Nine months of labor....

It's been about 9 months since I've written anything partly due to the sheer exhaustion of job hunting and partly due to the nuances of working full time as a night nurse...it took about a month and half after passing boards, but I landed a job, thank God (which by today's labor market for new grads, was lightening fast!)

Acute medical surgical telemetry...which means you get it all. Sick, sicker and sickest. Sepsis, pneumonia, post ops, chest pain, GI bleeds, MRSA wounds, vacs, UTIs, psych, dementia, DTs, knees, hips, pelvis, abdominal this and that, and an occasional prolapsed anything. Atrial fibrillation, PVCs, bigeminy and an occasional third degree block. This is the menu on my unit and there is always something new. In nine months, I have only seen one patient who had a family member present at the time of death. Every other patient died alone, except for their nurse who is always present.

Working nights, I have lost contact with a lot of my daytime friends and family. This is the only drawback, otherwise I have adapted to the changes in sleep, because my family has made the adjustment with me. We have a do not disturb button on our house phone and since all of us have cell phones now, we don't miss the ringer on the house phone. When I started working noc shift, I marveled at my co-workers ability to eat anything in the middle of the night, but within 3 weeks, my body clock shifted and I found myself famished at 0200. I usually wake up at 1600-1700 without any breakfast pangs and then force myself to eat something before 1900. By 0200, I am hungry. I eat one more time..usually at 0800-0900 and that is it for my work day. I eat twice per day. As a result, I lost about 20 pounds since starting work. It is so strange what your body does to compensate for the shift change. I wake up in the middle of the afternoon after working all night and the first feeling of disorientation is so strange (i.e. where am I, what time of day - should be morning but my brain realizes it is late afternoon, early evening) Some days, after working three 12 hour shifts in a row or an occasional 16 hr shift, I will wake up at 2100 (9 PM) and stay up all night. It's the most surreal feeling to live and work like this when your family lives on an opposite pole. I noticed during the holidays, everybody shifted to my schedule and stayed up later and slept later...so we could spend more time together.

I can say with certainty that I have no regrets about becoming a nurse. It is the hardest, most rewarding career. Everyday is different. After 9 months of labor, I still feel like a baby. I have wonderful colleagues who teach me something new all the time...it's a wild ride worth taking..and I hope I still feel this way 5 years from now.

Now what?

"So, Mom, did you get a job today?" greets me daily when the kids or hub arrive home from work and school. Looming on the horizon are several things that have me excited and terrified at the same time. One of the kids is graduating high school in May, heading off to Europe for month a half and is hoping to go to college out of state in the Fall. The middle child wants my car, literally. The baby isn't a baby anymore and I am weighing whether to send her to private school. So, in lieu of the hopes of dreams of three older children wanting to spread their wings, is a new nurse mother desperately trying to land a position as a nurse, somewhere...anywhere...hello nurse shortage, I answered the call ~ are you there?

I have applied for 150 positions. Five are in limbo someplace between recruitment and management and no interviews yet. I have tried calling, emailing, facebooking, and physically driving to see nurse managers. The words "new grad" taste like poi at the Luau. You know you have to eat it, but it doesn't taste good. How much can one emphasize one's maturity. Just look at me.

I have modified my resume 20 different ways, and yet the phone doesn't ring. In the meantime, I am selling my nursing books and homeschooling books. It is keeping my mind off the fact that my phone isn't ringing, and will hopefully buy my oldest a round trip ticket to Europe for graduation. I have a lot of books.

In the meantime, my suit is pressed, all my paperwork is in order, my license fresh off the press, and certifications updated for basic and advanced care life support. What more can I do? I have thought about catering lunches for units looking for nurses; seriously gone are the days of signing and referral bonuses. Whining.

Patience, I know. I think pray, hope and don't worry. Ok. Loans come due June 30...something has to happen before then. I'm better than poi.

4 AM....Train pulls in...

2 AM: I checked the BRN page and the system was starting it's update. I went back to bed. My stomach has been hurting all weekend.

4 AM: My husband gets up and goes out to the family room. He comes back into the bedroom and says you might want to come see this. I stumble out of bed and look at the computer. Beautiful sight after 30+ years of imagining..and 3 years of hard work. My nursing license. A train never looked so good.

NCLEX..waiting for my train to come in...

Nothing can prepare a nurse graduate for Boards and how you feel after you take them. In my mind, I envisioned hours of testing,thinking about the nurses who took paper pencil tests on every aspect of nursing from neonatal to geriatrics.

My boards were over before they began. I had taken a Kaplan prep course to practice questions and brush up on content I might have missed in school. I did everything Kaplan required and then got utterly tired of doing questions. I simply couldn't do another Q-Bank. I stopped the day before to rest and ended up getting a pedicure and massage. I went to bed early, thanks to Melatonin...and woke with the roosters.

Packing a bag of snacks, eating breakfast, two cups of coffee, listening to happy tunes, saying my prayers. Checking in. All these things I imagined. Then I took a couple deep breaths, put in my ear plugs and began.

Question 1...nothing looked familiar. Question 2....I don't know and so on..This went on for 80 questions and then the CAT screen went to black. What the hell? What just happened? Did I answer those correctly or did I just throw three years of schooling down the toilet?

I don't know...it felt awful. It was surreal. Two other classmates where there taking at the same time and they experienced the same reaction. How can this test that I just took in 2.5 hours determine if I am competent to be a nurse?

This is day 4 of my wait. I don't know what is next. I have 45 days to retest. If I didn't pass, I wouldn't even know where to go to resume studying. Is this the last bit of torture, or is just the nature of nursing..to always be exhausted, psychologically tested and wondering where you stand.

In the meantime, I am standing on the platform, waiting for my train to come in.

Pinning ceremony December 10, 2009

Dr. Berman…faculty, family & friends.. my fellow colleagues.…The journey that began 11 and a half months ago is now coming to an end.

We told you last January we would see you on the other side of this…and you bore it all so patiently.

How fitting that Dr. MacIntyre welcomed you all to our pinning ceremony, because in many respects, he took this extraordinary journey with the ABSN class from start to finish, Our work with him, from January through December was an examination of conscience & intellect for the rest of our practical nursing curriculum, providing the framework by which we learned about nursing standards, scope of practice, ethics, application of applied research and evidence-based practice.

The most important contribution he made to our cohort, however, was the assignment of a book in November that for all intent and purpose is a book written about us, a book about him…and about some of the very special patients we had this year….The title of the book is “Outliers, The Story of Success” by Washington Post business & science reporter and author Malcolm Gladwell. If you have not read this book, you should.

Outliers are a misunderstood, unique subset of people who fail to fall within in the normal bell curve in standard statistics. They are so far outside the bell curve that when taken into consideration, it is difficult to understand them. They fail to behave the way one would expect, their results are often unanticipated, it is difficult to make predictions about them. Outliers cannot be put “into a box” because their outcomes fall outside the veil of normal experience and expectation.

Our cohort cuts across four different decades, from backgrounds as diverse as photography & psychology to biochemistry and the neuro-biosciences. Our class has civil and electrical engineers, physical therapists, social workers and exercise physiologists. We have a professional homeopathic doctor, an Eastern medicine practitioner, and a theologian. We are a class of educators, writers, and business administrators. In addition, we have a professional musician and a seasoned television news reporter who climbs mountains in her spare time. Several of our classmates plan to be nurse anesthetists and family nurse practitioners and one is planning to go to medical school.

These individuals at this particular point in time decided to become baccalaureate prepared professional nurses. They answered a vocational call to the nursing profession and committed to the intensity of an accelerated bachelor’s program. Who does that? … And arrives on this stage… December 10, 2009 after 11 and one half months?

That would be the Outliers.

Gladwell theorizes that outliers are surrounded by people that allow them to thrive and be successful. People, who happen to be very special family and friends. Wedged into their background is a broad life experience, and additional outliers who are their mentors and teachers and in many respects, nothing but Providence is responsible for this.

Therefore, let our charge be, in our future practice to watch carefully and diligently, for our patients who are also outliers, in order that we might apply our best practice, because no matter what we read in nursing textbooks, in nursing research…No matter what we hear in report, on rounds….or read in a patient’s chart, as nurses who are outliers, we must rely on our other tools and skills, our intuition, our five senses, our own assessments, listening tentatively when we’d rather not, looking for the outlier who defies the odds, rebounds when we least expect it or needs us to advocate for them when no one else will answer the call.

Outliers apply knowledge from a variety of resources to treat patients across the life span because of broad based experience and will go that extra mile…. because somewhere in their past, outliers have had their own obstacles, special challenges, problems to solve and yes, their own suffering to endure.

We banded together as I believe Dr. MacIntyre wanted us to, in order to effect change in the nursing profession …this class not only adopted each other as family; we adopted patients with the highest acuity, the homeless, the dispossessed, the young, the ones left alone to die, and the undesired who desperately needed to be bathed. This class tended after the wounded, the abused, and the burned. We cared for the ones with cancer and the wee ones just born.

This is the story of the success of this cohort who successfully navigated the ABSN program somewhere on the outskirts of the bell curve.

Congratulations to the Samuel Merritt University ABSN Class of 2009.

Catching the ball....run Forrest run.

The last few weeks were difficult for our unit. We lost three patients close together. Two of the three patients were patients my preceptor and I had the weeks before. Nursing puts us all in that delicate position of helping people at their most vulnerable hours of sickness and death. One of the unique aspects of what we all do, is that when we go to work, we never know what the day will bring.

This week, however, my preceptor allowed me to take the ball and run with the patients I wanted. I always try to challenge myself to pick patients who are the "sickest"...however, in oncology, everyone is usually pretty sick, so the two I picked this week were a great opportunity to exercise old skills learned in med-surg. Taking and giving report, assuming total care, planning, assessments, interventions and evaluations. How would I plan and approach the day? Since I had good role modeling from my preceptor, I decided to use "her" method and hit the ground running the way she does. We round on our patients in the AM, pull labs and meds and bring everything at once to do assessments. This allows for the unexpected admission in the morning, the surprise fall backs and any other delays that frustrate any nurses' best laid plans. It also allows us plenty of time in the room, avoiding the back and forth. So, while one med is running over 10 mins, I can assess other things, do a little teaching and reassess before the next one is given.

The oppty to reconstitute and administer meds, try things with patients with my PRNs to see if they would help. These are all the things I love about nursing and of course, patient teaching. I know I probably won't always be this optimistic, but I like to see nurses who still love what they do 20 years later. It is the kind of nurse I hope to be.

While my patients weren't as critical this week as they were in the previous two weeks, I loved the independence of trying to do everything on my own, classifying, and getting all my charting done and being able to measure over the course of several days how decisions I made, impacted my patients. Running never felt so good!

Seeing the big picture.....at the end of life.

As a student, learning in the Hem/Onc/BMT unit has been a positive experience primarily because we care for the same patients over a longer term. In many case, patients are in for new diagnosis, post operative, and/or being stabilized towards going home, the outpatient setting, or they are inpatient due to relapse and now our goal is to help them transition toward death.

I've had several opportunities to work with patients who are new to their cancer treatments and those who are at the end of life. Perhaps the most difficult case I've had over the last two weeks is a female patient with Ovarian cancer/mets throughout, whose spouse is in the worst case of denial I've ever witnessed. The patient has intractable pain, unable to tolerate any intervention including sips of water or touching her, and the poor spouse is thinking the next ABX or blood transfusion is going to be the magic bullet. I know how hope and faith serve in rescuing our loved ones in crisis, but this patient had already crossed those turning points. Her body was fighting every intervention and was shutting down in violent opposition.

This has been going on for months...with the last month being the most painful: 3+ pitting edema, an abdomen 10X it's normal size, full of cancer. While I was changing and packing her open abdominal wound yesterday, I told her that she needed to get him ready and tell him what she wanted (she wants hospice..he wants her to eat and gets mad at her for not eating. He wants PT to work with her and she is no longer able to bear weight on her joints and cannot tolerate being elevated or turned in bed.) She cries that he doesn't listen and refuses to talk about it. I told her that it is difficult for him to let go, and she needs to help him.

The situation is like a big elephant in the room everyone refuses to acknowledge. She doesn't want anyone touching her due to her intractable pain, but yet, she is a full code, meaning that when her BP, heart rate and respirations slow down or cease, our response is to intervene with full force, including but not limited to CPR, chest cracking/opening/manual massage, mechanical ventilation, vasopressors, fluid resusciation etc.)

Nursing is struggling with this particular patient because medicine has been slow to address it with the spouse. Social work is waiting for nursing and nursing is waiting for medicine and this patient potentially could code any hour and the husband is still thinking his wife is going to beat the end stage diagnosis/prognosis.

Yesterday, the chaplain came by and wanted to know how she was doing. After reviewing the case with him, he took the husband aside and asked him to consider making his wife a no code, explaining what a full code would look like. A body FULL of cancer that has intractable pain should not be cracked open, compressed and pushed full of more fluids. The amount of intervention in a full code would be agonizing for the dying patient. I also talked to the patient about the importance of getting her husband ready...telling him, even though it would be hard for him to hear it, that she wanted to die, that she was ready to die. The body goes through the shutting down process and she has already started that process.

Death is the big elephant in the room that nursing in concert with medicine and psych-social, needs to acknowledge in unison, in order that we might more effectively guide our patients toward the end of their life in a manner that promotes for their optimal comfort, preserves their dignity and assists their loved ones in their grief toward acceptance.

PS: I got a call from my preceptor today that this patient passed away last night, just a few hours after her code status was changed from full to DNR. I was grateful to hear that she passed away peacefully in her sleep, which was the last thing she said to me, "please...let me sleep".