NocturneRN

One of the problems with this whole discussion is that the saying isn't "Look at the patient, not the monitor." It's "TREAT the patient, not the monitor." This distinction is important, because the first version implies that it's an either/or situation----that you must disregard one of the two, and therefore you should disregard the monitor. Obviously, that's not true. You should take both monitor and patient assessment into consideration, but, if the patient's appearance and behavior are widely at variance with what you see on the monitor, believe the patient, not the monitor. A good clinician uses every assessment tool available to get the best total picture possible. But in the end there's no piece of equipment, however elaborate, that can reliably replace good assessment skills.

Here's a less dramatic reason for treating the patient rather than the monitor. I have PVCs----lots of them, on a regular basis. Sometimes I feel them; sometimes I don't. Nurses often get concerned when they see me on a monitor, because they don't know if the PVCs are longstanding, or if they indicate an ominous new problem. But, when they see that I'm asymptomatic and vitals are stable, and I tell them that it's a chronic thing with me, that changes the picture considerably. Years ago, they did treat PVCs, regardless of how the patient looked or felt. Couplets or triplets, or even a brief run of bigeminy, or >6 PVCs per minute, would send the CCU nurse running for the lidocaine. Since then, we've learned that automatic treatment of PVCs (i.e., treating the monitor rather than the patient) is pointless, and can in fact be harmful. When it says "Treat the patient, not the monitor," it isn't saying, "Disregard the monitor." It's saying that the monitor is an important tool to determine what's going on, but that you should also take the patient's general appearance and vitals (and history, if possible) into consideration, before reacting to what the monitor says. Another example of this is asystole. If you've taken ACLS, you know that you don't treat asystole, per se. You consider possible causes (the "Hs and Ts"---hypovolemia, toxins &c.) and treat them.

I'm an introvert and a pretty obvious one, but that doesn't mean I don't enjoy interacting with patients and staff. In general, being an introvert just means that you're most relaxed and comfortable when you're in your own company. If you feel that you're being pushed to put on a fake demeanor for patients and staff, could it not be that (introvert or extravert) you're just tired of being told to smile and use corporate scripting? If interacting with patients and staff puts you on edge, is there a possibility that being overloaded, rather than being of a particular personality type, is what's stressing you out? I agree with others that there are different types of nursing that involve less patient interaction and troubleshooting. I also agree that night shift is great, because the teamwork is generally good; there are no bosses or administrators; and not very many visitors. But I also think that part of the problem can be poor management practices or insufficient staff. No nurse, however outgoing, is really comfortable being told to smile incessantly, and to use fake sounding scripting (saying "Things are active today, but we have adequate staff," for example, when what you really mean is, "We're three nurses down, I've got two critical patients down the hall, and you're complaining because the Kleenex isn't soft enough??").

I'm currently on the last leg of getting a BSN. (After 35 years in this profession, my employer decided to make BSN's mandatory. Not exactly mandatory, mind you, but just mandatory enough that I'm considered unqualified to work anywhere in the system except in my current job.) 3/4 of the way through, what I've noticed is that virtually every nursing class I've had is little more than an advertisement for getting a higher degree and specializing. My advanced assessment class advertised NP school. My community health and informatics classes advertised those specialties. I've learned very little that will benefit me in my present job as a staff nurse. I do have to wonder what effect this has on new nurses. Are they gradually absorbing the message that bedside nursing is just a stepping stone to what nursing is really about? If so, who's going to take care of the patients, if half the staff nurses are studying for higher level clinical and administrative positions?

I just had to mention this: on the list of trending threads, this "Code Blue: What Should I Do?" topic was immediately followed by "Just need to vent for a few minutes."

********************* I'm afraid I've got to disagree in this instance. In my workplace, the rule is that you don't interrupt a nurse who's pulling or preparing medications. The preceptor was wrong to interrupt in this, unless she was interrupting to point out an error in the way the medication was being prepared.

Wow! I'm going to suggest that to the ER doctors and NPs, the next time one of our usual suspects asks for Dilaudid.

Could you just say, "You're in my thoughts"? Most of the time, I think, patients just want to feel that you care about them, and will continue to care about them even after they're not right there in front of you.

******************* "Pumpkin"? That sounds a bit patronizing.

Talk to your unit's (or department's) clinical instructor. It's not a violation of HIPAA if the purpose of learning the outcome is to improve your nursing skills, and if names or identifying numbers aren't used. I'm an ER nurse, and whenever we transfer trauma patients to a higher level of care the receiving hospital does give us a follow-up on the patient (minus his/her name, for confidentiality's sake). Typically, they'll send a brief rundown to the nurse(s) and physician(s) who cared for the patient, labeling him/her "a 47 year old man who was transferred to this facility following a category I car vs motorcycle trauma on August 10," or similar. It's certainly not inappropriate to want to know that you did everything appropriately on your end, and didn't miss any potential complications.

Well, it's also possible that the unit you work on has a dysfunctional environment. That's a management issue, and there's little you can do about it, except put up with it (or switch jobs, if you get thoroughly tired of it). I was a new graduate on a very busy med/surg unit in a big teaching hospital. I stuck it out for 6 months. The manager kept telling me I needed to get more organized; I needed to work faster; I needed to come in early (but not clock in, which was a borderline illegal expectation on her part) and get ready for the shift so I could hit the ground running. I had good orientation there, but I constantly felt like a bumbling idiot, whereas the other new graduate seemed to sail through orientation, coolly and efficiently. Other circumstances caused me to leave that hospital and go back to one in my own community after six months of anguish and frustration. I dreaded it, because my new job required me to take an even bigger patient load. But what I found was that the new job was much less stressful. Why? Because my coworkers were more supportive; because my manager spent more time building me up than tearing me down; and because I'd actually learned more than I thought at the other job. I also learned, on the last day of my old position, that my experienced coworkers considered the cool, efficient new graduate to be "cocky," and predicted she was going to have trouble as a result of her overconfidence. I'd never suspected they felt this way about her, maybe because I was focusing so hard on my own shortcomings that I couldn't see anyone else's. So, whatever happens, keep plugging away, and try not to focus on how you look to others. That's a natural reaction for a conscientious new graduate to have, maybe because nursing school doesn't teach us that there is a big difference between minor mistakes and major ones. (I remember almost bursting into tears, as a new graduate, when a patient's IV ran dry. Sounds ridiculous, but in the nursing school image of perfect nurses, IVs never run dry. I felt like a complete failure!) As long as you learn from your mistakes, consult a coworker (or the physician) if you don't fully understand an order or procedure, and never let yourself get sloppy or careless, you'll most likely do very well. (But it will take a lot more than a few weeks, especially if you're starting out in a specialty field!)

I'm going to remind you of what I was told when I was a brand new graduate, struggling in my first nursing job 35 years ago: Your nursing education, as difficult as it was, gives you only enough knowledge and skills to enter the field. At least 60% of the education you need to functions smoothly on your current unit is yet to come. And it will come, but you need to be more patient with yourself. Instead of tallying up your mistakes, why not keep a list of new key points you've learned each day? As long as you keep learning, you're going in the right direction, even if you're not going as fast as you'd like to. Nursing instructors never say this, but, when you make an error, 9 times out of 10 it's not going to hurt the patient. If you forgot to check someone's episiotomy, just go back in and check it when you do remember, and eventually it will become second nature. If you can't hear a heart murmur, ask someone else for a second opinion. Even the best experienced nurses have to do that occasionally. Most nurses will tell you, "It's not the ones who require a lot of help and input that worry me. It's the ones who think they know it all, even when they don't." It's true. Every last one of us has made mistakes, some of them big enough or dumb enough to cringe over. As long as you correct your mistakes promptly, learn from them, and don't allow them to paralyze you with insecurity, you'll be fine. Just be patient, and do your reasonable best, and you'll eventually get there.

I agree with PsychGuy. I work in an ER now, but some years ago I worked in psych. The ER is just a holding tank for psych patients: you can't do anything with them; you can't take the time to build a rapport with them; and there are just too many distractions to do anything other than making sure they're safe until they get placed. I think the elephant in the middle of the living room here is the fact that, today, hospitals are being run by MBAs and CPAs rather than MDs and RNs. Over the past 16 years, I've seen my own hospital go from being a nice community hospital, where everyone knew everyone else and (whatever got thrown at you) you felt supported, to part of a big, faceless conglomerate. We've gone from having one level of unit management to four, and no one seems to agree on which level handles which issues. Consequently, when you have a problem, you don't know who to take it to. Meanwhile, our policies are constantly changing; our unit is being redone for the second time; and the main manager is leaving after less than two years (she got a better offer someplace else). Not only are we running around like chickens with their heads cut off, but on any given day we don't know where to find supplies, because they keep changing the system on us. But who do we complain to? Our shift managers? They have nothing to do with how and where supplies are stocked. Their manager? She just oversees personnel, and doesn't know anything about the supplies. The top manager (fourth level)? She doesn't even work in our building, because she was hired to oversee the ERs throughout the corporation. I wouldn't know her if she walked up and smacked me in the face. I'm not even sure what her function is; I'm guessing she just attends meetings with upper management. We recently had a new nurse leave within 6 weeks of starting. Another new nurse, who's been there about 3 months or so, is talking about leaving if her old employer comes through with the right salary offer. The ADNs are all furiously working on their BSNs, for fear that they'll get fired if they don't get it ASAP. (No one has said that, but the climate of uncertainty is causing everyone to imagine the worst.) This makes it harder for them to pick up extra hours, so the unit runs short most shifts. We were recently bought out by yet another and bigger corporation. We don't know yet what that means for the future, but we're pretty sure it DOESN'T mean that we can relax and let our guard down. As one newly hired nurse said to me on her first day, "I've heard that, if you can't roll with change, this is not the hospital you should be working at." She's dead on about that.

I remember having similar feelings when I graduated from nursing school many years ago, and started on a busy surgical floor. I had 10 patients, with the help of a CNA who had a habit of disappearing into the lounge and knitting. She was a lot older than I was, and had a chip on her shoulder, so I had a hard time getting her to cooperate. Meanwhile, I was overwhelmed by the IVs, the endless medications, the bed changes, the family members with a million and one questions, etc., etc., etc. The unit manager told me my time management skills left something to be desired, and I always felt as if I were just putting out fires, rather than managing the situation. (I found out later that I'd been stuck with that particular CNA because no one else wanted to work with her, and they figured I was too shy to make waves about it.) The confidence will come. When you first get out of school, it's been drilled into you that every single detail is important. They don't really teach you to prioritize very well, probably because they don't want to give you the idea that any nursing task is unimportant or dispensible. As a result, you're running around trying to do everything perfectly, and that's almost impossible, especially with a big load of patients! With experience, you learn which tasks you must not ever skip or abbreviate, and which can be safely put off. You get used to doing two or three things at once without even thinking about it, and sifting through 100 observations to focus on the ones that really matter. And you get quicker at procedures, just from repetition and developing "muscle memory." Don't worry about those other nurses seeming more confident than you. That doesn't necessarily make them better nurses. Confidence will come, as you get more comfortable in your position. In the meantime, you can always fake it. Someone once told me that school provides only about 30% of the knowledge and skills you need to function in a profession. It gives you what you need to enter the field, and then your real education begins. I believe it. I'm still learning every single work day, and I graduated in 1980.

There is no one specific personality type that's suited to trauma nursing. (I know that, because I'm a trauma nurse and my personality is about the opposite of what you'd expect.) But many of my coworkers ARE type A personalities (as someone else here mentioned). You have to have a quick, decisive mind and a very flexible personality, and be able to juggle several pressing concerns at once. You also need to be very team oriented, since major traumas require a lot of teamwork. There's a lot of documentation required for traumas, too, so it's important to be very thorough in assessments and documentation. It doesn't hurt to have excellent IV skills, too-----it can be rather challenging to get one or more large bore IVs in some of these patients.