RNJill

Oh my gosh...sooo many. Several years as an RN and now a short time as an NP has given me a wealth of odd encounters. And yes, I would agree with the previous poster who said that "odd" is the norm with patient interactions. LOL. 1) I had a patient once who was obviously withdrawing from a number of substances and ended up on my unit because of unaddressed complex medical conditions too (at this moment, cannot remember exactly what). She became increasingly agitated throughout the day, refusing a lot of treatments, pacing around her room, getting angry with her sitter...the usual song and dance. Of course during this lovely day I had an orientee with me who was understandably quite intimidated by this crazy lady. So finally, it's near the end of the shift and this patient has tried to light the toilet paper in her bathroom on fire with a cigarette lighter and I called the hospital police. The police tried to take a calm, hands off approach and the next thing you know the patient had slipped off her gown, tossed aside the cigarette lighter, and was parading around the halls of our small unit totally naked Had an interesting conversation with the MDs that hey, this patient is actively leaving, naked, and apparently doesn't have the necessary psych hold papers in order to prevent this. Of course like every other patient on our half-circle shaped unit seemed to be looking into the hall as this spectacle occurred. 2) Just recently, a patient told me with a COMPLETELY straight face that "I have diabetes but I'm not a diabetic." What? I didn't even ask anything further because it was just too bizarre. 3) Speaking of diabetes, I also have a patient that has fairly poorly controlled diabetes and inexplicably continues to eat a pint of ice cream every night...and complain about weight gain in earnest. Seriously. The entire story is confirmed by her husband at appointments. 4) A random patient's visitor (as in, not my patient that day and I certainly did not know the visitor) called out to me as I was walking down the unit where I used to work as a nurse. A middle aged, fairly normal looking guy. Said he just wanted to tell me that I "had the perfect nose for a girl." Ummm...thanks?? 5) When I was a charge nurse, I at times was summoned to patients' rooms to basically hear their complaints. I was talking to a patient who was providing a litany of complaints...she hadn't been helped right away when she came from PACU, her IV had beeped all night, this was the worst hospital, etc. I was patiently listening when dietary arrived. Patient exclaimed that she was hungry, starts shoveling in food. Tell her I'll come back to let her finish. Return and she's like, "Oh, I think I was just hungry. I'm good now."

The biggest thing that I can echo that has already been mentioned is taking the time to do protocol orders! When I was a nurse prior to being an NP, the hospital I worked at FINALLY underwent a research-based project to place more protocol order sets for patients-especially post op ones. While this is kind of a minor example, we suddenly had a lot more patients with more comprehensive PRN orders for Zofran, JP drain amounts, etc and it cuts down on at least some of the calls. Also, along those same lines, if a patient with baseline crazy vitals (sorry, that didn't sound very professional! Ha) is admitted, it is very helpful especially for newer nurses who may not be as used to a patient waaay outside parameters to have very personalized orders. Ie, notify for SBP over 180 and/or symptoms including headache. Additionally, if it's a teaching hospital with a lot of resident coverage or just a place where a provider has the ability to do this, it's nice when the provider very quickly touches base with the RN about the patients in the evening or early in nightshift. You never know what will come up later, but I think often the nurse could predict that pain might be an issue, the patient seemed better/worse, etc.

Unless you are on the verge of homelessness or something similar, I would NOT take a position with only a week's orientation if you're completely inexperienced. Yes, that is a nice salary especially if you live in lower cost areas. However, even for the most confident new grad with some sort of healthcare experience that is like 1/8th to 1/12th of the orientation length you should/would receive in the proper setting. And as someone else mentioned, as an RN in an LTC setting you'd probably be in a supervisory role. Save yourself the trouble of being destroyed by stress or burnout after a month or two if at all possible wait for a more suitable offer. They probably have high turnover anyway if they're only offering a week of orientation.

I definitely could cut down on sweets. Not overweight but I loooove chocolate, basically any homemade baked good, and ICE CREAM. And yes, over the previous long weekend I did visit a new-to-me but very popular bakery in my city and enjoy a large red velvet cupcake...after diagnosing multiple patients with type 2 diabetes at work Sometimes, especially after my long and busy work weeks, I'll spend Saturday doing absolutely.nothing. As in, wake up, eat breakfast, Netflix, play around online, random snack, nap...you get the picture. Those days, it's a miracle if I even do a load of laundry. And you're asked, pooh, did you do anything fun yesterday? And it's like, yeah, I Netflixed and introverted. My coffee consumption is creeping up as the years go by. After some dental work/implants followed by whitening, I was told NO COFFEE but I don't even care how poorly I'm following that rule.

I think one thing to realize that will hopefully be at least somewhat comforting-although not a magical fix-is that 3 months is just the beginning of a career. It is entirely natural to feel out of your depth at this point and feel like there is so much unknown in your day that can lead to feelings of anxiety and chaos. You're also in that no man's land of being definitely off orientation but so far from being an experienced nurse. So first, give it a little time. Carefully assess the entire picture to see if *anything* has improved. Are there skills that have become easier? A patient that you have really connected with? A crazy day that you have managed to stay calm in the midst of? A work buddy that you have made? I say all of this having ebarked on a new career phase a few months ago and feeling a lot of what you did-hating so much of my work and regretting my job change sooooo deeply. Now, however, things are kind of better. My skills and abilities have improved, my place in the work setting has been better defined, and the list goes on. Things are definitely not perfect and they will probably never be. I still get angry and or frustrated sometimes, but at least now when I do leave I'll be in a much more rational place to determine the next step. However, in the meantime for you there's nothing wrong with casually looking at other jobs, at least you'll know what's out there! In the meantime try to take care of yourself in any healthy way possible, and just know that sometime soon, a little more experience (painful though it may be) may alleviate some of these awful feelings. Good luck.

I used to get report a lot from ER, and in response to the last thread, yes I could read a lot about them in the EMR and had no problem doing that. Really, I had NO problem not hearing about every single operation they'd had since 1968 and not hearing normal lab values read off to me. I guess what it boiled down to for was an honest and current update. This meant.... 1) Brief reason for admit (the sheets we got often barely even said this because notes hadn't been written) 2) And honest set of vitals if things have changed drastically since the last set...e.g., if the BP has only been controlled for short periods after IV push meds 3) Outstanding meds/labs to give/do. And no, I wouldn't be snarky if some stuff hadn't been done. It is just helpful for planning. 4) Abnormals on head to toe; major/contributory medical history. 5) That they have a working IV. Not worried about every detail...just that it works and is hopefully not like a 24g...but if that's all anyone could get, not a problem. 6) Anything truly bizarre going on...patient is really confused, angry, etc. ....and really, I think if they're coming from ER that is a solid start.

It is definitely possible as I worked with at least a handful of people who'd moved from dialysis/LTC/clinics to my inpatient unit. Funny thing is, I feel like on the impatient side there were always those people who were desperate to go to outpatient settings after a year or two í ½í¸„

Depends on what you mean by that. On one hand, coming off as quiet and reserved can actually be an asset. I'm an introvert and those adjectives can fit me until I know someone, but they have never really been a disadvantage. I think in nursing they can translate to a quiet confidence that makes people feel well cared for. Also, people are tired/stressed/in pain/overstimulated so being a super bubbly classic extrovert is not inherently beneficial. Simply put, if you're stressed about being an introvert vs extrovert, please don't worry. However, if by "poor social skills" you are taking about not making eye contact EVER, not being able to do a quick handshake or introduction to the patient's family members, being rude or over-the-top unhelpful to coworkers, or just having no ability to empathize with patients or be gracious in difficult situations....it's going to be incredibly hard. A lot of nursing...heck, for me, even a lot of being a nurse practitioner...is connecting on some level with patients and then coworkers. If this is really difficult for you and steps aren't/can't be taken to correct that, nursing will probably be extremely frustrating for you.

I also feel like another issue, regardless of simply *whether* or not change occurrs, is if it occurs in a way that changes things before a long period of time has passed. My former workplace where I was an RN started to have some serious retention issues related to both staffing and heightened complexity of patients on the unit. It took six to 8 months where like 60% of staff resigned for measurable, real efforts to fix the problem began. By then, the unit's reputation for massive turnover and being "the crazy place" to work had gotten so ingrained that the cycle continued. Of course so many new nurses/preceptors needed/changes burn out the remaining few even more... So yeah, that was kind of a ramble, but basically to say that seeing the results of a change is an entirely different thing than "will they make a change"

The other conditions/issues listed seem irrelevant to the vanc dose issue...obesity, multiple comorbidities, tons of meds, etc. They definitely seem like things that shouldn't affect the rate of vanc too considerably for the patient. Vanc is typically one of "those" meds/antibiotics for the chronically ill/multiple comorbidities/MRSA + patients only, so seeing it along with a laundry list of meds shouldn't be surprising. A large dose (still would kind of like to know the mg amount) on a newly admitted patient would not be surprising esp in the case of a new or worsening infection. IDK if you have a pharmacist available or even micromedex/Epocrates, but your workplace should have at least one of those resources available to you be it online or in person. That way you can objectively verify doses and interactions with other meds. I would be concerned about deciding to hold IV meds, esp abx, or change dosing rates dramatically based on the opinions of others/yourself...it seems like a good way to be questioned in the future about why an unwise decision was made (NOT an attack, just thinking back to my RN days and giving zillions of meds).

Enjoy your 8-9 hour days...I would not recommend trying to orient/work as an RN on the weekends. Yes, it is nice to have RN experience (I had a respectable amount before becoming an NP) but I would say that now that you are an NP you should focus on that role and avoid getting burnt out. Obviously if you're enjoying the NP role right off the bat then you are doing something right...in terms of your own personality/work ethic/job environment/skills/etc and I would be hesitant to make your schedule much tougher by adding in essentially another job.

Ehhh, do what YOU want and tune out the peanut gallery :) I can tell you that people will ALWAYS have comments (even about the stupidest things at the most ridiculous times!) and really, that it all the more reason why YOU should make the decisions for yourself. We don't always love what seems sensible to other people and careers take unexpected paths that no one from the outside can judge. As long as you have really investigated whatever career path you want to take...be it nursing or something else...you should feel secure no matter others say. Don't feel like you have to give people a long-winded explanation either! Even when I was in NP school I had patients ask when I was going to be an MD. I reached the point where I merely told them, kindly but calmly...."never." It was amazing how quickly and painlessly that ended the discussion. Good luck!

Thanks Jules A. I'm a pretty intuitive person and I feel that you are probably right. Even though I'm kind of freaking out that I've basically uprooted my life only to realize that this position is not right AT ALL I appreciate the truth. On a only-half-joking note, if anyone is looking for a NP and willing to treat me like one- primary care, geriatrics, transplant, adult - I am SO interested

Thanks all for the suggestions; I appreciate it. Thankfully the other midlevel is largely on the same page as me re: autonomy. I think the biggest thing that needs to be determined between her, me and the MDs (yes, I'm in a transplant setting, and yes I realize this may be a little identifying but honestly don't think it's the end of the world) is what LEVEL of autonomy we can all agree on. I'm hoping that as I get close to my formal eval in a couple of months that this can possibly be discussed amongst ALL of us. The other midlevel just told me this week that she is NOT a billable provider (which actually doesn't make sense), so I think part of my "homework" needs to be figuring out what other NPs across the institution do before our group meeting. I honestly have a feeling that they are NOT all this hemmed in. Hopefully we can maybe even get some support from the administrators/financial people/other directors in the group in support of billing authority. Just have to tread carefully so I don't burn bridges. I also intend to continue to solicit feedback re: my performance, areas of improvement, what I can do to further my level of independence, etc. One MD has worked with MDs before and is very comfortable with them and I honestly have a lot more freedom with her; the others will definitely be more resistant and I have to tread carefully. I have a feeling I'll probably end up leaving sooner rather than later (nothing too crazy, but at the year mark) because of the combination of staffing + autonomy. I also think the autonomy thing can't be fully addressed until the staffing is improved, which I understand but I think the commitment to fixing that will become apparent over the next few months. And honestly, if it's not fixed well it will make my decision pretty easy. Thanks again all!

Re: seeing the MD, just tradition on their part and I think just them not embracing us as actual providers. I'm in a state with independent NP practice so it certainly isn't a legal requirement. Thanks for the encouragement to continue looking at least by the 6-9 month mark. It helps to know I wasn't alone/crazy in thinking this.

Sooo, I'm having a dilemma. I started my first NP job about a month ago and for multiple reasons it is just NOT turning out to be what I envisioned, both in a work-life balance and even more importantly, a professional way. I was initially so excited about this job. I'm working at a world class institution (if nothing else comes of this career phase, at least the name will look good on a resume) and thought it would be awesome/advantageous to further my RN specialty by taking a first NP job working with a similar patient population. I also suspected that being in an academic environment with multiple resources and the support of a fellow midlevel/a few experienced attendings would be a solid way to start as an NP. I'd heard from a few former RN coworkers turned NPs that some settings who'd never used NPs before or just expected COMPLETE autonomy instantly were pretty terrible work environments that they had quickly left. However, fast forward a month and there are some serious issues. First, and perhaps least important (LOL) is the fact that the other midlevel and I work 10-12 hour days 5 days a week. Truthfully, I would say 85-90% of the time it is 11-12 hours. Apparently for months before I came there was talk of constructively addressing this with increased staffing but it seems that nothing has changed. Our division used to have an experienced nurse working with us but stupidly enough she has been transferred elsewhere within this larger outpatient setting, leaving us again with a crazy amount of work. Because really, as I'll discuss more later, the reason for staying so late is NOT because we are doing mostly advanced practice level work, it is because the two us are doing EVERYTHING for this patient population between the two of use-refills, prior auths, disability paperwork, returning allllll patient phone calls, doing charting and notes that are apparently "supposed" to be done even though they mimic that of the MDs, seeing patients in clinic, tracking certain testing requirements/procedures for the patients, etc., etc., etc. When I interviewed for this job, it was reiterated constantly throughout the entire process that although this specialty/division had previously utilized RNs/LPNs alongside the MDs, they had realized for multiple reasons that it would be advantageous to transition to having APNs/PAs in the mix. Even during one of my interviews with one of the attendings, we discussed midlevel autonomy quite frankly and I was again led to believe that at some point I would achieve a reasonable level of it. Truthfully, now, my biggest gripe, even more so than my schedule (and my relatively pathetic salary given my area's insane cost of living/taxes...one of the highest in the country), is that the other midlevel and I are treated like glorified RNs. And really, this DOES NOT appear to be changing at alll. After every patient's appointment, one the the MDs has to see them before they leave, we discuss the patients with the MDs every day prior to our phone calls to them with updates/lab results and without fail the conversation pretty much becomes them telling us what to do, and although they have all been cordial to me, any "teaching" I get is pretty much from asking questions and pushing for a reason as to WHY they are choosing something. I'm not a whiner and certainly don't expect full freedom at this point, but it's abundantly apparent that we WILL be treated like non-provider staff indefinitely. I just feel like this is very sad because I have enough experience in the specialty that I'm far from clueless, despite of course still needing to learn a lot. I guess my question is whether I should stick this out for a least a year just so my resume continues to look solid. Of course even if a "better" job presented itself in the meantime I would not quit this job until I had secured another offer. I suppose I'm just worried that I will lose provider skills, thinking ability, and just that whole mindset/persona if I continue in this job. It is just very silly to get shot down about putting a patient with insomnia on 25mg of trazodone qHS and instead being told to put them on Ambien - no rationale, just, "No, give her some Ambien" (stupid example, but just what came to mind). Of course I try to research things, continue to learn, etc., but at the risk of sounding whiny I'm so bogged down but all of the above clerical junk that I mentioned...as well as "confirming" everything.I.do with an MD that this is tough to do. So, basically, hope that all of the above magically changes and try to hang on, or look for something more advanced-practice oriented to give myself a good foundation? I'm soooo sorry this is so long...apparently this is the result of holding your frustrations in at work.

Um, I absolutely loved my 12 hour shifts. Now granted I'm single and had an easy commute, but I still often stayed late as a result of charge nurse duties. However, knowing that those glorious stretches of days off awaited me made it alllll worth it. Now, fast forward to my new NP life and it is very different. Salaried so it is technically 40 hours a week that I'm paid for (academic med center setting) but realistically I get there at 730 before the patients start coming in at 8 and then on a reallllllly good/realllllly rare day I leave by 530. Typically it is pushing 630 by time I leave. This is not meant to me a woe is me commentary, and I know I'm not commenting in the RN realm anymore, but my point is simply that unless your shifts are truly very close to 8 hours they seem to just suck up more of your life.

I actually loved 3 in a row (or 3 days a week) a lot and am really missing it as an NP! Crazily enough, it seems that I'm pretty much workig 11-12 hour days 4 days a week and often pushing 10-10.5 on the other day. So the grass isn't always greener-lol. I was thinking about the aging thing too. I try to sleep reasonable amounts, eat well(ish), and exercise moderately, but it is hard! Hopefully my Olay Regenerist night cream and specific eye cream for nighttime will protect me a little.

Of all my "guilty pleasures," double stuff Oreos are at the top of this list. Oh my gosh...give me some trashy TV (sappy Hallmark movies) and a glass of milk and I can finish, well, a lot. I'm young and healthy and at a normal weight, but nonetheless one of my college nursing friends STILL (several-ish years after college) reminds of that time I ate almost an entire package of oreos at someone's birthday party. Can't say that I feel totally guilty over it either. On the savory side of things, a good hot dog (and yes, I realize that pig innards can't really be considered quality, but any fellow hot dog connoisseurs definitely know that a Hebrew National hotdog is soooo much better than a random Oscar Meyer one!) and crispy, perfect onion rings are my faves. Pretty sure my last meal would include onion rings and Oreos amongst other things.

I would definitely take some vacations. I've been guilty before of not taking much vacay for long periods of time, then realizing I'm a little extra frazzled, grouchy, impatient with patients, etc. Usually, after some time away I would have a better outlook on my job overall. If this is not the case, sounds like it's the job. If you have a lot of vacation time saved up...sounds like you might..maybe try to schedule some at regular intervals in the future. This might help things be more tolerable especially if you decide it IS the job and you're looking elsewhere.

I did some temp/agency work-specifically signing up for really easy stuff (no inpatient). I ended up giving flu shots around the area where I lived for $30/hr. While there was sometimes some travel involved, it was reimbursed, the work was suuupppper easy, and I was always paid for the full time I was scheduled for even if the crowd coming had trickled down considerably. The agency (Favorite Staffing...don't know at all if there is a location near you) also had some other "easy" opportunities like giving health fairs at pharmacies/etc. The only drawback was that since they are cake jobs you had to sign up or contact the agency QUICKLY once they were posted.

I HATE it when I see "track" written for tract...i.e., "intestinal track." Sometimes this error is from a nurse or other healthcare professional and that just makes it weirder to me!!

Wow, 7 patients is definitely a lot. (I had 5 on a specialty/med-surg-ish unit and that was quite enough. Anyways though, no matter what happens you have to get out earlier...NOT just for the facility but for your own mental health!!! 16 hour days will burn you out so fast! A couple of ideas...1) it is okay not to be able to finish everything that is ordered/happens in your shift. Even for the super type A amongst you cannot be dealing with a new admit, carrying out orders put in at 1850 and doing shift report simultaneously. Nor should you always be staying late to do all of that stuff. There is another shift who can at least assist with if not complete the "overflow" tasks. Do NOT feel guilty about this!! Be calm and honest about the status of patients/tasks and know that you will graciously return the favor for someone. Seriously though, this is a move that can save you upwards of 30-45 mins (IMO) 2) Chart at least some as you go. You probably can't chart your full assessments in real time but even completing some of the charting in the moment (part of an assessment, pain scores, etc) will cut down on the burden later in the shift when your brain is getting fried and you have new admits. 3) With patients who constantly call tell them very kindly that you we be back in x time and will bring coke/pain meds/etc. This may cut down a bit on unnecessary calls; if they still call about piddly things remind them sweet that you'll bring it in with their meds. In the same vein if you have a unit secretary asked them to take numbers of family members calling...that way you aren't suddenly pulled to the phone and out of your routine. 3) Find ways to make the most out of the first couple of hours of your shift. Lay eyes on everyone at least quickly (bedside report, although torturous in some ways, can help with this), assess/address immediate needs. This way, even if things hit the fan you cut down on the chance that patients will feel like they haven't seen their nurse for several hours. This will help you feel like you're more in control. 4) Cluster your meds!!! Often if one is once a day the pharmacy will adjust if for you without an MD order. 5) If you need help and someone asks, accept it!! Don't be too proud...it will make a difference in your day. 6) This is possibly a little controversial, but don't agonize over the silly parts of our charting. Definitely chart accurate assessments, I/Os, relevant pages to the MD, but all of that care plan/goals for the patient/etc is just garbage not worth spending precious minutes fussing over. good luck! In a few short months you'll be amazed at how far you've come!

I think it can be hard to really gauge exactly what is going on. Looking back on my journey through interviewing for NP jobs I can see that especially in the moment it is often difficult to tell. I mean, you can be confident with well prepared answers and seem to be clicking so well with the interviewer (or panel of interviewers) but if one person unbeknownst to you is not so into you...you will never know under their enthusiastic exterior until you just don't get the job. Sometimes you you also have no idea how many other people are interviewing, when the job posting will be taken down, how set the experience requirements are...and the list goes on. I even had one job that I'm now soooo relieved didn't come to fruition where the lead interviewer made all sorts of promises (even promising an awesome salary) only to change his comments/vibe drastically within days. All of that said, with the job I recently accepted I had a calm, good feeling throughout the whole interview process. Not an "I'm SURE I got the job sort of euphoria but the kind of feeling where I wasn't shocked when I received a job offer a few days later. So yes, you can have gut feelings. And I think the more interviews you do the more accurate the feelings become. However, I can say even more emphatically now that you just *never* know!

I have a pin from my MSN and a pin from my BSN...I've always enjoyed wearing the BSN pin over my 4.5ish years as an RN...have worn MSN pin sometimes since I finished several months ago. I plan to continue to incorporate the MSN pin into my daily outfits as I transition next month to an NP role. Neither one of my pins was made from the nicer metal options so although they still look nice they were not crazy expensive at all. I do love jewelry so that probably makes me biased but I don't regret getting either one at all. I LOVE that New Zealand nursing medal!!