Thursday, February 21, 2008

Wednesday, February 20, 2008

Will this be on the test?

I find myself giving test-taking tips at every tutoring session lately.

Five tips for taking tests in nursing school: *

  • Read the question.
Seriously, read it. Stop, don't look down at the answers yet. Read the question once more, looking for these words or phrases: LEAST LIKELY, MOST LIKELY, PRIORITY INTERVENTION, NOT, FIRST. Underline them when you find them. You absolutely must know what the question is asking before you attempt to answer it. If the question makes you think of that awesome little song that you made up to remember the cranial nerves, go ahead and jot them down out to the side right quick BEFORE you look at the answers.

  • Think of the patient.
When you study, think of how this will look in an actual patient. If I was in the room with someone who had a Foley cath in, what is the very first thing that I need to think about before that patient ambulates? My list of ALL the things to consider before they start traipsing about would include: where's the bag and who's going to hold it, when's the last time this person got up and should we sit and dangle first, are there any obstacles in the intended path and who will move them, and what other lines do we need to pay attention to (like IV poles, or wound drains, or whatnot). Now prioritize them. What must happen first? What can wait? What means Something Bad and what is an Expected Outcome?
Of those, I think that passing out onto the cold dirty hard floor of orthostatic hypotension has to top the list of Things to Pay Attention To. Having one's foley pulled out with balloon still inflated would be right up there as a very close second.

  • ABC, 123.
When prioritizing interventions, as above, or in questions where you are asked to assess a patient and choose the most worrisome data, start as low on Maslow's pyramid as possible.
Airway Breathing Circulation
1 heart, 2 lungs, oriented x3 (who are you, where are you, when is it)
Risk for Powerlessness is always going to appear on my list of Relevant Nursing Diagnoses for any hospitalized patient. Always. Let's face it, laying in bed with no underwear does not increase one's self-efficacy. But I cannot assess anyone's psychosocial needs or even their pain level (which is usually next on my list after the ABCs and 123s) if they are currently not breathing or bleeding out.

  • Do another med check.
Patient safety has got to be right up there at the top of the priority list. You have to do three med checks, but four can't hurt, especially if you're in a skills evaluation and you simply can't remember doing that 2nd one before you left the Pyxis. "Put on gloves" is always a good idea, along with "Wash hands and document". The phrase - siderails up times two bed low and locked call bell in reach - is burned into my brain forever. This stuff will find its way onto the written exams, too, so be on the look-out.

  • "Call the doctor" is almost never the answer.
It seems like a good idea, I know. Interdisciplinary blah-blah-blah? They're going to have to write the orders? I know. But resist, for just a second.
Think about this - What are you going to say when she returns your page? Stammer, stammer, the patient uh, is, uh, doesn't look right and I think you should come down here. Click.
Assess before paging anyone - unless it's a code that you think you should call, and then holler away! Think through the information that a consultant is likely to ask you if you paged them - axillary temp, blood pressures for the last ten minutes, hematocrit levels, intake and output totals for the last 12 hours? What is the thing that made you worry about this patient and what information do you need to gather about that worrisome sign or symptom? Get it all written down, and then call (abcd - assess before calling doc).

*of course, I only know about MY nursing school. I know that all nursing students do skills evals, but I don't know if you will be able to talk to yourself throughout yours the way we were encouraged to do. I think these are pretty universal, and not just based on my Fundamentals professor. of course, your mileage may vary.

Tuesday, February 19, 2008


i just left six hours of watching a first time mother labor. 2cm, 50% and -3 when I arrived. 3cm, 80%, -3 when I left, with membranes ruptured, epidural and foley cath in place. Foley so that when they 'went to the back' it would already be in place. fuck. just go on now, why not?

Pitocin running except when everyone in the nurses station decided those were late decels on the monitor and the nurse stopped the pit and then paged the doc who said start it up again, you can knock it down to 12 milliunits from 18. It wasn't until later that I understood that she had requested to be induced because she was in such misery, 2+ pitting edema, etc etc. and that that's why the pit was running in the first place.

what I don't know if she knows that, to them, to this doc, when she asked to be induced, she was asking for a section. I just don't know if she knows that. I didn't know that. but on my third week on the unit, it surely seems that way...

She was just lying there when I first got there. She was doing it. She was handling the contractions. She was resting between - I realized that I was still in my own stuff about not being able to rest in between, and perhaps more impressed by this than was warranted. But she was all still in the bed, only her face showing the contractions, and every once in a while, her feet would move around restlessly under the sheet.

I realized that I have a romantic, walk the halls idea of labor. The woman shuffles along, periodically stopping and grasping the railing or her support person's arm for 30 seconds and then off they go again. This doesn't happen in hospitals. Does it happen anywhere but in my head? Isn't the best place for a woman at 2cm who wants to keep labor moving to be in motion? In a world without continous monitoring, would I be out walking with this lady? Would we be laying down blankets for her knees and draping her across the birth balls that are all stacked up by the Pyxis mocking me.

On the bottom of last week's lecture notes, I scrawled: Why is the plan to tell the mother to wait as long as possible before coming into the hospital, instead of just NOT strapping her down to the bed on continuous monitoring as soon as she gets there, when we know that we'll end up putting in an IV and an epidural and a urinary cath and maybe narrowly avoiding a c-section? Doesn't this seem ironic when the community health prof defined empowerment as helping a patient or a community regain control of their life or environment? What was the process by which they lost control in the first place? Wouldn't that be a good place to begin with the empowerment interventions?

fuck this.

I am not a fan of Blackboard discussions.

But yet I soldier on.

Here is the epistle that I have constructed for a recent assignment re: professional socialization (which means how nurses learn to become nurses from other nurses, I think).

The Hinshaw-Davis Model of Professional Socialization really fits my experience of nursing school so far, and it relates directly to defining nursing.

Initial innocence is the definition that I entered the program with, which was not very detailed or well-thought out. I knew that nurses do more that people give them credit for, that as a career, it’s not a straight path to burn-out but that with the current staffing levels at most hospitals you have to really be careful where you take a job, that they are the people who are with the patients through the shift while physicians dash in and diagnose, and that they eventually end up wearing scrubs with kittens making snowmen whether they want to or not.

With the incongruities stage, I think of sitting in Fundamentals and being so frustrated while she was attempting to explain the nursing process. I know these words, I thought! Surely I should know what she means! It was so much easier to practice sterile gloving than to try to figure out how to integrate this broad definition of nursing that we were being given.
That definition of nursing seemed a bit contradictory – because on one hand, there’s the caring is the heart of nursing, but on the other, the point that nursing is a science and isn’t just about hand-holding and being a good person was being made. Eventually, what I decided is that valuing nursing really requires a shift in the world-view for most folks; caring must be as important as scientific data and the two must not be seen as mutually exclusive.

Dissonance is something I experience at the beginning of every semester – thank goodness, it seems to be getting easier and I’m getting over it faster. I think that the dissonance of the information we receive in the classroom about how to be a nurse and the information we gather in clinical about how to be a nurse is one of the biggest hurdles student nurses face. It’s crazy-making to hear that nurses must work closely in a multidisciplinary team and should always ensure pre-medication for painful procedures, and then see residents come in and do a major dressing change without any pain meds on board while the patient yells and writhes. It seems that one of those must be wrong or that it’s useless to learn the ideal when it’s not what we’ll actually see in practice. It’s like hearing – Don’t tell women in the second stage to hold their breath and push – in the classroom, and then the very next clinical day, hearing three separate nurses say to women in labor, “Hold your breath and push”. Why did I even write down not to do this, when it’s what everyone does in practice?

Identification happened for me with the first clinical instructor. When I heard her talk about how she defines nursing, and saw her practice, I saw clearly several behaviors and attitudes that I wanted to integrate into how I work as a nurse, how I define nursing by my own actions. Role simulation is what we’re doing every time we go into a room by ourselves after having dealt with that patient with an instructor or preceptor present. I also think that a lot of the care plans are sort of role simulation, since we don’t have the time to implement those interventions, nor the ability to do so, in many cases, so we’re acting as if we were in the role of the RN.

Vacillation is what I imagine that dissonce experience is like as a new graduate nurse. Our professors say that we will be the ones to change things, that we will redefine nursing. Vacillation will be when I don’t pray in my car before each shift that nothing horrible happens.

Internalization is how I will define nursing when I am at Benner’s proficient stage. After actually doing it for a while, what do I think “it” is?

Tuesday, February 12, 2008

Why, thank you, I'd be honored!

I am so excited! One of my top two picks for faculty advisors said yes to working with me for an Honors project! Full speed ahead! Here's the proposal:

I am interested in looking at the cultural competency of BSN students. The rationale for increasing cultural competency among nurses is obvious (but would be fully outlined in my final paper of course), but the logistics of doing so is much more complicated. We tend to leave the concept of cultural competency in the abstract, and never truly integrate it into practice. I've heard nurses ask patients, "Are there any cultural practices or beliefs that we should be aware of?", and I cringe because most of us aren't aware of our own practices and beliefs because they are so integral. It's a little like asking a patient if they are experiencing lupus - it's not a very answer-able question.
Using the nursing process, it seems smart to assess the level of competency that students have in issues of diversity awareness, personal values, etc as they begin nursing school, before interventions are planned for increasing that competency. As I've been researching the topic in order to write a resolution for ANS, I have found a tool (Josepha Campinha-Bacote's IAPCC-SV) that measures the level of cultural competence among healthcare professional students. One of the focuses of Campinha-Bacote's research is cultural desire, or the motivation to learn about culture and interact with awareness. I am particularly interested in trying to get a sense of the readiness to learn among the BSN population with regards to issues of culture, diversity, tolerance, acceptance, awareness.

So the research question I'm considering is: What is the level of cultural competence among BSN students at this school of nursing?

the politics of hope

I swear, this man, I love him. I get teary every time I watch this.


On Ash Wednesday, as we're getting ready to leave for school, the kid asks what happens on Ash Wednesday. I said it's a religious holiday, a pretty serious time for many Christians, and Catholics often make some sacrifice for the next 40 days before Easter to show how serious things are. (I tried to tackle the concept of sin and redemption and then let that one lie. There are some things that a goddessworshipping pantheist is not qualified and Catholic sin is one of them. )

Later, I'm replaying what I said as I brushed my teeth, checking for gaps in my story. I realize that I have not ever given up anything for Lent, and that maybe an example would help him get the idea. Lightbulb! I was a super asshole the night before, with lots of hovering during homework, and slamming the cardoor open so hard when we got home because we were arguing about Harry Potter that I snapped the little metal piece in the door hinge and now I have to manually feed it into the door to be able to close the door every time. I'll give up yelling for Lent, I announced. he got all stern-faced because I yelled for him to come make his lunch and I had to qualify my pledge to give up angry yelling, because there's no way I could go for 40 days without being loud, for the love of Pete! it's molecularly impossible.

On the way to school, the kid announced that he knew what he'd like to give up for Lent. It's not something that I do that's bad, he said. Does it still count? Let me hear it, I said, bracing myself. I'm giving up the after-school program, he said calmly. I'll be a car-rider like (insert friend from wealthy family with giant house and great toys) and we can play together all the time. Ah. I see.

Monday, February 11, 2008

aqui, no mas *

Quick run-down:

Maternity - test this week on labor and delivery, extrauterine transition of the newborn, newborn care and teaching. take home points: Babies should be warm, pink and sweet and labor hurts a lot. Aforementioned clinical drama. Excellent patient interactions for two weeks running now.

Public Health - 92.1 on last week's test. Proud of the studying I did - in small chunks, used textbook for making study sheets, even though I never read before class. Also aware that this is one class where more studying likely will not bring better grades, but taking more time to read the questions will. A big relief.

one of the Disciplines - panel with new grads for class this week. Take home point was there's a relatively high rate of job-changing 1 year out of school, and attrition rate from the profession altogether. Choose your workplace based more on the co-workers than the patient population - it's never worth it to work with nasty-assed people. Also made the mistake of sitting in the back of the class, and listened to the back row bitch and moan and make snide comments the whole time. The irony was lost on them, of course.

the other Disciplines - watched the movie Wit with Emma Thompson and cried unabashedly. Excellent, excellent movie. Fodder for hours of discussion. I will have a hard time limiting my paper to a page.

Spanish - survived another conversation hour, complete with dialogos enacted in front of the class. received positive feedback on paragraph re: the usefulness of the pain scale with patients who are not native English speakers. I said, Shit, it doesn't work so well with patients who ARE native English speakers. Again, did not die during public speaking en espanol.

Patho tutoring - still need to drop off paperwork for payroll. Held session on SuperBowl Sunday night - 25 students showed up! I was thinking, maybe 10 would come! What's worse is that we were doing my weakest lectures - immunity, B's, T's, NKs, types of hypersensitivity reactions and classes of antibodies. survived.

State Board of ANS - another marathon meeting, this one with hours of driving attached on both ends. It's looking bad for our upcoming mid-year conference, and it's hard for me to get all gung-ho about it because it's so clear that most of our activities are merely for self-perpetuation. Approved an operating budget of $65K at the last meeting that included $1000 for scholarships. AND that pittance took over an hour to agree on. excited about nationals in Texas in March, sad that I didn't get my shit together for a resolution, excited about folks planning outreach projects with kids. also, i'm a big dummy and volunteered to take the minutes and have yet to send them out. shrug.

Honors - hmmm. Thought a lot about this. It seems a little insane to take another thing on this semester. But I've been wanting to do an Honors project since I started the program and was thrilled when I squeaked through with the GPA last semester to qualify. So I decided - Yes, I am doing this thing. Now, I just have to find an adviser in the next five days to sign my intent to participate form. hmmm.

the kid - getting my head around re-districting for next year. processing more worrisome progress reports from the teacher who doesn't have credibility with me, and from the art teacher who was more worried that I thought was appropriate. planning birthday hockey game with friend.

the house - rearranged the living room, with the bookshelves I bought for shoes two weeks ago. Nice to have the lake of shoes off the floor behind the front door. Appalling to see the amount of cat fur that builds up in two weeks. Dishes are going on 13 days now since original use, although they have been rinsed and stacked in varying arrangements twice in that time.

in the category of Nothing to do with Nursing School - hang on, I know there's something... hmmm. made new list of scholarship applications due on March 15th? no no that won't do. chinese food with friend which included discussion of nursing school, but also of her new job and dying cat? better. did taxes, and was impressed that I managed to earn only $4K last year, down from $10K the year before. Now that's gross income! badumdum. attended Friends meeting. good. very intense feeling of peace this last week, lasted about 4 minutes. distracted by making mental lists of this weeks errands. watched leaves blow outside.

*literally - here, no more. I've heard it used to indicate to a professor that one is present in class, but not at their best that day, so don't expect a whole lot.

Mama Drama

I have a story.

At the beginning of the semester, I sent a note to the course coordinator, saying that my son's birth was traumatic, and that I was a bit nervous going into the setting again, although it had been several years. She said nervous is normal, and maybe I should let the clinical instructor know how I was feeling. Done, with conversation from course coordinator attached for history and context. I ended the email with this:

I feel confident that I can handle this course and I don't want kid-glove treatment at all! I just wanted you to know that I have really strong feelings about this stuff (in other words, I will cry during clinical at some point this semester!)

No response from clinical instructor, which was fine with me. It was perhaps too informal, I'll admit. But I did just come off Psych, and we all know how it went when I cried in front of that professor.

We've been meeting each Monday since the beginning of January with no mention of any of this, other than an aside on the first pre-conference that she knew I had a child, and who else has kids?
Last Monday, I saw TWO births (amazing, incredible and I'll write them up soon, I promise!). I also was talking about my son's birth briefly with two other students in the break room while we ate, and the CI was in the room. She said, "Oh you did have a traumatic birth." I used to enjoy the shock value a little, but I normally don't talk about it anymore - honestly, people are uncomfortable when they realize the implications of the vaginal delivery of an 11 pound, 11 ounce baby and subsequent fourth degree tear. Even indirectly, one's own rectum is not an easy thing to discuss socially, I've found.

The CI and I left together that evening, and she brought it up again. She said that she wasn't sure how to respond and so just played it by ear. I told her that's exactly what I had hoped that she would do, honestly, that I wanted her to know so that she could be prepared, but not because I thought that she would need to intervene in any way. She said, in her Midwestern drawl, "You know, it's been how long, seven years? If you're still having these strong feelings, you ought to think about getting counseling". I smiled uncomfortably and waited until she stopped talking and I could get away. Again? Really? Am I the world's craziest student?

got an email from her two days later that began and ended this waywith this sentence:

Although your clinical performance has been very good, I think you should seek counseling your issues related to your childbirth 7-8 years ago...

Your unresolved long standing issues impede your ability to learn as a student and grow. Please give this matter some serious thought.
See you next week.


There's that, then.

I've stopped screeching phrases like "how would she know?!" and "impede my ability to grow and learn as a student?!" incredulously. I have stopped obsessing about what I would do if she brings it up again as justification for a poor evaluation. While counseling is in order for me (as it is for most humans who have ever experienced anything), it's not on the wait-list for things to do this semester or even this year, I think. Also, I didn't fucking ask you. I guess since I brought it up in writing, she was obligated to respond in writing. but jesus. This is so intrusive, so cold and clinical.

I was all ready to fire off an email detailing my emotional reaction to her note. My friend said, No! She is asking you not to cry on her! Don't cry on her again! Mom said the same. I am immensely grateful for their translation. One of the things that disturbed me so much was that I was attempting to avoid this sort of interaction by sending the email in the first place. I was trying to construct some distance and professional detachment around an issue that is still tender for me, but I did it in a way that put my guts out there to begin with. In a way, it seems that I invited this intrusion into my emotional state; not literally, but on a sort of cosmic plane. What was I hoping to avoid in the first place here? Would I benefit from spending some time on this? Perhaps not with a counselor, but in meditation, doing some root chakra energy work, focused journalling?

I am practicing my pleasant, competent, yet emotionally detached personna for clinical conferences. I am wondering what this means about my way of being in the world in general and as a student in particular. And I'm thinking of it in terms of the conversation that Loving Pecola and darkdaughta are having about what can be expected from the world of academia.

Tonight went well, but I did give in to the temptation to tell a short form of this story to another student who got a similar nasty-gram. I regretted it immediately - it was purely for one-upping the other student, not because she and I are close or she needed my support. I even wonder about posting it here - but will leave it for now.

The instructor did add a comment at the bottom of my clinical journal entry from last week about the births: "I think this week was therapeutic for you!"

More than you know.