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If you made it this far--thanks for visiting. My name is Joe. I'm allnurses.com's Information Architect. I'm the tech behind the scene. I'm in charge of everything that makes allnurses.com tick. Isn't she a beauty! I consider myself to be extremely fortunate, because I love what I do.

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  • Sep 20

    I am pretty open about my late diagnosis of ADHD and the difficulties I have faced because of it. A lot of the hardship I have faced stems from the fact that there is so much misinformation out there about the disorder. There are a lot of disreputable people out there preying on the vulnerable and pushing unscientific “cures” and treatments. There are just as many good-intentioned people who are trying to “help” but have no clue. This article is the first in a series that I hope will shatter some of the misconceptions and bring the facts of ADHD out into the open.

    What is ADHD?

    FACTS:

    ADHD stands for attention-deficit/hyperactivity disorder. It is one of the most common mental illnesses. According to the American Psychiatric Association (APA), it affects an estimated 5% of children and 2.5% of adults.

    Usually, it is diagnosed in childhood, when the affected child starts having trouble in school. The condition is diagnosed more frequently in boys than girls. Unfortunately, there are some people who do not get diagnosed until much later in life.

    ADHD is broken down into three types: hyperactive-impulsive, inattentive, and combined type.

    Hyperactivity is defined by the National Institute of Mental Health (NIMH) as when “a person seems to move about constantly, including situations in which it is not appropriate, excessively fidgets, taps, or talks. In adults, it may be extreme restlessness or wearing others out with their activity.”

    The NIMH defines impulsivity as when “a person makes hasty actions that occur in the moment without first thinking about them and that may have high potential for harm; or a desire for immediate rewards or inability to delay gratification. An impulsive person may be socially intrusive and excessively interrupt others or make important decisions without considering the long-term consequences.”

    According to the NIMH, inattention is characterized by a person who “wanders off task, lacks persistence, has difficulty sustaining focus, and is disorganized; and these problems are not due to defiance or lack of comprehension.”

    ADHD severity and type vary per person. Males are more often diagnosed with the hyperactive-impulsive type. Females are more often diagnosed with the inattentive type.

    FICTION:

    There are a great many misconceptions about what ADHD is, and isn’t.

    “There’s no such thing as ADHD. That child is just spoiled.” ADHD is a condition, not a result of poor parenting. According to the CDC, ADHD is a neurodevelopmental disorder.

    “Everyone has a little ADHD.” According to the APA, even though ADHD is one of the most common mental disorders, it only affects approximately 5% of children and 2.5% of adults.

    "All children act that way!" While all children may display the symptoms of ADHD occasionally, affected children have the symptoms more severely, more often, and the symptoms reduce social function, school function, and quality of home life.

    "Only boys have ADHD." It is true that males are diagnosed more often, but females also have ADHD. Obviously, since I am female!

    "All kids with ADHD are hyperactive." Children with inattentive type ADHD often appear dreamy or lost in their own world.

    "There's nothing wrong with you, you just need to try harder." Believe me when I say that those with ADHD are most likely already trying as hard as they can.

    References:

    American Psychiatric Association (APA), “What is ADHD?”
    What Is ADHD?

    National Institute of Mental Health (NIMH), “Attention Deficit Hyperactivity Disorder”
    NIMH >> Attention Deficit Hyperactivity Disorder

    The Centers for Disease Control and Prevention (CDC), “Facts About ADHD”
    Facts | ADHD | NCBDDD | CDC

    CDC, “Data and Statistics”
    Data and Statistics | ADHD | NCBDDD | CDC

  • Sep 20

    FACTS:

    Hyperactive/impulsive behaviors

    Unable To Be Completely Still

    Children often fiddle with pencils/crayons in class, fidget, tap their fingers or their toes, take overshirts or jackets off and put them back on, toy with their clothing or with fasteners, click pens, etc.

    Teens and adults tend to bounce their knees, doodle, take excessive notes, pass notes in class, flip through textbooks, read and reread agendas or other meeting documents, flip through reports, twirl pens, tap pens, change positions frequently, and so forth.

    Have A Hard Time Remaining Seated

    Children will get up frequently in class, ask to use the bathroom frequently, find excuses to get up and look out the windows, get up while eating, get on the floor while supposed to be sitting, and get up for frequent snacks and bathroom breaks while doing homework.

    Teens and adults will offer to do tasks that require standing or walking, claim that sitting hurts their back and stand against the wall, shift position frequently, leave to get beverages or snacks. They may also take frequent bathroom breaks, get up and down for extras during dinner, clean or do several other tasks while watching television, and stand or walk around while talking on the telephone.

    Tend To Run Around Or Climb Inappropriately

    Children will often display these behaviors while participating in sports or other structured activities; to the child with ADHD, the world is often a fascinating obstacle course.

    Teens and adults have usually learned to stop doing this, but are often restless. This behavior can be exaggerated in situations where it is appropriate, such as while participating in sports or outdoor activities. Patients will often search out opportunities to be physically active, like participating in martial arts, taking self-defense classes, running obstacle courses and marathons, or sports.

    Tend To Get Loud While Participating In Quiet Activities

    Children can be loud, argumentative, and confrontational during structured quiet time.

    Teens and adults often show this while watching sports or television by talking to or yelling at the screen, as well as by becoming overly competitive and loud while playing board or card games.

    Seem Unable To Stop And Rest

    Children may be unable to stop themselves from an enjoyable activity, or may complete one activity and dive straight into the next; this is characterized as acting as though they are “driven by a motor.”

    Teens and adults may display “driven” behaviors towards school, work, or leisure activities. This can be mistaken for commitment, but is similar to short-term obsession. The teen and adult with ADHD are frequently enthusiastic to the extreme about a new project, video game, garage band, concept for entrepreneurship, and so on. Teens may stay up all night playing music or games even though they have class the next day. Adults may be unable to stop work in the middle of a task and continue on to finish it even though it takes hours and affects sleep patterns. Artists and craftspeople may work without sleeping until exhausted or until a project is complete. In teens and adults, this symptom can be mistaken for mania. Another term for this symptom is hyperfocus.

    Talk When It Is Inappropriate

    Children may talk excessively in class or during activities, tell stories constantly, socialize during class time, and may be characterized as a “motormouth.”

    Teens and adults may dominate conversations, especially when excited, or talk over others.

    Tend To Blurt

    Children do not wait to be called on and shout out answers in class or at home even before the question is finished, say whatever they are thinking without thought to the consequences, and change subjects in the middle of sentences.

    Teens and adults answer questions before they are finished, make uncensored comments, say hurtful things without meaning to, and have trouble staying on topic.

    Doesn’t Want To Take Turns

    Children have a hard time waiting for their turn, preferring for it to be their turn all the time. They may become frustrated and tearful when it is another child’s turn.

    Teens and adults may lose interest in long games and look for a more exciting activity, break in line, or get frustrated while waiting in line and leave.

    Butts In

    ADHDers often miss social cues that indicate an intrusion is not welcome and will do things such as interrupt speakers, interject during movies, walk through a photo op, barge into rooms, and break into other’s conversations. These patients may be labeled as a “busy-body.”

    Impulsive

    For ADHD children, action is often synonymous with thought; an affected child will chase after something it sees that it wants, change direction mid-stride, break into running, slide to a stop, grab for things without being careful, snatch toys, hit other children, scream suddenly, or throw things when frustrated.

    Teens and adults often make poorly thought out decisions, such as choosing a college because their friend got in, taking the first job offered, spontaneous road trips, sudden turns while driving, making expensive purchases on a whim. These patients may be described as “flighty.”

    FICTION:

    “Only boys are hyperactive.” Females are diagnosed with hyperactive/impulsive type ADHD, as well as combined type. In females, the trait displays more as excessive talking and hyper-social behavior.

    “There’s nothing wrong with that child except a lack of discipline.” While discipline and structure can help a child mitigate behavioral symptoms, the underlying ADHD is not cured.

    “Boys will be boys!” The often out-of-control behavior that is typical of males with hyperactive/impulsive symptoms is not a normal manifestation of maleness. These children often need help to learn how to regulate their behavior.

    “There’s nothing wrong with that girl except too much pent-up energy.” While getting enough exercise is an important element in treating ADHD, it is only part of a complete treatment plan.

    “That’s just a bad kid.” Children with ADHD are not inherently bad. With proper treatment, they can be very successful.


    First article in the series: Stupid, lazy, or ADHD?

    References:

    American Psychiatric Association (APA), “What is ADHD?”
    What Is ADHD?

    National Institute of Mental Health (NIMH), “Attention Deficit Hyperactivity Disorder”
    NIMH >> Attention Deficit Hyperactivity Disorder

    The Centers for Disease Control and Prevention (CDC), “Symptoms and Diagnosis”
    Symptoms and Diagnosis | ADHD | NCBDDD | CDC

    Children and Adults with Attention Deficit/Hyperactivity Disorder (CHADD) The National Resource on ADHD, “About ADHD:
    About ADHD | CHADD

  • Sep 19

    AN is pleased to present a press release from AHA which adds another dimension to out of hospital cardiac arrest care - telephonic assisted cardiopulmonary resuscitation via a 911 operator.

    The American Heart Association – the world’s leading voluntary health organization devoted to fighting cardiovascular disease – published recommendations this month that set standards for timely and high quality delivery of dispatcher-assisted CPR, also known as telephone CPR (T-CPR). The recommendations are accompanied by performance goals to measure successful implementation by first responders.

    To generate discussion among professionals engaged in improving survival from cardiac arrest, the program and associated metrics are open for public comment. The AHA will be accepting comments from interested parties through the website until November 16, 2016.

    Early access to 911 and early CPR are the first two links in the chain of survival from cardiac arrest. Currently, less than half of those who suffer an OHCA receive bystander CPR.

    “The most immediate way to improve survival from cardiac arrest is to improve bystander CPR rates,” said Michael C. Kurz, MD, MS, FACEP, FAHA, Associate Professor, Department of Emergency Medicine, University of Alabama at Birmingham and volunteer chair of the T-CPR Taskforce for the American Heart Association. “Providing telephone CPR saves lives by providing just-in- time bystander CPR instructions. When T-CPR instructions are not provided, preventable deaths from out-of- hospital cardiac arrest occur.”

    The AHA recognized the need for emergency response dispatchers to be trained to provide telephone CPR instructions prior to the arrival of EMS in the 2010 AHA Guidelines for CPR and ECC, and this was reiterated in the Guidelines most recently updated in 2015. As much as 50 percent of bystander CPR in communities that provide T-CPR instructions to 911 callers is directly attributable to those instructions.

    AHA’s six program recommendations stress ongoing training and continuous quality improvement:

    1. Commitment to T-CPR by both the emergency communications center and the dispatch center director

    2. Train and provide continuing education in T-CPR for all telecommunicators

    3. Conduct ongoing quality improvement for all calls in which a cardiac arrest in confirmed by EMS personnel and in which resuscitation is attempted

    4. Communication between the emergency communications center and responding EMS agencies to measure implementation and effectiveness

    5. Designated medical director to issue protocols and work closely with the responding EMS agencies

    6. Recognition for outstanding performance

    “In telephone CPR, the dispatcher and the caller form a team in which the expertise of the telecommunicator, combined with the willingness of the caller to assist, strengthen the first two links in the chain of survival,” said Kurz.

    The program recommendations are accompanied by a series of five performance metrics:

    1. Percentage of OHCA cases correctly identified by the dispatcher

    2. Percentage of correctly identified OHCA cases that were deemed recognizable versus those that were not because of complicating factors (e.g., language barriers, caller hang-up, CPR already in progress)

    3. Percentage of victims who receive T-CPR

    4. Median time between 911 call and recognition by dispatcher of cardiac arrest

    5. Median time between 911 call and first T-CPR directed chest compressions

    Following the public comment period, the AHA will update the program and performance recommendations. The final document will be published online along with a comprehensive guide to implementing T-CPR at the community level.

    So, this is the nursing community's time to comment on action that will have national implications. Voice your opinion, make comments, ask questions. Share your stories of out of hospital cardiac arrests and your commitment to improving care for these very fragile patients.

    We (nurses) will be instrumental in these guidelines so lets make our voices heard!

  • Sep 16

    Articles must be submitted July 1st - September 30th

    $600 in cash prizes! $150 each for the top 4 articles

    For this contest you can write about anything nursing related; the articles may be written in a conversational voice if you desire.

    Need some inspiration?

    Here are winning articles from past contests to give you some inspiration and ideas



    Helpful Tips

    TIP #1: Articles written on a personal level that answer a frequently asked question are popular with our readers.

    TIP #2: Articles that promote engagement and are personal (personal to you; personal to reader), usually have the most replies.

    TIP #3: The more descriptive the article is the better the response from the community.

    TIP #4: Articles written by members who provide helpful feedback on other topics/articles usually have the most replies and shares.

    Articles can encompass daily work, past experience, education, study tips, technology, etc. As long as it is nursing related it's acceptable. We look forward to you sharing your experiences and knowledge with our readers.

    Contest Rules:
    • Must comply with our contest rules and Terms of Service.
    • Must have a minimum of 600 words and be nursing-related..
    • Must be submitted between July 1st - September 30th.
    • No plagiarism
    • Articles will be reviewed and approved by staff for consideration before displaying publicly.
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    • You may submit multiple articles.
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    For more details read How to Submit an Article

    Start writing & GOOD LUCK!!!!!

    REMEMBER........

    4 winners - Total Cash Value of $600! $150 Each!

  • Sep 15

    How important is schedule to you?

    If you’re the kind of nurse who loves working three 12s and having the rest of your week off, you might find that options are limited away from the bedside. Many non-clinical positions are Monday-Friday, daytime operations that only offer 8 hour shifts. Some may offer 4-10s or rotating shifts, but 3-day work weeks are hard to come by outside of direct patient care.

    What part of nursing do you enjoy?

    If you really love taking care of patients, and really loathe sitting in meetings and doing paperwork, that’s something to consider when thinking about your BSN. Leadership and education positions tend to involve a lot of writing and speaking; if figuring out schedules, sending emails, and giving presentations is not your thing, most administrative BSN roles won’t be a good fit.

    On the other hand, if the clinical aspect of nursing is your passion and you intend to eventually pursue an advanced practice role as a nurse practitioner or nurse anesthetist, you will absolutely need your BSN first. CRNA programs also require at least a year of recent critical care experience, so you won’t want to stray far from the bedside once you have your BSN.

    Is your goal to get a raise?

    If you’re thinking of getting a BSN just to earn more and become more marketable, it helps to have the facts. In many hospitals, there is no wage increase for earning your BSN. Most facilities determine pay based on the job description, more so than the credentials. For instance, the administration looks at market values and determines that RNs at the bedside should make X dollars an hour. Some may add a bit to the hourly wage for a BSN, but many do not; a bedside nurse is a bedside nurse and they are paid as such even with a BSN.

    This is certainly something many would like to change, but before that can happen there will need to be a fundamental change in BSN education. Currently, a nurse can earn a BSN in a matter of months online without a single live lecture or any hands-on learning. Few, if any, BSN programs require a clinical component or practicum. There are no advanced clinical skills, no new knowledge significant enough to affect performance at the bedside, and therefore no real justification for an increase in pay. An overhaul to existing BSN programs, including advanced clinicals, might help to change that and make BSNs more marketable.

    If you do intend to transition into a higher-paying leadership role with your BSN, go for it; just bear in mind that most management and education roles are salaried, not hourly, so figure that into your calculations. If you’re someone who relies on occasional overtime or likes to pick up holidays for the premium pay, these differentials usually don’t apply to salaried (aka “exempt”) positions.

    Are you hoping for a competitive edge in the job market?

    If you’re trying to get ahead, continuing education and impressive credentials will certainly help. Bear in mind, though, that the BSN is becoming very commonplace now among bedside nurses. Many hospitals strongly encourage, and even require, nurses to obtain a BSN within a certain number of years after hire or in order to apply for transfers within the organization. In the recent past, BSN nurses were in leadership roles as nurse managers, directors of nursing in long-term care, and nursing instructors in diploma and ADN schools. Now that the average bedside nurse has, or is expected to earn their BSN, leadership and advanced roles are requiring even higher levels of education. You should absolutely pursue the degree if you want to advance, but many nurses now are also seeking additional certifications in various specialties like diabetes, oncology, or wound care, in order to stay competitive.

    Is money no object?

    One more thing any nurse should consider before returning to school is the matter of finances. Some may qualify for federal grants or full scholarships, but most working nurses will end up paying at least part of their tuition and fees out of pocket. If you’re lucky enough to get a free ride, take full advantage of it. If you’re like most nurses and have to rely on student loans and/or tuition reimbursement, take all the factors into account before you decide. For instance:
    ‘
    What is your current financial situation? Even with student loans and tuition reimbursement, many nurses often have out of pocket expenses for every semester. If your nursing job lands you a certain income bracket, you may only receive partial student loans and have to pay the remainder of tuition yourself. That’s something to consider if money is already tight. Also remember that currently, getting your BSN does not guarantee an increase in monthly income. All too often BSNs find themselves in the same job making the same money, but now with a student loan payment to contend with every month.

    How close are you to retirement? The repayment period for most student loans is 10 years, so it may not be worth it if you plan to retire in 6. However, if your finances are such that you could pay extra or pay the loan off early, you might want to go ahead.
    ‘
    Are you planning to relocate or change employers after graduation? Employer tuition reimbursement usually exchanges financial aid for months or years of continued service post-graduation. If you leave your employment before the debt is worked off, the benefit has to be paid back to the facility. Read the tuition assistance policies carefully to determine how long you’ll need to stay on after graduation and what your payback amount would be should you choose to leave early.
    ‘
    Is your projected BSN salary enough to balance out the student loan debt? Most BSNs end up paying around $240 per month for their student loan after graduation, so bear in mind that you’ll need to make at least that much more per month just to break even. The sad truth is that as it stands now, many BSNs find themselves struggling to make that monthly payment when there is no wage increase for earning the extra degree. Leadership roles will usually pay you a bit more, but remember to think about the schedule requirements and exempt/non-exempt status of those positions.

    What’s the bottom line?

    Generally speaking, you almost can’t go wrong with more education. The more letters behind your name, the better your resume looks, and there is also a sense of personal achievement. Still, when considering a BSN program, it’s important to examine all the pieces: your goals, your finances, your lifestyle and family situations, as well as your likes and dislikes when it comes to work. Do you need to be home with your kids more? Do you rely on overtime or shift differential to make ends meet? Do you love patients but hate paperwork? These are all things to consider.

    We all eagerly look forward to the day when the BSN translates to tangible benefits for the average nurse. Sadly, as it stands right now, for many there is no life-changing advantage and the BSN serves only as a stepping stone to an even higher degree or advanced clinical practice. The information here is not meant to discourage anyone from pursuing higher education, only to help put the undergraduate degree and its pros and cons into perspective.

    If your facility requires the BSN for bedside nurses, then your choice is simple. However, if you just really love taking care of patients and have no desire to enter leadership or administration, you may fare better with a specialty certification in an area that interests you. The cost is far less, and the BSN does not focus on clinical skills. If you do want to qualify for entry-level leadership and education roles, then the BSN is the way to go. In future we hope to see the BSN carry more weight and offer more leverage, but to do so it must also provide increased skills and greater knowledge. Changes in education are likely the only thing that will translate into changes in benefits. Still, the great thing about nursing is that we have a wide-open, versatile field where there is something for everybody. Hopefully the information included here can help you decide which of those somethings is right for you in your own nursing practice.

  • Sep 13

    Dear Nurse Beth,

    I was placed on probation by the BON in 2013 and ended in 2014. I have been working up to this point. I quit my job to move to another state. I have gone on interviews and once they look up my license and see the probation on my record the offer is taken off the table. I have an unrestricted license. will I ever work as a nurse again?


    __________________________________________________ _____________________

    Dear Was on Probation,

    If I understand you correctly, you were working between 2014 and now? Then you quit your job and moved to another state where I assume you had your license endorsed or is a compact state?

    Is it a consideration to move back to the state and job you left? The benefit is being able to network and having local, respected people give you recommendations.

    You say you have gone on interviews. Landing job interviews means they were interested in you and your resume caught their attention. Did you disclose on your job applications that you were on probation from 2013 to 2014? If you did not disclose this and they discovered it by looking up your license, then it is understandable that they would not hire you. They would assume you are attempting to conceal your past. Most nursing job applications ask the applicant to list any past or present discipline or restrictions on your license.

    I would address the probation in my cover letter and resume. Be upfront, brief, and positive. “While there is a short period of probation on my license, the problem has been completely resolved and I look forward to putting my skills to work”

    If the problem by any chance was drugs, have you considered applying to Dialysis or some other alternative setting? You may not land your dream job right off the bat, but it’s more important not to be unemployed for a long period of time- it will add to your problem.

    Related article: Writing a Letter of Explanation to the BON

    Best,

    Nurse Beth

  • Sep 13

    We all have our pet peeves, something that we are SURE is rude whether it bothers others or not. So I'm wondering -- what bothers you?

    Things that bother me:
    In a nurse's station with four or five unused computers, why does anyone have to sit down at the one I'm using, clearly marked with my scut sheet, my pen, my drink and my charting all pulled up and not finished? They take my spot, log me off (so I have to start over with any charting I didn't sign before the arrhythmia alarm jolted me out of my seat) and log in over me. Then when I return, they tell me "I didn't see your name on it." Why not just use the computer with the screensaver up and no ones stuff there?

    People who put their feet up on the chairs in the nurse's station. Not only does it look totally unprofessional to anyone who visits the station, including families, but the C. Diff that that they' we picked up on their shoes is now transferred to the impossible-to-clean fabric chairs in the nurse's station.

    Saying "no prob" in response to a thank you.

    Taking the nurse's chair. Our rooms has a sofa and two chairs for visitors, a recliner for the patient and a chair at the computer station for the nurse to use when charting. So why do the visitors always have to take the nurse's chair? Clearly, the nurse can't chart from the sofa.

    After you've taken the nurse's chair, why give me attitude when I ask you NOT to sit in front of my computer, but to sit in one of the five spots provided for visitors?

    Visitors using the patient bathroom.

    Staff who let patients use the staff bathroom. I've never been able to figure that one out.

    I'm cranky today, I have lots more. What's yours?

  • Sep 13

    I just hate it when I hear that nurses feel like they have to go to be a school to be able to work in the ICU or do invasive procedures. There is this myth that still seems to be circulating around that Physician Assistants (PAs) can do more than Nurse Practitioners (NPs) so, for example, if you want to have a role that involves more invasive procedures like central line or chest tube placement, you need to become a PA. This is not true and in fact is becoming more false each year as the NP role and profession keeps changing and adapting to hospital needs and patient populations. Many times in the past I had the discussion with my fellow nurse colleagues about whether to go to PA school or NP school, when contemplating going back to school. I considered going to PA school on the basis that I wanted to be able to do invasive procedures and assist in the operating room. At the time, in my hospital, we only had PAs in this type of role and I really didn’t know how the NP role had evolved into invasive tracks such as the ACNP role.

    Don’t get me wrong, I have absolutely nothing against PAs and work with some fabulous ones, I just want to provide a little “clarity” for those who are still unsure about which track they should take and what each role can actually do. The difference between the two roles is really just that one track requires a nursing license and one doesn’t. The NP track tends to have a foundation that involves more nurse theory and evidenced based practice, while the PA track tends to have more of a straightforward medical approach. I’m not saying that you don't learn medical management in NP school, you're just relating that management to nurse theory and research, where as in some PA schools, they only have 1-2 classes on evidence based medicine. The prerequisites are different as well. Prerequisites for NP school are usually obtained in your undergraduate program so no extra classes are required, where as, some PA schools require organic chemistry and biochemistry. For somebody with a nursing degree, these classes would have to be taken post-nursing degree because most undergraduate nursing programs don’t tend to require these types of chemistries. This is just something to think about if you’re considering going to PA school.

    Looking at programs people can argue that PA schools require a lot more clinical hours to complete in their programs, but you have to keep in mind the general PA student. The general PA student doesn’t have much hands-on patient experience, so the hospital is essentially a new environment for them and they will therefore require more hours. In NP School you still a lot of clinical hours to complete in the hospital (or clinic), but you've also probably worked a couple years prior to graduate school (and continue to work through school) so those extra hours at the PA students are getting, you've already had those in real world situations touching real patients.

    With all of this being said there is NOTHING WRONG with a nurse going to PA school. Sometimes people don't want the “nursing foundation,” they want the straightforward medical foundation, which is totally fine, to each his own. Whether you go the NP or PA track, by the end of your program, you will still come out doing the same job, being just as good at your job, and eventually (hopefully) making the same salary. So, if you think that you want to become a PA because they can do invasive procedures, now you know that NPs can also do invasive procedures with the appropriate program and training. I have had an attending physician tell me that they would much rather hire an NP than a PA because NPs most likely already have nursing experience and know how to talk to patients. But, I also do realize I'm a little biased being that I’m an NP graduate.

  • Sep 13

    I hear too often in the nursing world that we “eat our young”. This is not OK on quite a few levels, but the biggest concern is how often this happens and, despite the fact that so many of us disagree with this behavior and this sentiment, it still occurs frequently. The fancy term for the behavior of “eating our young” is lateral violence. I have been thinking about this a lot lately: Is that mentality different from other professions where people will clamor all over each other to get ahead?

    Not entirely, but it seems totally out of character for nurses, who give care to others and are healers for a living, to be laterally violent to each other. There may be times where we may, perhaps, be a bit short with an MD when we disagree upon a plan/intervention for a patient, or not be best friends with one of our coworkers, that is part of human nature, especially when working in a stressful environment. Who hasn’t been under a lot of stress in the middle of an insanely busy shift, and maybe come across as less than pleasant to a co-worker? Saving lives can be stressful business, but that doesn’t mean that we should demean one another. Lateral violence refers to a person of higher “power” or status on a unit, bullying or demeaning a co-worker, either through verbal or non-verbally aggressive acts. Usually, if you snap at someone because you are stressed, you will address it and apologize, or make some sort of note that you didn’t intend to come across as you did. Lateral violence is a continued trend of behavior that makes others feel uncomfortable, demeaned, and of less value.

    The thing about lateral violence is that some of the acts that constitute it, are so subtle. While any administration for any hospital or other healthcare arena would tell you that they take a stance on anti-bullying and/or lateral violence, the behavior and actions can be really tough to nail down, and it has been so long accepted in our culture that it goes under-reported. It’s not just the senior nurse on your unit that might get snappy or yell at a newer nurse for not being able to read their mind during an emergent situation, it could be the resource nurse that doesn’t schedule a break/lunch time any time that you work with them, or doesn’t offer you help when you are drowning in your assignment, but seems to offer to help everyone else out. It’s the charge nurse that gives you the heaviest assignment every single shift. It’s the person who runs the schedule and they put you on every single shift that you request off. It’s the co-worker that ignores you, or rolls their eyes at you, when you ask for help. If you have ever been in a situation at work where you’ve felt distressed by how you have been treated, you may have been the victim of lateral violence. These actions are what create a toxic environment that leads to a high turnover of nurses, and severely unhappy nurses on the unit in their short time there.

    And not only do the clinical staff suffer, but the patients suffer as well. When clinical staff are not working as a team, helping each other when they need it, and giving unequal patient assignments, it can be hard to meet the needs of our patients. If I can’t find a co-worker willing to help me reposition my bed bound patients, they are at a higher risk of pressure ulcers, right? And if my assignment is so heavy I don’t have time to change out that IV that was due to be changed at the beginning of my shift, that patient is at a much higher risk for phlebitis.

    What can we, as a culture of nurses, do about lateral violence? Just saying we won’t tolerate it isn’t enough. One of the biggest ways to prevent it is to educate staff on what lateral violence actually is; once behaviors are pointed out, and it becomes a part of the culture that those behaviors will be scrutinized and not tolerated, people tend to have more self awareness of their actions. We also need to speak out when we see it occur to others, or experience it directly, and report it. Nurse leaders on units should lead by example and set the tone for their unit, not only that they don’t bully their own staff or colleagues, but that they are supported by the policies set forth by their institution, and enforce a culture of anti-lateral violence. And when staff report lateral violence to their managers/directors, they need to feel comfortable and that there will be no repercussions for their actions, and that the person reported will actually be dealt with.

    None of us should feel uncomfortable or scared going to work, for any reason, and if you do, you need to speak out about it, and report it higher and higher in your institution until someone listens! Feel empowered to stand up for yourself, your colleagues, and our community.

  • Sep 13

    New Adventure

    Being a travel nurse for eight years was one of the most challenging and personally rewarding experiences of my life. On my journeys I laughed many times, cried more than a few, and was transformed as I cared for cardiac, burn, and trauma patients in 18 hospitals nationally. My journeys took me from the beaches of South Florida to the New York area (just before 9/11), to lively Austin, hot Arizona, hip West Hollywood, and dazzling Las Vegas.

    Packing up my 1997 Jeep Wrangler and beginning a new adventure always excited and scared me at the same time. I guess it was the unknown that held the allure. Never knowing what the provided housing was going to be like, how the new city would feel, how the unit at the hospital was going to function, and what unruly physicians I might encounter. It was all so wonderful…for a while.

    The Open Road

    One of the inspirational and profound aspects of being able to travel by car was the joy of getting on the open road and simply driving. Not five or six hours, but twenty-two to twenty-eight hours. Those really long cross country drives allowed significant amounts of time to simply think.

    As my Jeep buzzed from large city, to suburbs, to the outskirts, to the vastness of what seemed like nothingness, I reveled in the simplicity of just being behind the wheel. Driving was very purifying and allowed me to escape, to expand my mind, and to see my life from a new perspective.

    After I accepted an assignment in Scottsdale, Arizona I once again found my place on the mind clearing open road. As I journeyed from the Midwest through the nation's breadbasket to western Texas and into New Mexico, I began to see a parallel between the changing landscape and the development of my own burnout.

    The start of my journey was fresh, new and forest green much like the cornfields of Ohio, Indiana, and Illinois. But as I soldiered on, the newness and initial joy I once experienced began to fade to a muted and stale tan color, much like the rocky and dry, deserted plains of western Texas. As I made my way into the Southwest, I was amazed at the beauty of the variegated rocks that were millions of years old. I was struck by the starkness, isolation, and harshness of the landscape that mirrored myself. Could I see beauty in my own burnout like the stunning beauty of what was right outside my dusty Jeep window? Was that even possible?

    Head in the Sand

    But instead of listening to my heart and refilling my tanks, what did I do? Likely the same thing that others do, I stuck my head in the sand, ignored the feelings of being burned out and continued on. Isn’t that what we as nurses as supposed to do? Pretend it doesn't exist, ignore its nasty effects, be a martyr and soldier on.

    No wonder burnout causes so much destruction because we’re far too busy (taking orders, giving meds, documenting everything under the sun, being a patient advocate, being screamed at by doctors and family members, having an excessive number of patients among a ton of other responsibilities) to pay attention to how we are really doing, to how we are caring or not caring for ourselves, and to how we are coping with a highly stressful work environment.

    The Beach

    One of my last travel nurse assignments was in Orange County, California with its sweeping and majestic views of the Pacific. I worked on a busy telemetry unit with an endless flow of patients being admitted from the Emergency Room. But my favorite part of being in Orange County was the beach. Ahhhh…the beautiful and warm sands of Huntington Beach seemed to call my name even when I was admitting patients. I can still hear the seagulls crowing and the waves lapping on the shore. I wasn’t into surfing, I was into having beach bonfires and eating really tasty food. My favorite was bacon wrapped shrimp. Yum!

    Around the circle of the beach bonfire typically sat between ten to fifteen other hungry nurses who obviously enjoyed the beach as well. They really seemed to savor every minute just being there, being away from the craziness of their units, away from the business of their Southern California lives. Simply away. That’s what the beach bonfires provided.

    As the evening drew to a close, others started to rustle around in their bags of beach treats and pulled out making for S’mores. I have always loved them, especially the warm sugary goodness of chocolate mixing with a perfectly golden marshmallow that oozes out the side when you bite through the graham cracker. Perfection!

    Everyone knows the first step to creating that delicious treat is to roast the marshmallow carefully. I watched as everyone skewered their marshmallows and hovered them over the flames. A few of the nurses payed close attention to ensure their marshmallows were toasted to a perfect golden brown, some only occasionally glanced down at their marshmallows, and some didn’t pay any attention at all. Screaming and yelling quickly ensued as about two thirds of the roasters had a marshmallow that was engulfed in flames and were desperately trying to blow them out. Meanwhile, the attentive others were calmly assembling their tasty dessert and laughing at the calamity of their peers.

    The Raw Mallow

    Just like the changing colors of the scenery being a reflection of my own burnout, the process of marshmallow roasting was like the development of burnout. At the beginning, all of the marshmallows were pristinely white and unblemished, but as heat was added, it began to have an impact. The sugar molecules gradually heated up and over the period of a few minutes started to create a progressive browning effect. Soon, the sugar begins to burn and be replaced with carbon. Eventually, inattention develops into an out of control fiery blaze-up leaving a version of ourselves we no longer recognize.

    At this point we are left with a two choices, we can choose to pull off that charred and smoking outer layer to reveal our white and unblemished inner core or we can leave it undisturbed. Leaving our blackened shell intact will likely lead to us feeling used up, drained, frustrated, angry, and callous. The choice is ours, but we must take action to reveal the beauty that lies within. We must take an active role in educating ourselves about what burnout actually is, what it can do, where and how it is impacting us and learn strategies to lessen its effect in our lives. Only then can we begin to bounce back from burnout and create lives filled with more purpose, more love, more compassion, and more fulfillment.

    I was fortunate to have the opportunity to pull off my burnt and blackened layer. And when I did, I discovered my gooey, loving and compassionate inner core. I knew it was still there, but had lost touch with it during my time traveling mainly due to my own inattention and ignorance. My burnout recovery meant not traveling anymore and moving away from the bedside and into a role that was a better fit. I will always be thankful for my time being a travel nurse and feel truly blessed to have bounced back from burnout.

  • Sep 12

    You were one of my very first patient assignments I had fresh out of nursing school about two years ago. You taught me that behind the assignment was a person. With you I learned my first lessons in humility and compassion. As a stressed out new graduate on a postoperative unit it was hard at times to view patients beyond the assignment, beyond the task, beyond the pathology.


    You were a scared and anxious patient. At first I perceived it as stubborn and noncompliant with the medical treatment.
    I learned that listening closely, staying in the room even 30 seconds longer, and holding someone's hand can make all the difference.


    I remember how you insisted I give you a warning before flushing your PICC line because the taste of saline made you so nauseated! I remember how you used to eat a cherry sour with every flush. Drawing blood and flushing the line and giving you an IV push medication was always an ordeal. It annoyed me at the time but I began to realize that this wasn't about my feelings but about your comfort.


    Each time you came back to our unit you came back sicker and sicker. Your demands became less and less frequent ... and funny enough I missed your quirky demands that once used to annoy me.

    I knew these were signs you were getting sicker. Your hair began to thin, your generalized color was pale, your weight had dropped drastically. Your once loud and diva-like voice was lost in the midst of this illness.


    Months went by... I had not seen you anymore because I had moved on to the ICU.


    Until one day you became my patient again.


    The page came in from the executive nursing officer.


    "52 year old female respiratory distress history of PE to room 22" No name was provided so naturally I did not know this was you.


    And as we rolled you into the room and on to the ICU bed I recognized your face. Except this time it seemed so lifeless. So skeletal. Could this really be you?


    Then it happened, you began to code. You coded immediately after transferring you from bed to bed. I still remember the feeling of the compressions against your tiny frail body. You were but 5ft 2 inches in height. Frail and skeletal. No fat whatsoever on your body. No muscle either. Wasted away by disease. It felt grotesque, as any compressions usually do. I remember catching a glimpse of the people of whom I used to once work with outside the hall. My former coworkers, the floor nurses that brought you down to me.
    The look on their faces, as they witnessed the team of nurses and doctors try to revive you, I still recall. The nurse who brought you to me? She happens to be my best friend. She questions herself as to whether she could've done something to catch the impending doom. But we knew that death was coming.

    History of two pulmonary emboli. History of multiple DVT's. Hepatobiliary pathology. History of clotting disorders. Malignant cancer riddling your body.

    The doc finally called time of death. I was strangely relieved. Relieved that your suffering was over. Unfortunately your family did not know your exact desires regarding death and dying. They admitted this and preferred we do full interventions, "just in case". Which is an understandable and natural reaction from a psychological standpoint.


    That evening my friend called me. She kept wondering what she could have done. I assured her she did all she could. She called a rapid. She called the doctors. She made her voice heard. However most importantly she stayed by her side the entire time.

  • Sep 12

    To say the least, the NCLEX experience for me was one wild rollercoaster ride! One hour I would be fine and confident, the next hour my emotions would flip upside-down and I would feel anxious and insecure. I often went to this forum for help and support, to see how others felt, and how other people prepared and dealt with this situation. Now that it’s over, and I have conquered the dreaded NCLEX-RN, I will share my experience with the intent to help those that are on their NCLEX journey.

    As mentioned above, I took the exam about 2 weeks ago, and passed with 75 questions. It was my first attempt. I took the whole thing very seriously, treating it as my job. After graduating, I took 3 weeks off for vacation to rest. During the following 2 months that I prepared, I studied every single day, and did not go out at all. I got up at 5 am, started studying at 7 am, and finished at 6 pm. Every evening, I took a walk around my neighborhood for 1 hour, and went to bed at 9 pm. It was a rigorous routine, but I knew it was what I had to do to succeed. I did 75-100 questions a day, chewing and digesting all the rationales thoroughly. In total, I did over 3000 questions.

    About the anxiety, it is a normal part of this journey. In fact, a little nervousness helps you stay on point, so it is okay. Whenever I got really nervous, I did deep breathing exercises, and called my family for support.

    As for the actual preparation, I first made a plan. First, I need a solid foundation of content knowledge upon which I could build on, in regards to applying the knowledge to NCLEX style situations. Second, I need to master NCLEX strategies by doing practice questions. Doing just questions alone won’t help you – you need to have a solid content base, and only then will practice questions be of any use to you.

    For content, I used Saunders NCLEX Comprehensive Review. In addition, I often looked up things in my textbooks, and researched difficult concepts online for clarification. The Saunders online question bank that comes with the book has simple, content-based questions. These are nothing at all like the questions on the actual NCLEX exam, but they are good for reinforcing your content base, and for boosting your confidence as you get them right. I recommend this book for your content base.

    I also purchased the NCSBN Learning Extension course – the 3 week subscription. Although it is the cheapest course ($50), it was a mistake. The content part of the course was verbose and way too in-depth. I did the whole question bank of 1400 questions, and it only messed me up. There were grammatical errors, most of the questions only gave rationales for the right answer, and many of the answers I found later to be incorrect. As a result, I had to throw everything out of my head and basically start over and relearn everything. Don’t waste your time and money on this course.

    In terms of content, let me just say that learning happens through the entire journey, as you find out information that you may not have been taught in nursing school. Even when I was doing practice tests, I was learning new things. I learned a lot during my NCLEX journey.

    After I felt I had a solid handle on content, I went on to do practice questions. I got the LaCharity Prioritization, Delegation, and Assignment book. This was the single best resource, and I know that I would not have passed if it weren’t for this book. It is a book of really good questions that are comparable to the actual NCLEX exam. I sure got my behind kicked by this book! But at least I got it kicked then, and not on the actual test! Prioritizing is huge on the NCLEX, and this book prepares you well – presenting scenarios involving delegation and health conditions as they relate to nursing. This book is like NCLEX boot camp, and I am glad I did every page of it.

    Next, I had to tackle my fear of Select All That Apply (SATA) questions. I got Lippincott’s NCLEX-RN Alternate-Response Questions book. I liked that next to every question they show the level of difficulty of the question. I also did the entire book; their questions were good.

    I strongly recommend both of these books for questions, but if I had to choose only one, I would pick the LaCharity book.

    In addition, I took advantage of Kaplan’s online freebies. They offer a free NCLEX practice test, strategies seminar, and sample class. Those were helpful.

    And now, the actual exam! 3 days before my exam, I slowed my pace, and just did practice tests. I did my best to keep up a positive attitude. The day of my exam, I went in with the intent of just going in and getting through with it. Noise-cancelling earphones and a roomy cubicle made a good environment for a massive exam like the NCLEX. The questions in the preceding module of the exam are just there so you know how to use the system – they don’t count toward your result, but they do take away time from your 6 hours. Just skip over them and move on to your exam.

    The questions got harder as the exam progressed, which is what should happen. I got about 8 – 10 SATAs, which by the way is not an indicator of how you’re doing. Rather, it is the difficulty of questions that matters. I know that in the beginning I got some easy questions wrong, but later on I got hard ones right, which is what counts. I know this because my exam shut off at 75 questions, and about a week later I got my license. Throughout the whole exam, I felt like I was guessing. With the noise-cancelling headphones on, I heard my heart thudding as though it was about to burst out of my chest. My heart really started racing as I approached #75, and almost stopped when I hit “next” after 75, and got the blue screen on my monitor. I shuffled out of the test center in dismay, and just broke down in the elevator. I cried and trembled, and I had no idea why. Only after a half an hour did I regain control of myself.

    The next few days afterward, I did my best to think of anything other than the NCLEX. I listened to music and watched movies – something I didn’t do for the whole summer. This was an unforgettable experience that is comparable to a first love. Honestly, I have no idea how I got through this exam, successfully, but it seems I was properly prepared.

    Some points to remember are that there is so much information, that it is impossible to know everything. The different health conditions, the meds … Just do your best and know at least the general stuff – something that you can hang your hat on. Know infection control, prioritizing, delegation, and labs by heart. Remember, the exam is testing whether or not you are safe to practice nursing. Use your critical thinking skills to apply your content base to given scenario.

    If you believe in a Higher Deity, set aside time do that, because it helps. I believe luck is a factor in all this.

    Good luck to all those in their pursuit of the RN license. Study hard, and keep your nerves in check! Worrying and biting your nails will only ruin you - it is sticking to the grindstone and working hard (learning content/ answering questions) that will get you through this incredible NCLEX journey.

  • Sep 12

    Nursing leadership is faced with a very challenging dilemma. In order to drive the profession forward, those in the workforce for many years must adapt to changes in technology and systems while integrating their bedside practice to support an ample amount of time completing all the daily requirements of the job. Newer nurses must learn how to use their technology skills, yet learn to interact at the bedside, again finding the same balance.

    Nursing leadership has been tasked to move the profession forward thru education, certification, improved outcomes, and patient satisfaction. Today's nurse must use a variety of tools in order to meet the many needs of the patient of today's standards. The patient has shifted to a customer, where rankings and number of stars can help determine where you wish to receive healthcare services. The new nurse must maintain professional integrity while ensuring customer satisfaction. This concept has lead to job dissatisfaction in terms of the customer is always right, yet the medical staff receive all the training.

    The new nurse takes this responsibility in a mannerism that chooses movement, rather than sustainability. Many hospital cultures are facing new nurses entering the workforce who move around frequently. The dedicated old school nurse is far and few in between. The new nurse moves around, gains experiences, and leaves the dedication once viewed as the hallmark of nursing, at the door. The nursing leader must find new methods to motivate, entice, and keep the new nurse engaged and focused in their current practice. As we grow the nursing graduate into a productive nurse, another organization is willing to do the same in a specialty areas. New nurses are finding themselves in environments they may not be prepared for. It is nursing leadership's challenge as a profession to ensure we grow nurses up correctly and accurately prepare them for whatever environment we hire them for.
    It is important for leaders to communicate and network to ensure this new generation of nurses does not fall thru the cracks and just move around the profession. We must give them feedback, teach them, mentor them, and not allow them to move into situations they are unprepared for. As customer and patients expectations increase, we seem to have decreased are standards as a profession. By this, we must have policies in place that require minimal experiences and practice encounters before moving around a facility.

    This new generation of nursing enters the workforce and after 6 months feel they have the experience to move around. It seems thru the lens of nurse manager, that the plateau affect takes place quickly for many nurses. Mastering a medication pass and charting system seems to be the motivator to judge their readiness to more critical situations. The old school nurse experiences many situations over years of loyal service, allowing them to handle just about anything thrown at them in today's environment. The new nurse lacks the critical thinking and nursing judgement to handle many situations. As hospital's increase their speed of processes, the new nurse struggles to keep up.

    I often hear, I had to care for 8 patient's today. This means learning the history and personality of 8 patients during an 8 hour shift on the floor. We discharge patients home much quicker tan just 5 year ago, while emergency rooms flood with those needing to be admitted. The new nurse must learn more than skills and tasks. This constant turnover and lack of longevity, takes away from the overall experiences and ability to problem solve that the older generation nurse has. It is important for the new nurse to learn the whole system, the complete patient experience.

    We as nurse leaders must expose the new nurse to the complete patient experience while asking for their dedicated service to learn and gain knowledge. This is not just a job that pays the bills. This is not just a job that can give you the knowledge to be hired in a new area once the old area feels less enticing. We must force nurses to stay put and learn and grow rather than allow them to move around thinking they have the experience and knowledge to be successful in new environments.

  • Sep 6

    I follow some folks on social media who I keep on a “never miss their posts” list because they are well spoken and challenge me to be a better communicator. There are some posters here on AN who always add value, wisdom, and good thoughts to the discussion and I love to read their posts and learn from them.

    It’s also not unheard of to witness cat fights among nurses on social media, which makes a lot of us cringe. Plenty of people are watching to see how we nurses conduct ourselves. In social media, we really are on a stage with millions of viewers in the audience.

    Some of those viewers are impressionable students who are looking at us, the professionals...to see if we truly are professional. To see if we walk the walk and talk the talk.

    Here’s some guidelines I follow for social media behavior.

    Use Other Words


    Moms tell their little ones “Use your words!” and it actually applies pretty well to us grown ups as well. It’s mental work to come up with and use more descriptive words. I challenge myself to collect more words, and build up my vocabulary.

    Instead of “that’s awesome” I try to say exactly how it was awesome. Maybe it was inspiring, or thought-provoking, or clever.

    Likewise, instead of “it was a crappy shift” or “my supervisor was awful” I’d say “my supervisor was insensitive (or arrogant, or demeaning)” and “the admissions were non-stop and I had 2 RRTs”.

    Articulate


    It generally takes longer to clearly articulate my thoughts and feelings than it does to be knee-jerk sarcastic or to indulge in a put-down.

    For example, instead of saying"you idiot" on social media, try to stop and think "What do I really mean? What am I feeling?"

    Maybe you think the person doesn't know what they're talking about, doesn’t represent the facts correctly, or is wrong. Instead you could ask,
    "Interesting, can you share your sources?" or “Can you help me understand your rationale?” or “That’s interesting, can you explain that a little more?”

    Use I Statements

    Avoid provoking others to anger or defensiveness. Try using “I” instead of “You” statements. Instead of saying “You aren’t making any sense” say “I’m having a hard time following you from point A to Point B.”

    Agree to Disagree


    If you don’t agree, say you disagree, but avoid name calling or put-downs.

    If you are feeling angry, just take a deep breath and wait before you hit “send”. Maybe even Walk Away from the Keyboard until you cool off. Nothing on social media is an emergency that demands an immediate response.

    Take the time to prepare and express your point of view in a well thought-out and respectful adult manner.

    Acknowledge Others' Feelings


    When someone else is venting you can acknowledge the frustrated or hurt part of them without dismissing them altogether or responding in kind. "That must be frustrating for you." They are probably communicating in the best way they know how, which, even if inappropriate, doesn't mean their feelings are not valid.

    It’s easy to depersonalize the person on the other end of text on your screen. But they are real, and they have family, friends, and feelings...just like you.

    You never how unkind and judgmental words will affect another person. They may be timid to venture onto social media again. Maybe the person is not a nurse, and now they think “Wow, that ‘eat your young’ thing must be true!”

    Respond to what they feel as best you can without, trying always to build each other up, and not to tear each other down.

    Beware the Temptations of Anonymity


    In social media, it's tempting to shoot from the hip, especially when writing behind an anonymous handle. Anonymity lets you sink quickly to your lowest self. It reminds me of my little brother, Robin. Whenever he got in trouble as a small boy, he would deny it and say "Bad Randy did it." He thought we wouldn’t find out- just like anonymous people think their online persona is not discoverable. It may be.

    Write as if you are not anonymous to hold yourself accountable, or write as if your mother or grandmother is going to read your words.

    Your thoughts? And I know you'll tell me nicely if you disagree lol

    Best,

    Nurse Beth

  • Sep 6

    There's an interesting thread floating around here asking what topics members hate to see. I thought I'd switch things up with one asking what types of threads we actually like to read and respond to. (Please pardon that glaring grammatical error.)

    Some of my personal favorites include the articles. These are often entertaining and almost always educational. I also love the real-life stories about nurses being patients, the ones about the positives of nursing, and of course the funny ones and the WILTW threads.

    Anyone care to share?


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