Getting over a bad day

[amiris]

How do you get over a bad day at work? I know this probably comes with time, which is why I struggle with it being a new nurse... But I came home and I can't do ANYTHING else but dwell on work. Honestly, my day could have been worse, but it feels like the worst day I've had yet at my first job as a nurse. I have had this job for a little over 4 months, and have been by myself for a few weeks after a 16 week orientation.

I work at an outpatient cancer center as an infusions nurse. It's the job I wanted and I've never had a day where I've left crying or cried during the day, or wanted to quit or anything. I love it and 90% of the time I feel very competent and like I am doing a good job and am taking excellent care of my patients and I feel satisfied. But lately we have been so busy it has been overwhelming. I show up with 2-4 more patients than I am "supposed" to have in a day, and labwork is overlooked for being ordered, patient's schedules are not completed so I have to find the time to do that during my shift, pre medications are ordered incorrectly, or there are NO drug orders at all from the doctors. Paperwork for new patients is not complete... or we haven't gotten consent... the list goes on. Some days I spend more time fixing things that went wrong, or doing other people's jobs than I do actually doing my job.

Today all that could go wrong seemed to go wrong. After I was finally catching up on my day, trying to chart... my patient who had been receiving chemo for the last 3 hours (thankfully not a vesicant) was ready for their next chemo drug. I had been assessing her IV about every 30 minutes because she was a tough stick (and I did not start her IV, someone else did, so I always check more often with people with troublesome veins and when I wasn't the one that started the IV). I always got blood return and the site was never red or swollen and the patient never complained of pain. I did assess the IV 30 minutes prior to the chemo infusion finishing. Then, at the end, it's red and puffy. The patient said she had no clue and it didn't hurt at all. So that was about an hour of extra documentation and she had to be stuck 4 more times for a different IV to give her 2nd chemo drug. Clearly, even though I was getting blood return, toward the end of the infusion the catheter somehow got partially out of the vein. Even after noticing the redness and minor swelling, we got excellent blood return. The patient will be fine and even though I did "nothing wrong" I feel like I failed this patient. She was completely sweet about it but I am a perfectionist and the fact that anything went wrong with someone under my care... haunts me. If I thought something was wrong with the IV, I would have taken it out, but I saw no signs of any problem. I just worried because she has such difficult veins, so I was constantly checking on it... which is not uncommon, since a lot of our patients have really, really awful veins. And now, I just feel so defeated and terrified, since I DO give so many vesicants and we check for blood return to verify that we are in the vein to prevent extravasation... how can I even be sure that blood return means anything after today?

[Ruby Vee, BSN]

First, you have to be as kind to yourself as you would be to your patients. Perfectionism is a double-edged sword. It's good in some situations (med administration, for one) but bad in other situations -- when you've done your best and things still didn't turn out as well as you had hoped they would. Sometimes there's just no controlling a patient's veins, for example. You did what you were supposed to do -- you assessed and reassessed the IV site. Things didn't turn out perfectly, but you cannot control someone's veins.

Letting go of work is a self-care skill that you need to master. Have a ritual for getting off work. In the days when I had a long commute, I was able to let go of work before I got home. A long bus ride, a long drive -- plenty of time to obsess over what you missed or didn't miss so that you can let go of it when you walk in the front door. For a long while, I had a ritual of stopping at Panera for breakfast on my way home -- 30 minutes of dawdling over a cup of tea and a bagel, and I was ready to let go of work and go home. When I lived just a mile from work, I walked home. If you have a dog, walk him for 30 minutes to an hour when you get home and let your mind wander over what you did well at work, what you could have done better or talk to yourself about letting go of that which you cannot control. Colleagues of mine go to the gym right after work -- it works for them, but would keep me from going to sleep in a timely fashion. Cook yourself a meal or pack your lunch for your next shift. Cooking helps some people let go of work and take care of themselves.

I guess the bottom line is -- practice good self care and self-compassion. Whatever that means (and works) for you.

[amiris]

Thank you so much! Very helpful advice. It's something that I'm going to have to work on and see what works best for me, because I really don't want to spend my career thinking about work while I should be at home enjoying my family!

[Nurse SMS, MSN, RN]

It takes time and practice learning to let go of work. Just know that even the best of veins can blow with even the most mild of infusions and it can have nothing to do with the needle "getting out of the vein" and everything to do with weak vein walls breaking down etc. You did everything right. Everything. It was going to happen at some poin on a patient with weak veins undergoing chemo, who is probably nutritionally challenged and not getting enough protein to meet her needs who is getting hours of infusions of chemical agents that we take great care not to be exposed to because they are harmful. Get my meaning? You did fine. It happens. It is good you empathize with your patients. You just have to learn that things are going to happen sometimes even when we do everything right. Otherwise people would never die, right? I am so glad you care. That is a wonderful thing. Sometimes I think we can feel like, if we feel badly enough about it, it will prevent it from happening again. Or somehow atone for the fact that it happened. The truth is though, these are human bodies and in your case, very sick human bodies. I would tell you to forgive yourself but there is nothing here to forgive. From where I sit, it sounds like you are actually handling a pretty stressful job with a great deal of aplomb.

I second Ruby Vee's advice. Get a routine going, preferably involving a bit of light exercise, such as a walk with the dog or the spouse or a girlfriend or your headphones and favorite jam. The endorphins help a lot and something about being out in nature does a lot for the soul. If you can't do that, then Netflix your favorite trash TV. Or long hot bath with a fantastic bath bomb in the water. Or go out with your girlfriends. Or even better, go out with other NURSES and decompress by talking shop and laughing at the crazy world nursing is. I swear that there is the best therapy there is.

You are going to be okay and it sounds like you are doing so so well. Keep caring. Learn to figure care of self into the equation as well as recognition that human bodies break down, are frail, tend to fool us and change on a dime....there is no fault to be had in that. We can only do the best we can. If you did that (and from what you said you did and then some), you have nothing to beat yourself up for. It is the times you really didn't that need to stick in your brain, so you do better next time. There will be some of those too.

Hang in there.

[Leader25, ASN, BSN, RN]

Wow checking for blood return confirms the IV for you guys?In my areas we never rely on blood return to confirm placement, it is not reliable,hope there is another way for you to do this.

[amiris]

What do you do then?