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How does that work? If someone stops breathing but has a pulse, unless you do something about it, eventually they will have no pulse. Are you supposed to just stand around and wait for the pulse to stop, then do compressions because they are not a "DNR" as well? I realize I'm being nit-picky, but this image just made me think of Peter Sellers in Murder By Death: "Not breathing. No pulse. If condition does not change, he'll be dead!"

quote from akulahawk: I don't know that this is universal yet. I know a lot of hospitals are moving to this model for definition of DNR, but I don't think all have caught up yet. Some people interpret DNR as no compressions, no intubation only, but meds and shocks/TCP are OK depending where the person falls in the ACLS protocol. Would be interesting to see the differences between states/facilities. quote from music in my heart: THIS*** is exactly what's wrong with end of life care in this country. It is the one area where we are, as you put it, ethically bound to provide substandard/ineffectual care. In all other areas of what we do we are ethically bound to provide the most effective, evidence based practice, but not here. This absolutely has to change, and as I said before, should come from the organizations/experts who drive practice through protocols and standards of care. It will only change if we change our protocols. Working in oncology I've worked with a few attendings who say, "when they go, call the code but page me too. I'll come over and pronounce them." That way we don't go on and on in a futile effort, and the family knows we tried. It's not a slow code per se, but maybe a "short code"? We still go all out, but at least someone has the good sense to put a stop to it at a reasonable point. I think that's the main problem with codes - they can go on indefinitely if you let them. Meanwhile the person's chances of meaningful recovery decrease with every passing minute. There really should be a time limit on those things.

Quote from Samadams8: I'm a little disturbed by this line of thinking. It sounds, I don't know, paranoid maybe? I don't mean to pick on you in particular, but I've noticed this type of general theme a lot on Allnurses, and I feel the need to say something, because it is potentially damaging. I know a lot of people come on here to vent, and we want to to give them our support and lift them up. I get that. However, acting like the people who are venting are 110% A-OK/perfect/blameless while big, fat, evil, maniacal administrators/managers/higher-ups/bigwigs/"the powers that be" are setting them up to fail, is frankly, not realistic. It perpetuates the attitude of "us vs. them" instead of holding people accountable for their actions and truly helping them. That is, helping them emotionally (through understanding, support, and encouragement) and professionally (by helping them to acknowledge their own short comings and make a genuine effort to improve). Blaming others, especially when we only hear one side of the story, does nothing to help an individual improve or reach their full potential. All it does is perpetuate the concept of victimization and create a form of classism within nursing that is not helpful. I am not naive enough to think that management are all angels, nor am I cynical enough to think they are devils either. We all need to start looking at situations from the other person's perspective (yes, even managers/administrators) or we will simply keep perpetuating all these negative stereotypes about one another. That's all for now. This post has been a long time coming, so I appreciate any who read it. Thanks for the vent.

I'm so sorry this happened to you. You sound like someone whose heart is in the right place, judging by your level of humble introspection - very mature, and not often the case when someone is fired (people always want to blame the manager or someone else instead of taking responsibility for their own actions). These are all qualities that will serve you well in your next job. I also have to wonder if it was more than just these few incidents. You admit to a lack of critical thinking in these circumstances, are there any other occurrences that demonstrated a persistent lack of critical thinking throughout orientation? If so, this would be another area on which to reflect before you start a new job. Some of the new grads we had to let go where I work were really sweet people who were fastidious and so afraid of doing the wrong thing. We were all heartbroken about it because we so wanted it to work and were really rooting for them. Gave them extra time, etc. Managers do want their employees to succeed, believe it or not. Unfortunately, repeated patterns of behavior despite remedial training still did not yield the results we needed for these new nurses to practice competently or independently. Sad for everyone involved, but not all settings of nursing are appropriate for everyone. I firmly believe that anyone can find their niche in nursing, it may not be the one you initially want or expect, and that's OK. Chin up, reflect on your strengths and weaknesses, and keep searching for your nursing "home". I do hope you find it soon.

So glad I'm not the only one who didn't have clinical prep work. As I was reading this post I was thinking "what the?!?!? Did I miss something when I was in nursing school?" The idea of coming in the day before seems preposterous to me, for the reasons already mentioned. Also, I have to wonder how that affects learning. I am an experiential learner, and we would do a report every day after clinical. It was much easier to apply what we had learned in class to the patient's situation after having some experience with the patient, really helped to put all the pieces together. You don't show up to work knowing what patients you have ahead of time, so why should you in school? It doesn't reflect the real world...

I don't do obligatory gift giving. Not for Christmas, birthdays, anything. It feels fake to me. If I see something I think someone will enjoy, I'll get it for them, just because, doesn't matter if it's 12/25 or 6/17. Makes it more genuine that way. Occasionally if I find something and it's close to a holiday/special occasion I'll hold on to it for the event but usually just give it right away. Maybe this makes me a Scrooge but mostly it's because shopping gives me a ton of anxiety. I am always terrified the person won't like their gift and it will all have been a wasted effort. I also don't enjoy receiving presents - I am a simple person and most gifts that people get me never get used, so I would frankly rather not receive anything at all. The most appreciated present is just that - presence. I would much rather spend quality time with friends and loved ones than have them waste their time and money on shopping. Also, kind, heartfelt words mean more to me than anything else. Tell me how you feel, what you enjoy, what you appreciate about our relationship. That is life-affirming, and something special shared between loved ones that no one can ever take away.

Had a co-worker who was a total germaphobe. The thing was not only did she have all those rituals, she would talk about it incessantly, how everything grossed her out. Seriously, it would occupy a large percentage of conversation with this woman and it really made me want to ask "How/why are you a nurse? Clearly working in the hospital is exacerbating your neuroses..." I feel bad for these folks, OCD is terrible and can really cause major anxiety and impair a person's ability to function. My poor cousin's hands are always bloody from excessive handwashing with very hot water.

Jean Marie, What a sweet story. I think all children should have exposure to those who are less fortunate, whether they are poor, sick, elderly, disabled, etc. It builds empathy and compassion at a young age, and kids don't get enough exposure to that sort of thing anymore. I used to visit the elderly homebound with my mom when I was little, and it definitely shaped the way I view the world. Your story also reminded me of when I was a little girl, my dad was out of the country and my mom was in the hospital. My sister, 14 years my senior, took me with her to some college classes. Most professors I am sure cocked an eyebrow at the five year old sitting in the back of a chemistry class, but we didn't have any other options. I remember her classmates giving me magazines to look at, and putting on a white coat (which was huge on me) for lab. I got the sense that the students enjoyed me being there - they thought it was cute, my sister was proud of me, and I felt like a big girl to be with them - definitely a confidence and self-esteem builder. I'm sure your children felt the same, and it is clear you are very proud of your children and they way they behaved that Christmas, as you should be. I guess there's a lot to be said for "bring your kids to work day", especially on Christmas :)

elkpark: Yes! Coding people is, in a way, fraudulent. It's providing care that has been shown, time and again, to be largely ineffective. How is that practicing evidence based nursing/medicine? It is sooooo expensive, and we are essentially taking our patient's money under false pretenses. I've heard of wrongful death and wrongful birth suits before. What about wrongful...life? vegetation? assault and battery? What should we call it when we "bring someone back" only for them to die a slow death later? I don't know...maybe down the road, as more evidence is accumulated, the ACLS/BLS protocols can change so as to cut down on this stuff? Such as, unwitnessed inhospital arrest with PEA, no pulse after 2 rounds of epi/CPR, end the code....we'll see. The way things are I think that's our only chance to cut down on all this suffering and waste.

I think the biggest endorsement for any facility comes from the customers. I will never forget when my sister joined the Little Sisters of the Poor. They run nursing homes for impoverished elderly, and they do it with precious few resources (yes, they still go out and "beg"). When we were visiting my sister at one of the facilities a little old lady walked up to me and said "I'm 106. There are several centenarians living here and do you know why? It's because they love us..." Still brings a tear to my eye to this day.

"For instance, I read up a few days ago on a program called "Does Jesus care for Klingons..." it cost just over a million $." It was one session of a larger workshop run by the DOD that totaled $100,000, and it was entitled "Did Jesus die for Klingons, Too?", discussing the implications of Christianity if life is discovered on other planets. Somewhere out there Tommy Lee Jones and Will Smith are snapping to attention... In all seriousness though, this question of healthcare as a right really does come back to where we as a nation want to place our values. I am always torn over this, as the compassionate side of me bristles at the thought of anyone suffering for want of money/insurance coverage. Then the practical side of me kicks in, and I realize that all the best intentions in the world don't mean much when you don't have the means to pay for it. With no money, there's no mission. Here's my reference: http://www.cnbc.com/id/49844670/Did_Jesus_Die_for_Klingons_Too_The_Pentagon_Wants_to_Know

This can be a truly challenging thing to discern, even for those who are trained! All it takes is one encounter with an over-sedated patient who was discounted as actively dying to make someone gun shy with narcotics. For example, a patient with seven fentanyl patches on who was of course confused but still complaining of pain. Family and clinic docs thought he was reaching the end based on his presentation, when he changed into his gown for the exam the nurse saw the patches and maybe that's what's wrong... After switching out his meds and giving the fentanyl time to wear off, he returned to his old self and lived for several more months. Did he still have a terminal disease that warranted hospice? Yes, but in his case that day it really was the meds, not the disease process causing his symptoms. I imagine this is something that is particularly challenging with the elderly population as the reaction to narcotics may be more pronounced, and it can be difficult to discern, is it the disease or the meds? An experienced individual should be able to put the pieces together and determine what's going on, but you're right, sounds like these people need more education...

Reply to cienurse: "Do you fear the unknown?" Interesting question. I fear that you would not give me a job, for my answer would be yes. However, I would follow it up with my definition of bravery: Bravery is not the absence of fear. It is being afraid but acting anyway. Only fools do not feel fear when the situation calls for it, because they fail to understand the gravity of the situation. Seeing a carotid bleedout for the first time? Terrifying. Being brave enough to act anyway? Priceless

This is a toughie. I understand the wish to not saddle your child with enormous debt after school, especially since he'll have to go for 8 years! While I agree with the above posters, I am also sensitive that your son could accumulate double the debt they experienced from school. Have you talked about it with your son? I am the youngest of five children in a one income household. All of my siblings had school paid for by a combination of scholarships and my parents, none of them had any debt when they graduated. When my sister was looking at schools I was 13. My dad sat me down and was honest with me "With the cost of school these days, there may not be enough for you..." I understood and appreciated his candor. He paid room and board freshman and sophomore year and gave me $400 grocery money junior year. I covered the rest through scholarships, grants, loans, and work. It can be done, but he needs to know in advance so he can plan accordingly, especially if he's expecting you to pay. It is true, some people are not mature enough to have mom and dad pay for college, they drink it all away. Others are mature, appreciate what their parents did for them, and are productive with their time. Only you can decide which type of person your son will be, but it starts with a conversation. I say keep the job you love, and talk with your son.

My alma mater had us include clinical experiences under a heading "clinical experience", not "employment". The point was so that potential employers could see where and what type of experiences we had under our belt. Also the "objective" line would say something like "graduate nurse seeking position as an RN on a medical surgical unit..." This way there would be no confusion about our background. Once we had experience working as a nurse, we were instructed to remove the "clinical experience" section from our resumes - they were only to be used when we were new grads. On a side note, I once got a position as a nurse extern because of my handwriting. No lie, I went to a job fair and filled out a postcard. The HR lady said she picked mine because out of 400+ cards, mine was the easiest to read. God bless my second grade penmanship teacher...

As to the phone chargers, our unit treats them like a "take a penny, leave a penny" We have a bag FULL of chargers, many the same, and if someone asks for one, we bring them the bag. While we probably shouldn't do it (we cavi wipe them before hand) in 4 years, we have yet to have a patient or family member call or come to retrieve a charger. Crazy. Boldest request was from a "VIP" patient. She wanted someone to run to CVS to get her some cold cream. And do you know what? The head, mind you the head of the radiology department ran out and got it for her. Talk about reinforcing unrealistic expectations...then again, if she purchased the top of the line CT scanner or something, I'm not surprised when she said "jump" he said "how high?" But that's a discussion for a different day...

Good luck to you! It sounds like you have a good plan in place. As far as what is best - it really depends on what your priority is...getting out and starting work as soon as possible or the end job. That's what made the difference for me - I was a lot like you. Living at home, working as a cashier, just itching to get out on my own. I became an EMT and started volunteering at the hospital in my free time to get a feel for what type of patients I wanted to work with. I also had the plan to go ADNThat really left an impression on me, and made me reconsider my plan. I sat down with someone and worked out a timeline of how long it would all take. Basically I wanted to get into a nursing program and get out and working as soon as possible. The idea of spending an extra year or two in school was absolute agony, not to mention the extra cost. However, once I worked out the timeline, I realized getting the ADN first and then going for BSN would actually wind up taking more time and costing more money in the long run. That solved it for me - I went for the BSN instead. Even though I was in school a bit longer, once I started working, that was it. No more school unless I wanted to go. The other thing that weighed on my mind was the possibility of getting married, having kids etc. in the interim and I cringed at the idea of being pregnant or having little ones while in nursing school. Ultimately going straight for BSN was the best decision for me, but that doesn't mean it's the right path for everyone. My friend did the LPNYou sound like you know where you want to be, and if the LPN will let you do that, then it may be worth it to you. You seem comfortable with the idea of working for a while, going back to school, etc. And who knows? You may love what you do and decide you don't need to go back to school. Either way I wish you the best of luck and hope it lands you in a place where you can be happy.

Congratulations Sunny! I wish you all the best in your new job - keep us posted on how you're doing, especially if it's good. So many people come on here to vent/for advice, it's wonderful to hear the success stories sprinkled in. We want to share in the joy and laughter as well as the tears, so thanks for sharing your happy news!

That's terrible. I am so sorry it's that way on your unit. Sounds like the age old tale of people not having any appreciation for the work others' do. They say the grass is always greener, well when it comes to complaining, "the load is always heavier" on one's own side of the fence. What we need is mutual understanding. The orientation program on our unit was extended by a week to allow the new grads to shadow all the other staff, HUC, NA, PT/OT, nutrition, RT, etc. in an effort to build respect and understanding of the work of the unit. On the other hand, what may appear to be laziness may not be. A family member chewed out a nurse for not spending any time with the patient. What she didn't know was the nurse spent 2 hours on the phone trying to arrange home O2 since it was the weekend; needed insurance approval and everything and she didn't know how to do that. Also, a nurse was complaining about an NA for not getting her blood sugars done by a certain time. What she didn't know was the NA had been helping me w/ a patient who had 10 Stage IV pressure ulcers, the dressings took almost an hour to do. When mutual respect fails in these situations, I guess you can always do what my coworker did. An RN was notorious for not helping. Another nurse had had enough, ran into the break room and screamed ", get off your fat, lazy a** and come help me!!!!!!!" Now, while I do not recommend anyone do this, wouldn't you know, the "lazy" nurse suddenly became one of the most helpful on the unit? The nurse who lost her cool immediately went to the nurse manager crying and said, "I think you might need to fire me..." Well, the three of them were able to talk it over and the situation worked to everyone's benefit but that could have gone so much worse...apparently the "lazy" nurse genuinely had no idea that was what everyone thought of her. She was devastated to know what the general opinion was of her and made a good faith effort to improve from thereon out.

I love my Quark Pro-Air II Nurse's shoes. I had a pair of Dansko's and my feet have never hurt so bad. I returned them soon thereafter, but then someone told me that you have to give them 2 weeks to break in. No break in time needed for my quarks, they are durable, comfortable, have great padding/inserts, and vents on the side so your feet can breathe. They are also less than $50 a pair - can't beat that! I have also heard good things about the Z-coil, several coworkers swear by them, one w/ plantar faschiitis. Weird lookin shoes, but they work and make a fun conversation piece

This is always a tough part of being in a leadership position, of any kind. I found what works best for me is to 1) Respect the people I work with. 2) Earn their respect in return. What does this mean in real terms? Simply put, do unto others as you would have them do unto you. For example, I used to work with an RN who would walk all the way down the hallway to "delegate" (tell) the CNA to empty her patient's urinal, then walk back down the hallway to finish whatever she was doing. Of course, the CNA's hated this, not only was it completely inefficient, but it gave the image that they were only there to deal with bedpans and urinals. They did not feel respected or appreciated, and it certainly impacted their willingness to help in future situations. While it is certainly within the RN's job to delegate, it must be done judiciously, with respect and good sense. I found that by doing what I could for myself, I earned a reputation as a hard worker, and built loyal, trusting relationships with the various team members. They know that if I ask for help, they better come running, because I need it. Now they offer help when I don't expect it, again building on mutual respect. And I use that for leverage. On the rare occasion that someone is not being a team player, I say "You know me. If I didn't need you to do this for me, I wouldn't ask. Please help me, and I'll be sure to return the favor. Thanks." Another thing that goes a long way is praise - people absolutely need positive reinforcement to feel respected and appreciated, and this cannot be said enough. I worked with a nurse that was great clinically but mean to everyone on staff - no one escaped going home in tears at least once because of her. Then one day she was behind the curtain. I didn't know it, and praised her to my patient, saying she was the absolute best at starting IV's. From that day forward she was never rude to me again. I guess people rarely praised her because she had such a gruff countenance, but wow, what a difference a little praise made! I think the sincerity made a difference too. People can smell horse manure a mile away, so make sure when you give praise, you mean it.

Congratulations to all of you on starting your new careers! This is an exciting time for you, and I wish you all the best. As far as tips/pointers go, there are a few things to remember when starting out as a new grad. 1) It takes time to adjust, usually about 6 months to a year before you really feel comfortable and get into a groove. This is normal and your manager, charge nurses and other coworkers should be supportive of this. 2) Time management is often the hardest skill to learn. So much of what we do is task oriented, but we still want to pull it all together into a comprehensive and thorough plan of care. That can be hard to do when you're concentrating on learning skills, but be patient. The skills will come the more you practice. 3) Watch the experienced people - learn from them, take the tips and tricks that work for you and leave the rest, you'll need to trust your own judgment on this. As far as oncology specific stuff goes, there is a lot of info. Oncology is unique in that it can impact every bodily system in weird and bizarre ways. I once saw a patient with blue skin! No, he wasn't hypoxic, it was some sort of reaction between his chemo, liver and other meds. Strange but true. What you encounter the most will depend on the patient population you are dealing with. I've worked all kinds except pediatric. One was solid tumor w/ mostly head and neck, colon, and prostate patients: lots of trachs, g-tubes, foleys, ostomies and carotid bleed outs. One was solid tumor w/ tele overflow, one BMT and another medical oncology w/ inpatient radiation (lead lined rooms for MIBG and people w/ radioactive implants for cervical cancer or sarcoma). The most common things encountered on all of them were: 1) Interns and residents who are afraid to write for narcotics. In a teaching hospital they rotate so you need to get them comfortable with the cancer patient population. These people have cancer for crying out loud, they are not drug seeking. You need to advocate for your patients and get the docs to write for an appropriate dose that will actually do them some good. 2) Fluid/electrolyte imbalances: lots of dehydration, and complications from the cancer and treatment. You'll be giving lots of supps. Also blood products of all kinds. Folks with liver involvement may have impaired clotting in addition to low platelets, so FFP as well as platelets and PRBC's. 3) Risk of infection/neutropenic fever. Lots of antibiotics, contact precautions and protective isolation. Buy some decent lotion that's compatible with your facilities' products, you'll be washing your hands a lot. 4) GI/GU issues: diarrhea from disease, treatmemt, GVHD, etc. or constipation from the opioids. Either way it's a frequent symptom that needs to be managed. 5) Dyspnea/pain - more symptom management 6) Psychosocial needs for patients and families - this one is a no brainer. You very well may have your own "Terms of Endearment" moment. Just try to be understanding and not let their anxiety get to you. Everyone copes differently. Don't forget your own needs. See my post on "Am I the only one?" That's all I can think of for now. It's 2am and time for bed. I wish you all the best of luck and please do keep us posted on how you're doing.

I have a sneaking suspicion I'm not alone in this, but I would like to hear from others in the field. What I am referring to is what one of my co-workers calls the "crazy cancer nurse" phenomenon. Every few months or so I go through a total catharsis (and yes, it does usually coincide with "that time of the month"). I wake up in the middle of the night with an intense feeling of sadness and start sobbing uncontrollably. It started a few years after I had worked as an oncology nurse. The first time it happened after I was married, my poor husband didn't know what to do. It was 3am and I didn't want to wake him so I took a shower thinking it would cover the sound of my crying - it didn't. Since then we talked about it and now it's just a fact of life - every few months I just need to cry it all out and I feel better. I've been doing some research on this but I'm not really sure what to call it. I'm not depressed, I love my work, I am a happy person and I would in no way describe myself as burned out or suffering from compassion fatigue as defined by the article referenced below: "Compassion fatigue: a severe malaise as a result of caring for patients who are in pain or suffering." (Aycock & Boyle, 2009, p. 183). Probably the closest description I could find is "Secondary traumatic stress disorder: encountered by those who care for people who are directly experiencing a traumatic experience; also may be referred to as vicarious trauma, indicating secondary distress imposed by witnessing trauma" (Aycock & Boyle, 2009, p. 183). It also seems like it could be some sort of delayed, vicarious grief that I feel on behalf of my patients and their families. I don't know though. I avail myself of the many services out there that are shown to help with burn-out and compassion fatigue, such as counseling, the employee assistance program, education regarding stress and coping mechanisms, and staff retreats. I also work with an amazing team of nurses - I love them all and can't imagine doing what we do without such a strong source of support. I consider what I do to be an honor and a privilege, to work with people during one of the most personal and gut-wrenching time of their lives. But still, what we do is just so darn sad. Is this response normal, or should I be concerned/is this a warning sign of something more serious? I tell you, when you see a 23 year old woman who gave birth to a baby only for the doctors to find a belly full of cancer...it's just not right. She died two weeks later without ever seeing or holding her baby. How can you not cry? But sometimes I wonder, do other nurses have this random choking sob thing, or am I just an oddball? Reference: Aycock, N. & Boyle, D. (2009). Interventions to manage compassion fatigue in oncology nursing. Clinical Journal of Oncology Nursing, 13(2). doi:10.1188/09.CJON.183-191.

I once had a young male 20-something patient make completely inappropriate advances towards me. When I told the doctors about it, I made the comment that maybe if nurses weren't portrayed as little sexpots in pop culture and in Mediaos, he wouldn't have gotten the wrong idea. Their response was "Whoa! What kind of TV/movies do you watch?" I was genuinely surprised that they were unfamiliar with the concept of the "sexy nurse". To me it's as cliche as the cable/pizza guy or sexy teacher image. Maybe because they were men they didn't realize how offensive and damaging that stuff can be? Anyway, they made the guy apologize to me. His response? "I'm sorry, I thought you would have taken that as a compliment..." Geez oh man...

This reminds me of when my mother had bladder prolapse surgery and she had some serious itching around the wound. I went to the pharmacy and got some over the counter generic medicine that said literally on the package "Anal itch cream" Wouldn't you know, the cashier needed to get a price check and proceeded to ask for one over the intercom. It was like something you would see on a sitcom. All I could do was stand there and say, "I swear it's not for me..." Yes this stuff does matter and it doesn't take much effort to act with discretion, or at least awareness and sensitivity. What if someone was taking antiretrovirals for HIV or something of a particularly sensitive nature? In a small town pharmacy, it wouldn't take much for word to get out. Yes, we need education about our meds, but there is a way to provide it while still maintaining privacy. Talk in a low voice, take a few steps to the side, put a line on the floor a few feet away that says "wait here until called", anything. A little effort can go a long way when it comes to maintaining people's privacy.