TrishJK

Interesting for me watching how it has been almost unanimous amongst the responders - who all appear to be from the USA - that this young woman deserves a harsh punitive response. There have been precious few posters who have shown mercy, compassion, a lack of self-righteousness, some kind of demonstration that there might be extenuating circumstances etc.... what is shocking to me, as a mental health professional from another country, is: 1) how overwhelming your reverence for the "almighty dollar" appears to be - for the loss of $114 a career is to be lost (and I am not interested in hearing about how dangerous she is to patient safety - that's a furphy to justify your "cut off her hands" responses) 2) what is such an indecisive person doing in such an important position of authority to be coming onto a gossipy site like this to ask how to behave in such a weighty matter? The OP would perhaps benefit from some quiet reflection and some stand-up-and-be-counted decision-making of your own. Use this as an opportunity to grow as a teacher and supervisor: think through the issues yourself and then advise/discuss the matter with your own supervisor

Greetings all I am undertaking some post graduate research on evidence-based practice in working with lesbian, gay, bisexual, transgender and/or queer patients - particularly in the mental health/psychiatric field, but any other kinds of nursing are relevant. In recent months I have witnessed a number of incidents where mental health nurses have displayed from gross insensitivity - up to unintentional cruelty towards gay and lesbian patients in acute care. I suspect their behaviour springs from ignorance rather than malice - there appears to be very little material around to guide good practice. In particular I am looking for EBP guides, position statements and the like from nurses' associations. I found one from the Royal College of Nursing (RCN) in the UK but can't find anything similar for nurses in the USA (excluding GLMedicalA materials) Canada (except this medical one) or Australasia - or anywhere else for that matter. Does anyone have such (or white papers by their association etc) that they could send me, please? Thank you in advance

This is probably silly, but have you thought to remind people to wash their hands thoroughly with soap and water (not alcohol based cleansers - which apparently don't do such a good job with C. diff because of the resilience of the spores). Also, it can't hurt to throw some white vinegar in the washing machine with his clothes and sheets; and all over the bathroom for that matter. You haven't said how advanced the dementia is - but, assuming he's no longer competent with ADLs - is someone ensuring his fingernails are clean and short? Finally, gastrolyte or similar is probably a good idea to keep his electrolytes balanced. Hope this helps.

Hi Lola I agree with Moogie (Hi Moogie). Here are my suggestions: 1. Time management skills - learn how, fast. 2. See a doc to check for any underlying conditions. 3. Learn how to set boundaries - all that overtime suggests a need, here. 4. Stress management - e.g. relaxation and mindfulness exercises - need to practise daily - if you don't learn to de-stress your cortisol will kill you! 5. Sit down with your best friend or a notebook and figure out a) where/why it is going wrong for you (you then know what else you need to change) and b) where you want to go in your life and in your career in nursing. You can then work to a plan. Take control sooner rather than later, Lola. Best wishes Trish

Hi Thunderwolf Great article - thanks muchly. I have just discovered two great theoreticians/clinicians on BPD: 1. Dawson, D & MacMillan, HL 1993, Relationship Management of the Borderline Patient, Routledge Taylor & Francis Group, New York, NY Dawson is really big on the tactic of having the BPD solve her/his own problems by deflecting - "I don't know, Sally. What do you think?" This serves several purposes: not getting the therapist sucked in to the current psychodrama; helps to focus the interaction on the BPD as a competent adult; gives practice in objectifying and thinking through issues etc. Dawson also recommends the use of the uncomfortable silence as a place which encourages what he calls "switching" - where the BPD goes from acting out oppositional and other unhealthy needs to beginning to think how she/he can solve the current problem (empowering). Dawson's key theses are summarised in this article. 2) Marsha Linehan's work is illuminating in suggesting ways to work with BPDs. Linehan developed dialectical behaviour therapy (DBT). DBT uses validation and dialectical change-based strategies to help BPDs learn new ways of coping. This reading list was developed by Linehan. Thanks again for a great primer, Thunderwolf. Best wishes Trish

Hi Rachel Zana2, HouTx and Emmalou have said more useful stuff than I could think to say. I went back and checked out last year's comms. You got some t'riffic advice there, too. So, as requested, here goes again - apologies to the three above - you have probably already said it: 1. Remember the universe wasn't created in one semester. Slow down. If you run the whole time (from experience to experience) you won't really appreciate any but the most shocking/toe-stubbing moments. And, as you discovered last year, your metaphorical charging around upsets the locals. 2. Keep a small notebook in your pocket so that when you feel that almost uncontrollable urge to interrupt with your oh-so-important question you can consider stepping away and jotting it down for reflection/research and/or later clarification with an experienced nurse. This will depend on the situation and all those variables already identified. Learn how to exist in the moment without seeking validation from others that you exist. 3. You are the future of nursing. You are an important person. You are a valuable person. You are being given a huge privilege by very sick people and very hard working nurses - the opportunity to learn from others' experiences and to practice so that you can make mistakes safely. I applaud your desire to be as good as you can be. Regard this semester as an opportunity to hone your judgment skills. I sense your fear that you will receive more criticism than praise - and that this is your personal valley of the shadows. You have a huge hunger for approval. If you are not careful, it will continue to be your undoing - in nursing, in life, in general... Learn to make a steady, quiet inviolable centre, Rachel. Learn it sooner rather than later - and spare yourself this continuing world of hurt. (Consider signing on with a private psychotherapist who can help you to build it). People will not remember what we said. People will not remember what we did. People will remember how they felt when they were with us. Sometimes the best we can be is quiet and present for someone else - learn how to be quiet, Rachel - so that you can really learn what's going on around you. If you can really learn what's going on and then respond appropriately, you will make the kind of difference that people remember because it mattered (and coincidentally, get the kind of recognition that you crave.) When I was an oncology patient I felt very, very physically sick. Early on after my surgery, if my oncologist had stood at the end of my bed and said "You're cactus, babe." I would have said "Thank God." That's how physically sick I felt. There was a young nurse there who was assigned to look after me. She thought it was all about her. She had no idea that I even existed as more than a praise and gratitude machine for her. She spoke loudly, she moved loudly. Her keys rattled loudly. She smelled loud! She bristled with a sense of dramatic self-importance ("Look at me - I am Flo Nightingale reincarnated. And I am sexy - just like those gorgeous nurses on tv.") If I had had the energy I would have told her to go away. If I hadn't been scared that the quality of my care would deteriorate even further, I would have told her to go away. I dreaded hearing her coming. She didn't notice that I was in pain and too sick to say so. She didn't notice that the sun was reflecting off a picture hanging on the wall right into my eyes and I was too sick to turn over without help. She didn't notice that my mouth was dry but I was too sick to sit up to take a drink. I told her I was lying in a puddle of urine and she was hugely irritated that I wanted her to change the sheet. I used the very last of my energy to ask her to wash her hands when she tried to change my SPC without doing so first. She stormed off in a huff and I didn't see her again - thank gawd!! I will never forget her - and I love to tell the story of her complete incompetence. She made me feel that I didn't matter; that I was a nuisance. She terrified me. If I ever see her again - I will happily tear her a new a-hole. Good luck, Rachel. You can do it.

overview from australian government here and/or here suggest you answer this after doing some reading from the above links like everything else, depends on the nurse, the treator, the circumstances in general. could you be more specific? depends on years experience as well as qualifications, hours of work, employer (eg govt or charity not-for-profit or private for-profit), state etc. interesting article covering lots of the issues here.... otherwise, suggest you google "nursing pay rates in australia" very - desperate shortage of nurses australia-wide - especially in rural areas. do you mean apart from the satisfaction of a worthwhile job done well? tax concessions on salary is the obvious one. good luck with your assignment

It'sa beatup. I do na believe't.

Congrats, you go-getter you! Wow. That is verrry groovy.

this sentence appears to be the crux of your problem: whoever told you the patient didn't want you for a nurse is NOT your friend. Stay away from this person. You are so upset you're not expressing the problem in terms others can readily understand. Do an SBAR on it OK? (State the Situation; briefly describe the background; briefly give your assessment of the problem; recommend what needs to be done next). By the way, what needs to be done next is to 1) stop beating yourself up. Are you the first perfect humanoid on the planetoid? 2) Calm down. Take a deeeeeep breath. Go for a long swim. Sleep for 8 hours. 3) Get over it. Say "wot the hell, I did my best. Next time I'll do better because I'm a good person." Repeat this enough times until you stop feeling the need to beat yourself up. By what you've written, no great harm was done. Buck up, babe. Chill. ps. where is your spouse? Why isn't this person saying what I'm saying? Where is your best friend, ditto? best wishes Trish

Or - why it's a good idea to insist on medication reviews Or - what about seeing a psychologist and maybe changing your lifestyle? Here is the meds list for a woman (50) with a medical history of COPD, seizures, seasonal allergies, HT, impaired gastric motility, anxiety, depression, and GERD ... oh, and epistaxis attributed to the current diagnosis: Osler-Weber-Rendu syndrome: -Fluticasone /salmeterol - the former is a synthetic corticosteroid (anti-inflammatory); the latter is a long-acting β2-adrenergic receptor agonist (bronchodilator) used to manage asthma and COPD; -Albuterol (Ventolin) - a short-acting β2-adrenergic receptor agonist used to relieve bronchospasm - for example, in asthma and COPD; -Ethosuximide is a succinimide anticonvulsant, used mainly in absence seizures (who wouldn't want to disappear with this arsenal to pour into yourself every day - but, see the other drugs below that can cause seizures). -Loratadine is an antihistamine marketed for its non-sedating properties. -Verapamil is a calcium channel blocker used in the treatment of (inter alia) HT. It has also been used as a vasodilator during cryopreservation of blood vessels. Could this excacerbate the telangiectasias associated with O-W-R syndrome?; -Metoclopramide is an antiemetic and gastroprokinetic agent primarily used to treat nausea and vomiting, and to facilitate gastric emptying in patients with gastroparesis. -Promethazine is a first-generation H1 receptor antagonist, antihistamine and antiemetic medication. It can also have strong sedative effects and in some countries is prescribed for insomnia when benzodiazepines are contraindicated; -Alprazolam (Xanax) is a short-acting benzodiazepine used to treat moderate to severe anxiety disorders. It possesses anxiolytic, sedative, hypnotic, anticonvulsant, and muscle relaxant properties. Is there an argument that it could replace the ethosuximide, metoclopramide and temazepam?; -Temazepam is another benzodiazepine. It is generally prescribed for the short-term treatment of sleeplessness. It also has anxiolytic, anticonvulsant, and skeletal muscle relaxant properties; -Duloxetine is an SNRI (serotonin-norepinephrine reuptake inhibitor) that is effective for major depressive disorder but has been described as inferior to antidepressants like sertraline and escitalopram; -Esomeprazole is a proton pump inhibitor used in the treatment of (inter alia) GERD (could she be trying to "throw-up" her life?) -Aminocaproic acid (Amicar) is a derivative and analogue of the amino acid lysine and is used to treat bleeding disorders; -Ferrous sulphate is used to treat iron-deficiency anemia; (resulting from all that bleeding) and finally -A multivitamin (to give her the strength to cope with all the meds?). Inhaled corticosteroids like fluticasone are associated with oral candidiasis, while salmeterol may increase the (low) risk of asthmatic death, promote bronchial inflammation and sensitivity and increase BP - all of which is fairly depressing, especially if you have HT. The most common side effects of albuterol include nervousness, dry mouth, and palpitations. Other symptoms include disturbances of sleep and behaviour. The salmeterol makes the albuterol necessary. Could the COPD regime contribute to the symptoms for which the alprazolam and temazepam are prescribed? Common CNS effects of ethosuximide include insomnia, nervousness, and others that misleadingly suggest depression; common GIT effects include dyspepsia, vomiting, nausea and others (hmmm... just as well she's also taking esomeprazole and metoclopramide) and one would also be looking out for pruritic erythematous rashes (aka malar or butterfly rashes). Dry mouth, blurred vision, and GIT disturbances are amongst the most common side effects of loratidine but it is also associated with (inter alia) depression, sleep disturbances and hypersensitivity reactions including bronchospasm - oh, and it's contraindicated in epileptics. Could her telangiactasias be ecchymoses due to the facial flushing associated with verapamil? Metoclopramide is contra-indicated in patients with long-term depression. Promethazine commonly causes respiratory depression in patients whose pulmonary function is compromised (e.g. people with COPD) and (extremely rarely) seizures. Alprazolam's possible side effects also include respiratory depression and.... wait for it: skin rash and (more rarely) suicidal ideation. Temazepam is contra-indicated in people with hypoventilation and depression. Duloxetine commonly causes nausea and insomnia and is also associated with disturbances of the GIT, such as nausea, indigestion, vomiting and profuse bleeding as well as anxiety, nervousness and agitation. Could this tendency to precipitate bleeding also be linked with the epistaxis (the cardinal sign of O-W-R syndrome)? Common side effects of esomeprazole include GIT symptoms like abdominal pain. More severe side effects include severe allergic reactions, severe stomach pain, and unusual bruising or bleeding. In other words, could this poor rattling/rattled woman be suffering from adverse pharmaceutical effects rather than O-W-R, depression, anxiety, and ... just what exactly is causing her GERD? Looks like a case suitable for pharmacological review, psychological counselling, a second medical opinion and maybe a change in lifestyle. References: Case study; medications actions, adverse effects, etc from any reputable pharmacopoeia (example) Comments from the front line by experienced RNs and Nurse Practitioners would be welcome.

Priceless - more proof that it's ok to consume people in the same way we consume stuff: and he's not even just from the retail trade - he's from FMCG - fast moving consumer goods.

Wow! That's brilliant, Diane - so succinct and yet so comprehensive. I am taking a copy of this! Thank you.

Poor you, Scrubby. Bummer and a half. how did you land yourself in this fine mess? I agree with the other poster. Surely you can get out of this awful supervising-of-soon-to-be-ex-friends job? Good luck Trish

2ndwind you're a comedy writer! I'm laughing - and oh yeah - I can see it - and Act 2 is where RN rushes off to tell all the other RNs ENs MOs cleaners, kitchen staff and anybody else she sees, her delicious new goss.

It's not the face to face meetings that bother me so much.... I guess you'd just be happy to turn the other cheek, eh? having said that, I'd rather my fellow nurses didn't know I was officially crazy ...er... that is, if I was, which I'm not - officially anyway.... you get my drift

Are nursing students paid for their labour on clinical placements in the US? In Australia we "volunteer" our time in exchange for the chance to gain experience under a preceptor. It has a really medieval guild flavour.

speaking as a patient I would refuse point blank to be cared for by anyone I knew. I can't imagine much worse, in fact, than being nursed by someone I went to uni with, or was taught by...shudder. No way! I would hope that they had the manners to get themselves transferred to another patient before I had to make a scene about it. OP - can you imagine allowing one of your classmates to attend to your BMs or give you pain meds per rectum?

G'day Is a GPA of 6.5 from an Australian university considered good/reasonable/average/acceptable - what? for applying to do grad dip; a PhD? Do prospective employers care? I'd appreciate your thoughts - particularly if you are an academic or a boss. Also - one of my lecturers said "You should do research for an advanced degree; you already have a Masters (in an unrelated area) so you could probably go straight into a PhD program. I'd be happy to be your supervisor." Is this a personal honour/compliment or are lecturers looking for students to do projects under their supervision for some reason (eg continued funding?) i.e should I be flattered and touched by a compliment or am I inflating my sense of myself? Again, I'd appreciate your thoughts - particularly if you are an academic. Thanks in advance

How about instead of challenging them to a debate here, you join the union, join the RCNA, go back to uni and do a teaching cert and maybe do a better job of teaching than the people you're criticising (because you have more recent experience? My teachers all still do regular clinical shifts to keep their hands in), start some practice development projects with your team in your work place, go back to uni and do a research masters on your topic and then get it published; go on the conference circuit. Maybe you could switch your specialty - go into learning and development? Lots of options for you - lots of things you can do to promote change and/or debate if you're that unhappy, eh? Speaking as a student with a number of degrees in related and unrelated areas, including a Masters, and doing placements in aged care, rehab and mental health, I have so far found terrific cooperation from allied health, and experienced nurses have been great tutors - I don't think anyone thinks I'm a dodgy dangerous idjit - and I don't think I am either. I take my studies very seriously as do 95% of my fellow students - and I am streamlining my subjects, placements and readings to end up where I want to be. Finally, I haven't gained the us/them impression in any of my placements (and instead, the respected nurses' opinions were valued by all). Good luck ps a holiday first might help - you do sound a bit tired pps I just had another thought - if you've recently had a bad experience - or are currently copping grief from someone here is a website where you might get some tips on how to deal with him/her/them. Best wishes

You are a gem Rachel - except maybe now you're being too hard on yourself. I think (here I go again) that intelligent, reflective people who are passionate about the things they care about and who have the confidence to speak out effectively are a very rare breed. (Most of us end up - like me - with foot in mouth). It is especially impressive when someone can take a kick and get right back up and stay gracious. Very rare. For what it's worth, I think you have shown huge strength of character and courage in this thread. Simply huge. Wow. I am sure your meeting with the advisor will be a triffic success. Best wishes

Rachel I was far too much of a smart arse in my reply to your OP. I apologise for being so opinionated and coming across as an aggressive sheet rather than helpful. From all your posts I've read you come across as a smart, energetic, lively woman. Take care and good luck

i make the following assumption in my analysis of your text, grace: that you have highlighted the second statement to demonstrate what you see me doing with the first statement. in which case: very good grace - ya' busted me! in my (i hope gutsy, reflective) analysis here i will claim one thing: i directed the first blue statement strictly to one person about whom i made certain "intelligence, social awareness, warmth and understanding" assumptions (based on reviewing a number of rg posts over time) rather than to "all the members" (many of whom are demonstrably not "filled with intelligence, social awareness, warmth and understanding") - hence my bs assertion in the second blue statement (which i stand by). my direction to rachel to behave in a certain way (i.e. i expected that it would be hard to read - she has already made it clear she doesn't like to be criticised) was at her invitation (to provide "thoughts/opinions/advice"). upon reflection (thank you, grace), i recognise that i would have been better to leave out that first blue sentence. rachel i apologise for being manipulative - i should have said "brace yourself - i'm about to write some possibly hard-to-read thoughts atya." let's not fall into an epistemological rabbit hole, ok grace? best wishes

Thanks Scrubby - I agree. To clarify, then - while working with them she is an honorary member of the team - who they can expect (hope) to rely on to do as she is requested, and participate as required. Teamwork in the multidisciplinary team is essential. As such, the student needs to learn how to be a teamplayer and will be measured on this variable. Best wishes ps mykidzmom was right, Rachel - I absolutely do not intend to take out angst on you - I purely intend in my blunt way to give constructive input on the basis of my experiences. My response took hours to write. I believe that spleen and vents tend to show signs of rapid "explosive" typing with typos etc

I agree with most of what Grace, Whispera,mykidzmom and emmalou said and think they have given you wise advice. I think Teensmom's idea of getting a hearing test is a good one. Dolcevita's point about passive aggressive people complaining sotto voce behind backs is valid in this case particularly because people are being asked to judge your performance behind your back. So why do I post separately, here? I want to be tough on you, Rachel - since you've got the guts to take it and reflect on it constructively. If you leave it for a couple of days, (until the heat goes out of you on this) you'll see that while your post gives the appearance of acceptance of the drubbing and trying to learn to do better, there is also a strong underlying element of "poor me - nobody understands (those Philistines - I have a heart of gold) - it's not fair." You are on placement as a courtesy - but it's an even balance - you give your labour for free and in return you are entitled to be given tips by your preceptor - not every other RN or EN on the floor or in the lunch-room, or the NUM (who, depending on his/her age and ego-strength may be entirely unaccustomed to being questioned by a brash student and in any case is too bloody busy for you). Shut up. Speak only when spoken to. Ask questions only of your preceptor (who has agreed to be placed with a student) and only after the rush is over and he/she is receptive to your desire to clarify things - never in the middle of his/her work - unless by prior agreement (eg "Is it OK with you if I ask why you're doing things while you're doing them - or would you prefer me to save questions for later?") Shut up. Look alert and interested at all times and ready to engage if someone is willing to engage with you. You are on their turf. They are busy. They may be tired or sheety or wotever else you don't know about - and don't need to know. You'll be gone soon; you may never see them again; you are not a member of their team - they have built trust with each other over time you don't have. Never ever ask a leading question - ("Here comes that smartarse student") - it implies you know better and are giving them the opportunity to explain their mistake. (eg. "Why are you giving that IM dorsolateral? We were taught that EBP is ventrolateral.") another example where you are directing people to behave in a certain way is Really? BS, Rachel - you are trying to direct your audience to behave in a certain way. Listen. Learn to listen. Listen harder. Listen to body language as well as to words. Shut up and listen. Stop giving the appearance of honesty and be honest - with yourself mostly (Sorry that sounds hard - you can take it, you sort of first year, sort of second year student, sort of expert in so many different nursing areas, you.) No you don't - not of the RNs' perspective - and since when is the other students' behaviour relevant? (Hint: it's not.) Could it be they heard you coming, Rachel, and ran the other way? Listen to your facilitator - don't give us the "what would she know", number In this quote you are doing the same thing you did in my first quote from you - telling us how you want us to think. (Think about this - it is not conducive to learning.) Bad. Very bad. Shut up. What's natural? Dogs bark at strangers - do we allow it in the house? I'm not going to do this for every one of your points, Rachel, but trust me, I could if I wanted so to do. You're a smart woman, you'll get the gist from this one: 1. "I let out" implies that you don't own the mistake - it escaped by accident/you were not in control - why not? Were you not conscious, alert and oriented? If so, you are responsible and should own it if you really want to learn. "extra large gob of sputum" implies that you think anyone sensitive would have responded as you did (ie another justification for your error - and one that also implies other people are not as sensitive (valuable) as you. 2. "Totally unacceptable, as even though the pt was sedated..." You again demonstrate that you believe you don't own the unacceptable action - there is no pronoun here - whereas elsewhere you use the pronoun easily. 3. I can see you resentfully rolling your eyes - after all - the guy was doped up - that should have made it ok, right? (Won't someone please agree that they've been too hard on poor lil me?) - ie another special pleading. 4. "I could have scared them awfully" is just pure sarcasm 5. Your apology was you and your strong personality forcing yourself into their consciousness again, begging them to treat you as one of the team. 6. "Unfortunately they treated ..." bullsheet, Rachel - stop lying to yourself, let alone your audience - some of us are smarter than you and most are as smart as you (surprise, surprise) and none of us likes to be patronised - especially by a young pup with an ego as big as the great outdoors. All your examples are like this, Rachel. You want to learn? Take the ouch - I mean it well - obviously I too have a strong personality and have made the kind of mistakes you're making - and still do: pobody's nerfect. You don't "appear" "overly confidant" - you are - and you are defensive - saying you're not don't make it so, too) Specifically, I think you need a hand with: Being willing to learn - you can't step "outside [your] role as a student" - duh - you are a student. Learn to listen, first. Don't they teach active listening at your uni? Shut up and listen with respect to your elders and betters and do as you're requested to do. "Carrying myself as "a professional" - not a friend of the patient or the staff (and not an equal of the staff, either)" correct - and stay away from the NUM Taking your licks with dignity and honesty Be kind enough to yourself that you allow yourself to make mistakes - so you can own them when you do make them. Because you're a smart, energetic, passionate person I'm sure you'll do well. Good luck. ps I wouldn't have bothered if I didn't think you were worth it Best wishes