour and half pouring through our patients' data in the computer and chart. We then went home and spent another two hours per patient working up the diagnoses and meds and labs on a least five sheets of paper (each) that we had to bring with us the next day. Now, we get ONE sheet of paper with which to prep, and we are told that it shouldn't take more than 5-15 minutes. Again, "Trust yourself. You know this stuff." At first we balked a little bit, clinging to the security of all that data, but the truth is, does knowing EVERY SINGLE THING about a patient make us better nurses on the floor? Not really... nurses don't even know who their patients are until they get to work in the morning, and then they only have about 15 minutes to review data for a minimum of 4 people before getting report from the night nurse and hitting the floor running. They have to be able to filter through a ton of information quickly and determine what's important to set their priorities. Last year we had to learn where all the information was and what it meant. This year we have to decide what to pay attention to and how to use it. I like this! I'm not very good at it yet, but it feels really good to be here.

I'm back!

My second year of nursing school has officially started. Which means I'm already exhausted! I've struggled to decide if I should continue this blog, mainly because of the time commitment but also because I've realized that deep nursing content is kinda boring for non-nurses. I mean, do you really care that today I learned how to hang IV piggyback medications? Does anyone even know what that means? However, in our Psych theory content, we've learned that journaling is very therapeutic for stress release, so technically this blog is still beneficial to my psyche. I've decided to compromise and instead of listing the boring and gruesome details of the skills I'm learning, I'll focus more on the human aspect of what I'm going through.

That said, have I mentioned that I'm exhausted? I went from having a nice and relaxing summer to having to get up really EARLY again and put in long days learning complex content! And boy have I lost a lot of information! I was embarrassed and horrified yesterday during a review session when I couldn't remember some of the normal lab values I used to know so well. Time to get back out the flash cards... Even though I'm complaining, I'm actually relieved to be back in school, because it means that I'm finally making progress. I'm tired of living in a transitional state and look forward to actually starting a career, making some money, and moving on with my life! And graduating to "Second Year" nursing student status is like going from a freshman to a senior. Suddenly we are cool and the ones who know something. The new first year students look at us with awe and envy and we have now earned the right to shake our heads sadly at them as they trudge by us in the hallways. To differentiate ourselves we get to sew patches on our sleeves that announce to the world that we are now experienced second-year students! [See crappy picture above.] Thus far I've only managed to sew one patch and have two more to sew this weekend.

I think I'm going to like this year a lot better because we finally get to learn the complex content, give the scary drugs, and make the big decisions. Last year we were so limited in our scope that I never felt like I was actually nursing. This year, the RN year, is how I will truly become a nurse! So far I really like the instructors too. They are much tougher and have higher expectations, but that motivates me to exceed their expectations. We get to do a short psych rotation at the state hospital and I was super thrilled to learn that I'll be working in the forensics department with patients who've committed crimes. (That is not sarcasm, by the way, I actually requested it.) I want to start with the scariest scenario and see how I handle it, and then I can decide if I want to a pursue a career as a psych nurse. I've found myself very inspired by our psychiatric content and our orientation at the state hospital and feel a strong pull to investigate this avenue further. We are already starting clinical rotations next week and I'll be back at Salem Hospital, this time on a general medical floor. In the past I've cared mostly for post-surgical patients, so this will be a challenge. My instructor has assured us that she is going to assign us the "most complex" patients as possible. Here's to not holding back and jumping right in!!!

Done with Year 1!

I did it! I successfully completed my first year of nursing school! As you can probably tell, I sorely neglected (okay, completely abandoned) my blog during Spring term, but my schedule was just too crazy and something had to go. My clinicals were at Silverton Hospital, starting at 6 am, a schedule that I found very challenging being the night owl that I am. However, I discovered that I absolutely LOVED the hospital and staff and will now consider applying for jobs there after I graduate. My first day there I was taken aback by how small the hospital was - for godsakes they only have 48 beds in their medical/surgical unit and only THREE in ICU, compared to the 700 beds at Salem Hospital. But by day 2 I was starting to see the perks of working somewhere so tiny. It's like growing up in Lakeview where everyone knows you. There's a feeling of community! I actually got to know the regular RNs and they were very welcoming of us students, even remembering our names!

I learned a lot at Silverton Hospital and it helped immensely that I had a great instructor. I spent one day at the hospital's outpatient clinic called STEPS where I helped with the anticoagulation clinic (they mostly just do a finger poke to see how well the patient's anticoagulation medication is working), gave a super huge hormone injection to a really skinny man with prostate cancer, and watched several wound dressing changes. My favorite was a young guy with an abscess in his armpit the size of a golf ball! He wasn't sure how it happened - it just showed up one day. He has to come in daily to get it drained and packed with absorbent dressing. The whole time I kept wondering, "Could that happen to me?" I also got to watch the nurse manager place a PICC line in a patient who was going to need IV antibiotics for 2+ weeks. A PICC is a peripherally inserted central catheter that is threaded from a vein in the arm to the heart. It can stay in place for weeks and be used to various IV therapies, instead of using the traditional IV site in the arm that has to be replaced every few days. As you can imagine, the process is quite involved and completely sterile! I got to assist by handing the ultrasound wand to the nurse while not contaminating her sterile field.

By the end of clinical, I was taking care of 3 patients at a time and came to the realization that it's not the skills that make nursing difficult, it's the time management. All three of your patients may need pain meds at the same time each morning, and somehow you have to juggle that with doing assessments and documenting your findings in a timely manner. My instructor was really big on teaching us how to prioritize. She'd come up to me about two hours into the shift and ask, "Which patient did you see first? Why?" With nursing you have to be careful to stay in a PROactive mode and not let the little crises of the day take over and throw you into a reactive mode. Once that happens, you never get caught up! While I definitely learned a lot, I came to the major realization that I have a LONG way to go. My two meager days of clinical each week can give me a basic idea of what nursing will be like, but I won't be good at it until I've been on the job for at least a few months. Nursing is something that you learn with repeated practice, and at times that can be very overwhelming. I just have to take one day at a time and appreciate the little victories.

Wrapping up term #2

My instructors really weren't kidding when they warned us that this was the most difficult term. They jam-packed tons of theory content along with clinicals and miscellaneous activities, and I think we are all feeling it. As of today, all I have left is my 5th exam on Friday and my comprehensive final next Tuesday. Friday's test covers 6 chapters of labor and delivery content, greatly contributing to my new fear of having kids, and small chapters on ethics and tuberculosis. (How random is that?)

Last week I completed clinicals with my final rotation at a nursing home, and I have to admit I really enjoyed shadowing the LPN charge nurse and trying to picture myself in that role over the summer. At long-term care, LPNs have much higher positions and essentially perform like RNs in hospitals. If I choose to work as an LPN, I would most likely start out in charge of 4 CNAs (Certified Nursing Assistants, who do all the dirty work) and 20+ patients. It would be excellent experience and allow me to practice many of the skills I will have learned this year, AND I'd hopefully make some good money to put towards school next year! The only downside is the licensure process... wow is that ever involved!

I also passed my "Comprehensive Skills Check-off" which is one of the more nerve-wracking aspects of nursing school. You are given a patient scenario and 30 minutes to prepare, then have to go into the skills lab with one of the instructors and show them how you would perform various skills pertaining to the patient (which is a mannequin). It's deathly quiet and the instructor is just watching you, so naturally I chatter away like a mad hen, insanely nervous and desperate to fill the silence. This time it actually worked in my favor, because I was talking through procedures as I did them and at one point mentioned how before starting a new IV bag, I'd flush the line with 3 ml of saline. I then completely FORGOT to do the flush, but she didn't say a word and just reminded me after I had finished all my tasks, and asked me to show her how I'd do it. If I hadn't previously mentioned it, she technically could have failed me, but thankfully she knew I was just nervous. I also accidentally contaminated my sterile field while setting up my catheter supplies, but again, she was really cool about it and chalked it up to nerves. Eventually this stuff with either get easier or I'll graduate... I don't care which comes first!

I did have a nice reprieve over the weekend... Kevin was in Chicago for work and was going to have to stay there by himself through the weekend, so we checked into his frequent-flier miles and were able to get a free plane ticket for me. His hotel room and meals were paid for by GE, so all we had to buy were my meals and parking fee at the airport. Of course I was really stressing just trying to GET to the airport and get the dog boarded, etc., but once I arrived we ended up having the best time ever! We walked around downtown and admired all the high-end shops, ate ice cream sundaes, and checked out two really amazing museums: The Art Institute and the Field Museum. I'm glad my Chemeketa ID is permanently attached to my wallet, because I ended up receiving student discounts at the museums! We saw two amazing exhibits: one on Edvard Munch, the painter of "The Scream" that everyone assumed was insane (but really wasn't) and one on pirates and the excavation of the Wydeh, a slave ship turned pirate ship that sank off the coast of Cape Cod in the 1700s. I learned a great lesson over the weekend, that no matter how stressful life gets, I always need to take time for myself and my family and remember what's important in life. (And eat ice cream!)

Debcubitus ulcers

I should NEVER have whined or complained about clinical being boring last week, because I got what I wished for: a very complicated wound patient. And it was the most horribly sad experience of my life! I was SO NAIVE about what can happen to the human body. So here's my disclaimer up front... if you are at all squeamish, do not read this entry. I'm including a really nasty picture that represents what I saw this week.

My patient this week was young (seems to be a trend with me!) and paralyzed from the waste down due to a birth defect. One of the biggest concerns for people who are immobile is the development of decubitus ulcers, also called pressure ulcers. When there is continuous pressure on a bony prominence for more than 2 hours, tissue damage occurs. If it is caught early, it looks like a warm, red spot on the skin, and extra care must be taken to prevent it from becoming worse. When care is NOT taken, it progresses to a stage 2 ulcer, which involves the breakdown of the top layers of skin, then to stage 3, where it becomes a huge, open sore with no skin covering it. The worse-case scenario is a stage 4 ulcer, where the tissue damage progresses through the muscle and to the bone. By this point there is usually tissue necrosis (death) and it will take a minimum of 6 months to heal.

My patient had a stage 4 ulcer on the tailbone area, which is really common for wheel-chair bound people. Because he needed to be off his back, he developed 2 more deep ulcers on the side he lies on most frequently. They got infected and he was admitted to the hospital for septic shock. He underwent temporary colostomy surgery to divert fecal matter away from the biggest ulcer near his rectum, but his abdominal wound got infected and opened up. So now he has FOUR major wounds, all connected to wound vacuums to help them heal. They had trouble getting the vacuum seal to "stick" on the tailbone area, so they took it off during the night and packed the wound with sterile dressing. When I got there, it was time to change the dressing and the nurse wanted me IN THERE, removing the packing. Another student helped and we both stood there in total shock at what we were seeing. This patient essentially had a 9-inch by 6-inch hole in his lower back, and it was probably 5 inches deep. You could see INSIDE him! I didn't feel queasy, just sad and frustrated that it could get so bad. I felt like crying. I don't know how nurses can leave this stuff at the hospital and not take it home with them. It's been absolutely haunting me. I so badly want to help him! But there's only so much you can do when the wounds get to this point. I can't fathom how something that deep can ever heal!!

I found a picture online of a similar ulcer. My patient's was much deeper and more pink inside because they were surgically debriding (cleaning) the wound out. But as you can see, it is horrific and should NEVER happen!