Profession for some...attempted by many..

Nurses General Nursing

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The number of new grads who are already contemplating leaving the profession is something that has blown my mind on these threads. Going into nursing school we had fair warning about how difficult of a career it was going to be; the patients who are so thankful for bringing everything when they demand it, the pleasures of dealing with stubborn doctors, the glorious hours, the emotional stress of seeing what we do on a daily basis, the coworkers who always go out of their way to help us. Do people think that we are kidding or that the professors are trying to scare you”? They aren't. Nursing is challenging in every way which is why it is so rewarding. If you have never been challenged in your life, then this will be the most challenging step of your life. But persevere. Stretch yourself. Be patient. And be willing to grow.

Going into the first job we had been prepared (as a BSN student) that finding a job was not a cake walk. Only applying to the L&D jobs or OR jobs is no realistic and I do not understand where these ideas are coming from? Med-surg experience is indispensable regardless of the career path you are on. Prior to applying to my first RN job I got my ACLS and PALS to be marketable and because I am a firm believer in knowing more than you may need for your job description. Though my dream job may be ER nursing one day, I knew that my ideal out of school was med-surg.

I started working on a med-surg floor that is the dreaded unit of the hospital.” Float nurses come to the morning huddle already defeated and frustrated. We have patients in full-blown sepsis, suicides, behavioral health, post-surgical overflow, and everything in between. Just the other day I had a thrombocytopenic patient on the verge of DIC bleeding from every orifice. We do insulin drips, IGA infusions, chemo meds, CIWA protocols, sepsis management, you name it. This is NOT to say that I have it harder than anyone else and you all should be ashamed of yourself.” This IS to say that you can do it and should build your knowledge base. At least for 2 years. You will have a competent base to make a solid decision about furthering your career path and figuring out where you truly want to end up.

NP your calling? Great, how many patients did you actually spend time caring for? CRNA? Awesome, but do you know what happens after they come off of the anesthesia that you administer and pass onto the floor? 6 months is not enough time to be competent in your skills or communication abilities. If you are reading this and want to go to nursing school, do it!! But be realistic and know that it is a JOB. You get paid to deal with literal and figurative poop; from people and coworkers. If you think that nursing is where you can make people feel good all the time, you can't. You are going to be wrong, you are going to handle more than one situation wrong and wish you could have done it differently, you are going to be reprimanded for not calling out report before transferring a patient or not introducing yourself to the patient with your first, middle, and last name....the list goes on and on. You have to find a way to LEAVE IT AT WORK. The emotions you'll take home on some days but find a support system or an outlet. Realize that life is life. We have a huge responsibility of managing people's lives. If that gives you anxiety reading that maybe this isn't the career for you. Not harsh, just honest.

You have to have a backbone, you have to compartmentalize, and you have to realize that it is a job; you have a salary, some sort of insurance (though every healthcare worker has some complaint about their coverage), and you are helping people whether it is appreciated or not. If someone talked you up telling you that you have the personality of a nurse.” That is not good enough. Not everyone can do this profession. Not everyone was built to be a nurse. The nicey nice people pleaser is not going to make it at bedside nursing (Let me tell you, you can be nice, but if you don't have the skill to manage my dropping BP as your patient or recognize changes in cognition level, I sure as heck don't want you as my nurse. We can be friends outside of the hospital.) Covering up incompetence with being overly polite does nothing for your patients. I have seen nurses burn out because of that stubborn old man with CHF who cuses her out. It's ok to have sarcasm with patients and to reinforce the facts of their diagnosis. Our job is to get them better, not become their best friends….Rant over.

Please please please reevaluate how much stress you have been able to handle and how easily your feelings are hurt. Otherwise you will become another statistic in the first 6 months of your nursing career; sad but a cold hard fact. Nursing is a respected profession that many seek out. However, the reality is that only some have the personality and realistic perspective to make it a career. Those blunt, honest, and knowledgeable nurses are the ones that I would want if I had to be hospitalized. Not the nurse who wants to befriend me while dodging questions as to whether my test results came back and the risks of the new medications I am starting. Buyer beware. I love nursing because I was not jaded when I came out of school in the least. I knew exactly what I signed up for….Nursing students, do your research on what you are going into. If you have been reading many of the threads and they are scaring you, this is NOT the career for you. As crazy as they sound, they are accurate :)

Specializes in Geriatrics, Home Health.

Then there are the nurses who couldn't find a med-surg job. I wanted to work med-surg as a new grad. I graduated in 2008, just before the economy collapsed. No one wanted new grads: even nursing homes wanted a BSN and 1 year of experience. I never wanted to work in LTC, but after a 10-month job search, a cancelled job, and a 250-mile move I found a job in an ALF.

I started applying for jobs again at the 1 year mark, to find that the jobs that wanted 1 year of experience now wanted 3-5 years of experience in the specialty you were applying for. I found a job that turned out to be Nursing Home Hell, and ran screaming after 6 weeks. If I hadn't found a job in Home Health I would have left nursing. Life is too short to stay in a job you hate.

I'm sure there are good nursing homes out there, somewhere, but I will only work in one if my family is facing immediate homelessness.

Have you ever heard of Super Nurse Syndrome??

I hope you are transferring these patients out because from what you describe, these are definitely NOT med surg patients.

Specializes in Med/Surg/ICU/Stepdown.
If the patients are in full-blown sepsis, then they are not appropriate for a med-surg. If they are septic per some piece of sheet, then that is a different story. We have "septic" patients that are septic per protocol but not what we would consider septic traditionally. Per the new protocol sheet we have, about 80% of the patients we see are septic but we are not going to do a full sepsis work up on them (nursing home patient is one criteria per the sheet).

Suicides/behavioral health? Those can differ greatly in terms of what they are. Insulin drips generally should not be going to med-surg and should go to a stepdown just due to how often the protocol needs to be done. Chemo meds should be done by a chemo certified nurse. CIWA protocols are generally done initially on every patient and that one seems easy.

One concern is that either your floor is a dumping ground or they could potentially be sending you inappropriate patients. One good thing is when a nurse knows not to play heroics and knows when to ask for help or when to transfer a patient. If the patient is not appropriate for med-surg, then the nurse needs to be able to able to get the patient transferred to a higher level if necessary.

"not appropriate for med/surg" is very vague. It depends on a lot of different factors and it is largely facility dependent. At my first hospital, IV chemotherapy, insulin drips, CAPD, and CBI were totally floor appropriate. At my current facility? Not so much. However, what is appropriate is anything not intubated or sedated or on a cardiac, insulin, or diuretic drip. Everything else is fair game. I held a patient on our unit (who was a recent MICU transfer) for a full week when she was rapid responded up to twice a day simply because "ICU will not do anything differently for her than you will do here." The nurse-to-patient ratio and hours of care required by the patient means absolutely nothing in the grand scheme of deciding if someone needs the ICU or not. And sometimes, "stable" is debatable depending upon who you talk to. This is why each floor needs a set of standards of the types of patients they are and are not capable of taking care of.

I held a patient on our unit (who was a recent MICU transfer) for a full week when she was rapid responded up to twice a day simply because "ICU will not do anything differently for her than you will do here." The nurse-to-patient ratio and hours of care required by the patient means absolutely nothing in the grand scheme of deciding if someone needs the ICU or not. And sometimes, "stable" is debatable depending upon who you talk to. This is why each floor needs a set of standards of the types of patients they are and are not capable of taking care of.

In this day and age of "consumer satisfaction," it's a shame that more people don't understand the implications of nurse to patient ratio. Being a former ICU nurse, I would recognize in a second that my loved one was ICU appropriate, not floor appropriate (due to nurse to patient ratio issues, not nurse competency), and you better believe it I would be taking it up the chain of command on that deal.

They clearly count on nurse submission and patient and family lack of knowledge in those kinds of situations. Just smh...

Specializes in Med/Surg/ICU/Stepdown.
In this day and age of "consumer satisfaction," it's a shame that more people don't understand the implications of nurse to patient ratio. Being a former ICU nurse, I would recognize in a second that my loved one was ICU appropriate, not floor appropriate (due to nurse to patient ratio issues, not nurse competency), and you better believe it I would be taking it up the chain of command on that deal.

They clearly count on nurse submission and patient and family lack of knowledge in those kinds of situations. Just smh...

I (stupidly) attempted to explain this to the MICU fellow who refused to accept the patient. He looked at me like I had 10 heads. It isn't just patients and families that don't get it, but physicians as well. It's an entire epidemic of not one single person in the hospital (including former bedside nurses now in management) understanding the implication of overworked nurses.

"not appropriate for med/surg" is very vague. It depends on a lot of different factors and it is largely facility dependent. At my first hospital, IV chemotherapy, insulin drips, CAPD, and CBI were totally floor appropriate. At my current facility? Not so much. However, what is appropriate is anything not intubated or sedated or on a cardiac, insulin, or diuretic drip. Everything else is fair game. I held a patient on our unit (who was a recent MICU transfer) for a full week when she was rapid responded up to twice a day simply because "ICU will not do anything differently for her than you will do here." The nurse-to-patient ratio and hours of care required by the patient means absolutely nothing in the grand scheme of deciding if someone needs the ICU or not. And sometimes, "stable" is debatable depending upon who you talk to. This is why each floor needs a set of standards of the types of patients they are and are not capable of taking care of.

As an ICU nurse I see M/S floor trying to send us patients all of the time because they are too "difficult". These patients are the ones no one wants and there truly is no reason to send them to the ICU. However, sometimes managers or hospital supervisors will cave and approve these transfers. I have straight up refused the assignment because its not the ICUs job to take a patient because you are sick of them. Rapid response means nothing a lot of the time as many nurses call one because they are inexperienced or just do not know what is going on. I would know, I am on the RR team...

I agree M/S can be difficult in its own right, but CBI and CIWA are totally M/S appropriate as is dialysis. I don't know what else you consider fair game is but I am pretty sure it is M/S or maybe step down appropriate as well.

Yes I have worked M/S and PCU for some time as well......

Specializes in Med/Surg/ICU/Stepdown.
As an ICU nurse I see M/S floor trying to send us patients all of the time because they are too "difficult". These patients are the ones no one wants and there truly is no reason to send them to the ICU. However, sometimes managers or hospital supervisors will cave and approve these transfers. I have straight up refused the assignment because its not the ICUs job to take a patient because you are sick of them. Rapid response means nothing a lot of the time as many nurses call one because they are inexperienced or just do not know what is going on. I would know, I am on the RR team...

I agree M/S can be difficult in its own right, but CBI and CIWA are totally M/S appropriate as is dialysis. I don't know what else you consider fair game is but I am pretty sure it is M/S or maybe step down appropriate as well.

Yes I have worked M/S and PCU for some time as well......

The rapid responses were not called due to "inexperience" or not knowing what's going on, although to be fair, should a Med/Surg nurse with no bedside monitor and no ICU experience be expected to be able to manage someone that remains that ill? The patient in question had just had her tracheostomy replaced after being extubated, was a new dialysis patient, and continued to desat and have extreme hypertension despite the nurse utilizing the appropriate Med/Surg resources (deep suction, PRN medications).

I have never attempted to have a patient shipped off for "being too difficult," although again, if a patient is requiring more than hourly checks, they are not Med/Surg appropriate. I carry a ratio of 1:5 most days--including transfers and admissions. It is unrealistic to expect that I can provide adequate care for a patient requiring 2 or more rapid responses in one shift when I have no bedside monitor and limited interventions I can provide.

With you having Med/Surg experience, I'd think you'd understand the need for lower nurse to patient ratios based on acuity with acuity being related to how ill someone is and how many interventions they require.

If the patients are in full-blown sepsis, then they are not appropriate for a med-surg. If they are septic per some piece of sheet, then that is a different story. We have "septic" patients that are septic per protocol but not what we would consider septic traditionally. Per the new protocol sheet we have, about 80% of the patients we see are septic but we are not going to do a full sepsis work up on them (nursing home patient is one criteria per the sheet).

Suicides/behavioral health? Those can differ greatly in terms of what they are. Insulin drips generally should not be going to med-surg and should go to a stepdown just due to how often the protocol needs to be done. Chemo meds should be done by a chemo certified nurse. CIWA protocols are generally done initially on every patient and that one seems easy.

One concern is that either your floor is a dumping ground or they could potentially be sending you inappropriate patients. One good thing is when a nurse knows not to play heroics and knows when to ask for help or when to transfer a patient. If the patient is not appropriate for med-surg, then the nurse needs to be able to able to get the patient transferred to a higher level if necessary.

You should come talk to our house manager then. I'm on a M/S floor. We take vents, insulin gtts, Cardizem gtts, heparin gtts, full blown septics, suicidals, Lasix gtts, tele pts, post surgicals, post transplants POD 2 and on. Dialysis pts, bipaps, etc. M/S may have been less acute before, but it is ratcheting up fast. This *is* my specialty. I initially thought I wanted critical care, but I am slowly and surely coming to appreciate the complexity and opportunity from my floor.

I don't think it's the acuity. It's the ratio.

You should come talk to our house manager then. I'm on a M/S floor. We take vents, insulin gtts, Cardizem gtts, heparin gtts, full blown septics, suicidals, Lasix gtts, tele pts, post surgicals, post transplants POD 2 and on. Dialysis pts, bipaps, etc. M/S may have been less acute before, but it is ratcheting up fast. This *is* my specialty. I initially thought I wanted critical care, but I am slowly and surely coming to appreciate the complexity and opportunity from my floor.

I don't think it's the acuity. It's the ratio.

Define "vent", define "sepsis".

Vent = pts who require a ventilator to remain not dead. We take pts wo haven't weaned yet, are weaning, are weaning with ridiculous difficulty, and long-term vent dependent. I HATE the long-range apnea/sat/HR monitor alarms.

Septic - Mews of 5 or more, requiring anything short of pressure support gtts. Boluses, bipap, hourly monitoring, IVP rate conrollers, that jazz.

Vent = pts who require a ventilator to remain not dead. We take pts wo haven't weaned yet, are weaning, are weaning with ridiculous difficulty, and long-term vent dependent. I HATE the long-range apnea/sat/HR monitor alarms.

Septic - Mews of 5 or more, requiring anything short of pressure support gtts. Boluses, bipap, hourly monitoring, IVP rate conrollers, that jazz.

Don't get me wrong - having vents on a "med-surg" unit is pretty crazy - but there's a HUGE difference between a wean/failure to wean with a trach and someone with an ETT with huge FI02, huge PEEP, and completely dependent on control modes.

As for the "septic" patients, these patients may have SIRS, but I assure all of you a patient in true septic shock isn't going to fly on the floor.

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