How many times have you cried???

[CareBayer]

How far are you into your first year and how many times have you come home and cried?

I've been off precepting for five weeks and have come home and cried three times....most of the time it's because I was so overwhelmed on the floor....once I almost started crying at the nurse's station because I was being pulled in a million directions!

How about you?

[SoundofMusic]

I saw some of that when I did a rotation in nursing school on an OB floor. Here these poor moms were just need and in labor -- totally natural and normal -- and these nurses, many of whom didn't seem as if they'd had any kids at all, unfortunately, were totally uncompassionate - like you said -- just saying how they were "whining." I couldn't believe it.

Maybe I should go into L&D myself. I'm not for all the screaming, as we do have epidurals now, but I wouldn't begrudge any woman for turning in to herself, or acting wimpy -- going through childbirth can be totally terrifying, especially the first time -- even sometimes the 2nd or 3rd times if things go differently. Heck, it's just hormones that made women do what they do.

One of my dreams is to become a lactation consultant. I wonder if I have to have my year of med surg, or if I could just go straight into L& D now and get on with it.

I need to find out the requirements. Let me know what you know, Chloe.

[nursemike, ASN, RN]

Actually SofM,

it makes me even crazier to hear the seasoned nurses turn hard on a pt who is showing emotion. I work in OB and it incenses me no end to hear the nurses complaining about pt "X" who is "whining" or acting "wimpy". I've heard them gossip things like "get over it, you had your C-sec 2 days ago!" among various other comments. These are the nurses that make me cry harder over fear of what kind of environment I've set myself up for.

I know they won't be there for me when I crack or need a kleenex. And actually I already did crack and cry in front of them. No one thought to hand me a tissue either.

WHAT IS WRONG HERE? Is nursing going to turn me this tough too? Where's the compassion? I keep hearing instead that I better develop a thick skin or I'll never make it, and that I take things too personally. Yet I truly believe that it's my sensitivity that makes me so welcomed to perform such intimate care for my pts and their families. Now I have on occasion had a pt offer me a tissue. Go fig that one!!

Chloe

Warning: About to get all Taoist, here...

I think it's a matter of finding a balance. I also think it's a matter of being honest, to yourself and to others. I suspect that most nurses start out all caring and compassionate, but almost all of our patients need a lot from us, and some will just suck you dry if you let them. Over time, and usually without a lot of conscious thought, we develop defenses. That "thick skin" is scar tissue. And no, it isn't as sensitive. But it's hard to keeping going with exposed nerve endings, too.

The key, I think (hope) is to take a hard look at yourself and make conscious choices. Don't leave it to your survival instinct to make you hard, but do recognize that you have to find a level of detachment that will allow you to keep going. Maybe if we actively choose to give all we can, (including, at times, tears) but not all we have, we can be caring and effective without burning out or breaking down.

I am still in the process of analyzing the last couple of shifts I worked. I mentioned some of my feelings about it on my previous post, but I'm still working on it. I'm feeling okay that I wasn't Supernurse, after considering that one of the nurses who followed me was one of the best nurses on our unit--one of the best in our facility--and was nearly in tears by the time I finally finished my charting. If she had a hard time with my assignment, it's no wonder I did.

What made our assignment so difficult, essentially, was one patient with severe, uncontrolled pain and a bad attitude. She was flat-out mean. She was rating her pain 11/10 most of the time, getting oxycontin 10mg BID, oxy IR q4 prn and 0.2 dilaudid IV q2 prn. She was maxing-out her prns, and if I were allowed to rate her pain for her, I'd say it was 5/10 with meds, and about 8/10 between meds. That is to say, it was bearable, at best, and pretty unbearable, at worst, and never really acceptable. I did page her service about it, but the best answer I could get was that they would review the problem when the primary team was back, in the morning.

So the question everyone kept asking was, "Why is she so mean?" Calling aides and nurses stupid to their faces, snapping answers to simple questions, throwing fits over things like HS snacks, and just generally being a pain in everybody's butt. And the answer is pretty obvious--she was in a lot of pain (and more than willing to share it.)

So, because it's a requirement of my job, when my patient calls out can I please for the love of God have some pain medicine, I ask, can you rate your pain on a scale of 1-10, and she thinks anyone with any sense should be able to just look at her and see she's in a lot of pain, but I have to put a number on it or catch flak for my documentation (again!). And so now I'm caught between two bad alternatives: shut up and get the damned medicine, and screw the documentation, or make my patient feel worse by asking stupid questions. Or--use the behavioral scale I'd use with a patient who was unable to communicate verbally. Except, then every time I give a pain med, I have to document the s&s I base the assessment on--screaming, crying, cursing...

So, you can't win. If you had only this one patient, you'd be running your butt off and it still wouldn't be enough, but meanwhile the guy down the hall is satting 92% on a 30%ATC and coughing thick, tan sputum out his trach, and his neighbor is barely responsive to a sternal rub, and your new admission looks just fine, but has a psych and substance history, so you have to keep checking them, and your other two are easy enough, but still deserve some attention...and yeah, I really should have gone to truck driving school.

So, do you have a nervous breakdown on the spot? Do you block off your feelings until you don't have any? Do you hold it together as best you can and cry in the car? Do you snap at your aide? All of the above?

I think--and this is still a work in progress--you find a way to accept yourself as a human being with human limitations, do your best to balance the demands, don't even pretend you're anywhere near perfect, but try to remember that no one else is, either. Understand why the patient acting out is acting out and try to hold on to your empathy, but to heck with the employee handbook/customer-service responses and if you're ******, act ******--but try real hard not to cuss. Give all the pain meds that are ordered, explain what you've done to try to get more relief and don't even hesitate to throw the docs under the bus, forget about pretending you have all the time in the world and be willing to say, "I'm sorry, but I have to check on my other patients..." Be honest. Be real. Do your best, but try not to take it so much to heart that her pain is your pain, because, in the end, it's just a job, and at the end of the day, you've got to go home and feed the cats.

At least my cats love me.

[Chloe'sinNYNow]

Hey Mike,

I never studied Taoism, because my religion professor loved Hinduism so much we never got off it in time to study the others in the syllabus.

Does your quote to me mean it's ok to cry but that I have to make a decision to not take things so personally and as long as I'm there as a pt advocate, damn the naysayers and walk out of work w/ my head held high?

Thanks! Why didn't ya say so?

(p.s. after reading your night about pts in pain, tell me. Does your facility require you to go back and reassess a pt if you give a scheduled med and they say their pain registers 0 out of 0-10? ) Ours does and it's making extra work and more miles on these tough ole legs.

Chloe

:smackingf

[SoundofMusic]

NurseMike, you are just talented. You can validate our feelings as new nurses, yet somehow make us realize what we need to do to survive -- wish you were my manager, or that you get to be one someday.

We absolutely have our pain assessment flow sheets now that we have to fill out with any pain med intervention, right down to tylenol. I think it goes make sense, though -- as I guess any nurse could medicate someone and forget to follow up on them. But with hourly rounding, I don't see how that could happen either. At least it gets you to document your work.

Some of the other forms, I could really, really do without.

[SoundofMusic]

If you had only this one patient, you'd be running your butt off and it still wouldn't be enough, but meanwhile the guy down the hall is satting 92% on a 30%ATC and coughing thick, tan sputum out his trach, and his neighbor is barely responsive to a sternal rub, and your new admission looks just fine, but has a psych and substance history, so you have to keep checking them, and your other two are easy enough, but still deserve some attention...and yeah, I really should have gone to truck driving school.

So, do you have a nervous breakdown on the spot? Do you block off your feelings until you don't have any? Do you hold it together as best you can and cry in the car? Do you snap at your aide? All of the above?

I've had nights w/ a chronic pain person like this, although I just could not believe that she was in all that pain, as she switched personalities at the drop of a hat. First she was pleasant and conversational -- and then at "med time" she was crying, whining and demanding the dilaudid q4. Very aggravating.

At this point, however, as a new nurse, I wouldn't hesitate to ask the charge nurse for help and hopefully she would take pity on me enough.

[UM Review RN, ASN, RN]

Warning: About to get all Taoist, here...

I think it's a matter of finding a balance. I also think it's a matter of being honest, to yourself and to others. I suspect that most nurses start out all caring and compassionate, but almost all of our patients need a lot from us, and some will just suck you dry if you let them. Over time, and usually without a lot of conscious thought, we develop defenses. That "thick skin" is scar tissue. And no, it isn't as sensitive. But it's hard to keeping going with exposed nerve endings, too.

The key, I think (hope) is to take a hard look at yourself and make conscious choices. Don't leave it to your survival instinct to make you hard, but do recognize that you have to find a level of detachment that will allow you to keep going. Maybe if we actively choose to give all we can, (including, at times, tears) but not all we have, we can be caring and effective without burning out or breaking down.

I am still in the process of analyzing the last couple of shifts I worked. I mentioned some of my feelings about it on my previous post, but I'm still working on it. I'm feeling okay that I wasn't Supernurse, after considering that one of the nurses who followed me was one of the best nurses on our unit--one of the best in our facility--and was nearly in tears by the time I finally finished my charting. If she had a hard time with my assignment, it's no wonder I did.

What made our assignment so difficult, essentially, was one patient with severe, uncontrolled pain and a bad attitude. She was flat-out mean. She was rating her pain 11/10 most of the time, getting oxycontin 10mg BID, oxy IR q4 prn and 0.2 dilaudid IV q2 prn. She was maxing-out her prns, and if I were allowed to rate her pain for her, I'd say it was 5/10 with meds, and about 8/10 between meds. That is to say, it was bearable, at best, and pretty unbearable, at worst, and never really acceptable. I did page her service about it, but the best answer I could get was that they would review the problem when the primary team was back, in the morning.

So the question everyone kept asking was, "Why is she so mean?" Calling aides and nurses stupid to their faces, snapping answers to simple questions, throwing fits over things like HS snacks, and just generally being a pain in everybody's butt. And the answer is pretty obvious--she was in a lot of pain (and more than willing to share it.)

So, because it's a requirement of my job, when my patient calls out can I please for the love of God have some pain medicine, I ask, can you rate your pain on a scale of 1-10, and she thinks anyone with any sense should be able to just look at her and see she's in a lot of pain, but I have to put a number on it or catch flak for my documentation (again!). And so now I'm caught between two bad alternatives: shut up and get the damned medicine, and screw the documentation, or make my patient feel worse by asking stupid questions. Or--use the behavioral scale I'd use with a patient who was unable to communicate verbally. Except, then every time I give a pain med, I have to document the s&s I base the assessment on--screaming, crying, cursing...

So, you can't win. If you had only this one patient, you'd be running your butt off and it still wouldn't be enough, but meanwhile the guy down the hall is satting 92% on a 30%ATC and coughing thick, tan sputum out his trach, and his neighbor is barely responsive to a sternal rub, and your new admission looks just fine, but has a psych and substance history, so you have to keep checking them, and your other two are easy enough, but still deserve some attention...and yeah, I really should have gone to truck driving school.

So, do you have a nervous breakdown on the spot? Do you block off your feelings until you don't have any? Do you hold it together as best you can and cry in the car? Do you snap at your aide? All of the above?

I think--and this is still a work in progress--you find a way to accept yourself as a human being with human limitations, do your best to balance the demands, don't even pretend you're anywhere near perfect, but try to remember that no one else is, either. Understand why the patient acting out is acting out and try to hold on to your empathy, but to heck with the employee handbook/customer-service responses and if you're ******, act ******--but try real hard not to cuss. Give all the pain meds that are ordered, explain what you've done to try to get more relief and don't even hesitate to throw the docs under the bus, forget about pretending you have all the time in the world and be willing to say, "I'm sorry, but I have to check on my other patients..." Be honest. Be real. Do your best, but try not to take it so much to heart that her pain is your pain, because, in the end, it's just a job, and at the end of the day, you've got to go home and feed the cats.

At least my cats love me.

I nominate this for a Best Post of the Month Award. Excellent, Mike, excellent. I put my favorite part in boldface.

[NotReady4PrimeTime, RN]

What Angie said!!

[nursemike, ASN, RN]

Thanks, all.

I guess I didn't get quite as Taoist as I thought I was going to, but generally, I do believe balance is crucial, and as best I can I try to embrace both the joy and the pain of life. Not always successful, by any means, but still trying.

We are, indeed, expected to go back and reassess pain within an hour after pain meds. Since I work nights, my follow-up is often "UTA, pt sleeping, appears comfortable." This is not acceptable, but I just can't bring myself to wake someone up and ask them if their pain is better. Usually, one of the major reasons they want the pain med is so they can sleep. And, sadly, many of my patients just don't see my charting as one of their higher priorities.

I have to confess, in cases like the one described, I sometimes adopt the position that pain is what I say it is. That is, I asked her to rate her pain when it was at it's worst, and asked her to rate it when it was at it's best, and then I quit asking for numbers and put down what I thought she would rate it, just to placate the Joint Commission AHO's.

I don't entirely defend this practice; it would be more strictly ethical to use a behavior scale, but then I have to document the behavior I base the assessment on, and that's time I need for interventions. So I know when she's at her worst, she'd say 11 on a scale of 1-10, and I put a 10. After the med, she'd say 7 or 8, so when she appears less uncomfortable, I put a 7 or 8. In fact, she looks to me more like a 5, is calmer and even telling a few jokes, but still clearly in more than acceptable pain. 5/10 pain still requires further intervention, but please forgive me if I just don't quite believe guided imagery is going to be of help in this situation. So I tell her the truth, that the resident on call has agreed to discuss the situation with the dayshift docs and decide whether she needs a pain management consult.

I do wish, now, that I'd thought at the time to ask the doc about some Toradol, since a lot of the pain seemed to be in the bone. For that matter, p.o. Ibuprofen might have done more good than the dilaudid. I suppose a Hx of colon CA might argue against NSAIDs, but I think they're more of an upper GI problem, and she was tolerating a daily aspirin. Crap. Hopefully, as I get better as a nurse, I'll get better at thinking critically and running my butt of at the same time...for now, I'm afraid I have to rely a good bit on post-game analysis to think of what I'll do differently, next time. As noted previously, I'm still very much a work in progress.

Probably the best thing I did on two whole shifts--at least r/t this pt--was take a few minutes just to pull up a chair and listen to her complain. Put me behind on some other stuff, but it did seem to help. Gave us both a chance to see each other as people, and we actually got along pretty well, after that.

So, going on three years as an RN, I'm not yet the nurse I want to be, but I'm working on it, and I try to remind myself from time to time that a couple of my coworkers who are the nurses I want to be are still working on it, too. Gol durn lifelong learning processes, anyway!

[nursemike, ASN, RN]

Hey Mike,

I never studied Taoism, because my religion professor loved Hinduism so much we never got off it in time to study the others in the syllabus.

Does your quote to me mean it's ok to cry but that I have to make a decision to not take things so personally and as long as I'm there as a pt advocate, damn the naysayers and walk out of work w/ my head held high?

Thanks! Why didn't ya say so?

(p.s. after reading your night about pts in pain, tell me. Does your facility require you to go back and reassess a pt if you give a scheduled med and they say their pain registers 0 out of 0-10? ) Ours does and it's making extra work and more miles on these tough ole legs.

Chloe

:smackingf

Er, uh, yes.

Still working on that succinct thing, too.

[shmoofins]

I have cried more times than I can count both at work and at home after work. I've always been a bit of a crier, though. The stress of it all gets to me.

[poopsie9466]

I'm a new grad and work on a med-surg floor. The other night I got three admissions within a few hours, one of them was a direct admit and took up so much of my time I felt like I was neglecting my other patients. A coworker told me the charge nurse was likely "testing" me to see if I could handle the pressure. After my shift, I cried out of exhaustion and frustration. The day totally sucked.

[ltmja]

I've cried a few times. Once when i first started and then a couple after the shift was over. I think I just dread going into work more than anything. It's not knowing how the night is going to go what really get's me. Other jobs I've had before school I at least knew somewhat of how the day was going to be!