SarahRN2013

Days on that type of unit can brutal constantly transferring or discharging to make room for admits from the cath lab means it never ends! Have you considered finishing out your year on nights? WAY easier. At most, one late cath lab patient who needs a radial band off or a line pulled. Rarely a discharge. Rarely more than one admission. Less family and interdisciplinary interactions. I love nights on cardiac stepdown. You couldn't pay me enough to work days on that unit!

THIS.

Thank you for the suggestions, Ruby Vee. I already do post-shift processing in a variety of forms. I am hoping to figure out some things that might help during the shift too. Some people just seem so chill no matter how much crap is being dumped on them. I'm wondering what they're thinking and doing that lets them be relatively relaxed despite the storm.

On average, my job is quite enjoyable with reasonable patient:staff ratios, fair distribution of acuity in assignments, etc. I like my job and might even say that I love my job. Most shifts, a few unexpected/unplanned things pop up and need to be addressed -- chest pain, new afib / afib RVR, nausea, breathing difficulty, new confusion, etc. -- and that's not a problem. I adjust and address as needed. But some shifts - maybe 1 shift every couple of months -- some shift seem to be a never-ending pile up of multiple patients having issues that need to be addressed. Getting calls within minutes of each other for every single one of my patients wanting something addressed right now. (Often, I can see the clear priority, but I can see why it would be distressing for a patient in pain or vomiting to have to wait while I check on a chest pain or new a-fib RVR patient. Sometimes it's not so clear cut which patient is a priority which makes me feel guilty about the waiting patient.) As an added bonus, sometimes even after the initial storm settles, it sometimes seems to continue through much of the shift with new problems popping up seemingly every time I sit down to try to chart anything that I did (or if I try to eat or visit the bathroom, LOL). I start out feeling a little stressed, but capable, and am confident that I am prioritizing correctly (and asking for assistance when truly necessary -- whether delegating to an NA or getting help from another RN), but as the night goes on, my coping reserves get depleted and I start to have the urge to scream or cry when there's yet another unanticipated patient need / demand on my time. It starts to feel like the universe is against me. Objectively, I know this is not true and I am generally a positive person, but when my coping reserves have emptied by repeated challenges.... ugh. What do you do when there are so many demands on your time to keep yourself from going crazy? What do you say to yourself to avoid spiraling into negativity when it's seemingly one challenge/problem after another? How do you deal with the patients who can't be your first priority but have legitimate concerns/problems? Thankfully, this doesn't happen often, but I'd love some advice to help me keep those coping reserves from running out during challenging shifts.

I have many co-workers hired as ASN-RNs who are now completing their BSN's as part of their new hire contract (75% paid by our employer!) for a magnet-certified hospital. Actually, even nurses who have been at our facility for a long time were given a deadline for earning their BSNs or finding new employment. For the most part, the RN-BSN classes are theory type classes about informatics, management, research, etc. -- not focused on skills the directly relate to better patient care. Most who have completed the RN-BSN programs don't feel it's made them a better nurse. Basically, it's a hoop they had to jump through to keep their jobs. I'm aware of the research suggesting that there are better patient outcomes when there are more BSN nurses on staff. Just sharing what the consensus seems to be for the ASNs at my facility who have gone through, or are going through, the RN-BSN process. (I have a bachelor's and a master's degree in non-nursing fields, as well as my BSN. The two non-nursing degrees have meant nothing to any of my nursing employers in the last 5 years.) OP - when you mention "classes for and advanced nursing degree" are you talking about your BSN, MSN, DNP or something else?

I think the NA to patient ratio is just as important as the RN to patient ratio, as well as what type of support staff is available. I recently left a second job (med-surg/med-surge tele float pool) where the NAs routinely had 12 or more patients each while nurses had 5 or 6 med-surg or med-surg tele. There were no other support personnel at night (respiratory, transport, phlebotomy). I often felt that it was unsafe, not because I had too many patients, but because the NAs did (and I didn't really have time to be doing breathing treatments, occasional transport and blood draws because I was helping out with a lot of other tasks that could have been delegated to NAs if they weren't so busy). Day shift had respiratory and transport, but there were no phlebotomists in this hospital, the NAs were the main phlebotomists day and night. Charge nurses usually took 4 patients who were walkie-talkie. My other job is in a stepdown/progressive care cardiac unit at a different hospital. Our NAs usually have 7 patients (and sometimes have only 6, sometimes 8) while nurses usually have 4 patients (rarely 3 and rarely 5). At night the charge nurse gets 3 walkie-talkies and on days, the charge nurse takes no patients. We often have an ANM that works 1500 to 2300, overlapping part of the day shift and part of nights. All night (and day), we have respiratory, ECG techs, transport and phlebotomists. (We also have an excellent support system of on-site PAs/NPs who can provide new orders within a very short time frame for all admissions and for any emergencies - minor or major. At the other hospital, new admissions can arrive with almost no orders for the floor, even for patients who have been in active pain, nausea and vomiting in the ER, they arrive with no orders for meds to treat pain or nausea and have to wait for the attending to return my page.) My patients are very well cared for by both the NAs and the nurses, really the entire medical team, at this hospital. In the same hospital where I work the cardiac stepdown unit, I have also worked orthopedic med-surg/tele. On that unit, NAs have a similar, but slightly higher ratio, 6-7:1 and RNs have 5-6 patients (typically starting with 5 and sometimes an admission during the night). On this unit, the charge from 3-11p has 4 lower accuity patients with the possibility of night charge taking an admission after the ANM arrives at 11p). During day and night, there is an ANM from 7a-3p and from 11p to 7a who has no patients. During the day, there's also a treatments and admissions nurse who has no patients and does dressing changes, IV starts, and admissions as well as other "helping out" tasks. Same support staff that the progressive care unit has. Nursing ratios mean nothing if you don't also specify other support staff. I believe that if my hospital was mandated to have 3:1 for stepdown/progressive care, then we would lose at least one NAs per shift, causing each NA to have 9-10 patients (versus 6-7), and maybe even as many as 14 patients per NA because RNs would be expected to do primary care and do all nursing and NA roles at 3:1. I could also see them cutting other support staff (hospital-wide ECG tech pool, respiratory therapists for nights, phlebotomy techs) if it was mandated 3:1 for stepdown and 4:1 or 5:1 for med-surg.

I was a biochemist before I went to an accelerated second degree program for nursing at 38. I didn't enjoy being a biochemist for two main reasons: (1) turns out I love science but I don't love endlessly repeating variations on the same experiment without making progress (something that happened often in the early drug discovery phase and (2) not enough interaction with people on a regular basis, just plugging away at my bench next to other people doing the same with their earbuds stuffed in their ears. Nursing is so much harder than being biochemist, and my first two nursing jobs were OK, but not a good match, but now I love my job and am so much happier than I was as biochemist! Go for it!!!

Agreed. Recently some of our physicians have started ordering SCDs for patients currently experiencing a DVT -- and they actually mean for the nurses to apply them (whereas some physicians order them (out of habit, I suppose) and do not want them applied to a patient who has a DVT). It's gotten to where if the off-going RN can't tell me if someone has spoken to the physician to clarify the order, I have to call the ordering provider because I don't which it is. (And of course I follwo-up by putting in a physician to nurse order so everyone will know that they should be applied, or discontinue the order if they should not be applied).

Agreed! My first job we usually had 1 NA for 13 patients, no night respiratory therapists, no ECG techs, no phlebotomists and no onsite providers at night (other than an EC doc for codes). At my second job, the we have all the support staff (including multiple midlevel providers & residents as well as a house physician) and the NAs usually have 7-8 patients and occasionally 9. What a difference!

I also think that nursing school prepares you more for the tasks as my clinical instructors never let us have more than 3 patients (except my capstone preceptorship, which for me was in an ICU so I still only had 2-3 patients). Even so, my GN orientation period was more than enough to get up to speed with having 5-6 patients. "Up to speed" being a relative term as for the first year, I was always having to stay an hour or more to finish charting, but that late charting time slowly trended down over time. I think the way a unit/hospital is run/staffed and the patient population can make a huge difference. At my first job (only about 3 years ago), they were still on a paper charting system and the physicians were not good about using the system that was intended to notify the nurses that there were new orders, so it was easy to miss a new one. That first job was also always short at least one NA every night (putting more work on everyone) and the staff didn't like their manager and spent lots of time griping. RNs were given more tasks than my current job (respiratory treatments, phlebotomy), there was no pneumatic tube system for having pharmacy send up meds or for sending lab specimens, and a tiny Pyxis with hardly any meds so nurses had to run to pharmacy to pick up most PRN meds. There was minimal onsite provider coverage at night, just the ER doc for codes so you had to call docs at home and wait for them to call you back. I was on an ortho unit with nearly all patients on q2h or q4h meds (which seldom synced with their q4h neurovascular checks) and pretty much all were fall risks (so could not be left alone in the bathroom) and often required a lot of physical labor assistance to get to the EOB to stand. Whenever I was pulled to other med-surg floors, I couldn't believe how much easier it was on those units. In contrast, my current hospital is better staffed and better equipped. We have an EHR so when I peek at it between tasks, I always get my new orders notice. We have huge, well-stocked Pyxises so I rarely need to call pharmacy to have something sent up (and there's a tube system for sending it). We have teams of phlebotomists, respiratory therapists, and ECG techs. We also have multiple onsite providers (residents, mid-level providers, house physician) available all night, and the physicians that I deal with are respectful and appreciate the nursing staff, even if they feel something has been missed they generally use it as an education opportunity. Our NAs usually have 8 patients instead of 13. I currently work in stepdown and usually have just 4 patients. When I was on our med-surg floors, RNs usually had 5-6 patients where as at the old job, it was not unusual to have 7 or even 8. My point being that maybe bedside nursing at this particular hospital is the problem. Perhaps just trying out (floating) a different unit isn't enough and you need to move to one with better staffing and/or equipment.

Do you have any contacts from your ADN program who might be willing to make introductions (or at least give you a manager's name)? Or maybe from your BSN program? I was initially hired part-time at one hospital. A few months in, I was ready to get a to get a second part-time job with a different hospital system. However, I wasn't getting any call backs from my online applications to their posted positions. I finally got a call for an interview when a position posted for a unit where a former classmate was already working. She gave my resume and cover letter to her manager and the rest is history. Good luck!

From the research that I have done so far, this doesn't seem to be a problem only at for-profit/private schools. Even many established, seemingly well-respected public university programs are having their NP students find preceptors. Also (not in direct response to xenogenetic's comment): For many NP students that I know, the decision to go to a school that requires them to find their own preceptor was a balance of logistics. There are only so many programs, public or private, that are within a reasonable distance of their current home. With spouses who can't easily relocate (due to their employment) for the NP student to attend grad school, to not wanting to uproot kids from schools (or move them away from family support systems that are needed even more when a parent is in grad school), these students had to choose between the many problems caused by relocating to attend a school that provides preceptors and the cost/benefit of going to a local school that doesn't provide preceptors (but doesn't require them to sell their home or move away from other resources - employment, family, etc.) . If family logistics can't support the NP student moving for a school that provides preceptors, then the only choices for that student were to skip school altogether, or accept the less desirable option of finding their own preceptors, even if there are problems with this system.

I don't have any different tips than the ones already offered. Just wanted to reassure you that other people have initially struggled but then thrived once they found the right combination of sleep products (sleep mask, fan, white noise machine, etc.) and schedule. I was truly DREADING working nights. I am not a night owl at all. But with the right products & schedule, I love nights and have a hard time imagining working days on the floor. I do not stay 100% nights and do just fine, but it was probably a month or two of trial and error to find the right schedule. For me, I sleep 2-4 hours before starting a set of shifts (I try to work 3 in a row as much as possible). I sleep a solid 7-7.5 hours between shifts and then I sleep for 5-7 hours after my set of shifts. Even after sleeping 5-7 hours after my set of shifts, I generally don't have trouble sleeping 7 hours from 0000 to 0700 that same night to switch back to days for my off dates. It's a little trickier when I'm not able to be scheduled for 3 in a row, but even in those situations, I've figured out what schedule works for me. I hope you'll quickly figure out what schedule and products work for you!!

One other tip that I didn't notice anyone else suggesting: If you have computerized charting, find out if your system supports "smart phrases." What these phrases are called varies by EHR system, but they're short-cuts to writing your "standard" progress note. For example, you can save a phrase like this: Pt A&Ox3. VSS on 2L O2 via NC and IV fluids infusing as ordered. PNI dressing CDI. [R knee] dressing CDI. Incision approximated with skin glue, no drainage or s/s of infection. Pt reports [knee] pain [X]/10. Medicated with Norco per eMAR. Neurovascular assessment WNL with the following exceptions: (1) generalized edema to surgical site, (2) decreased ROM to RLE s/p R TKA and (3) B/L numbness & tingling to feet which patient reports is not new. Foley catheter to dependent drainage of clear, yellow urine. Pt up with max 2 person assist, immobilizer and RW. Abdomen soft, non-tender, BSx4, last BM prior to sx. SCDs on while in bed. Medications reviewed and given. POC reviewed with patient. All questions answered, pt verbalized understanding. Incentive spirometer observed and encouraged. Pt able to recall knee precautions. Fall and PUP precautions in place. Care plan reviewed, hourly rounding continues. By just typing something like .KNEE, your saved phrase for knee patient's initial assessment narrative note pops up. You just tweak it to reflect the current circumstances (foley, DTV, voiding without difficulty only able to pivot to BSC or walking all the way to the bathroom? Is the PNI still in so the immobilizer is in use or are they past the 24-hr window and are just using a walker and 1-p standby assist? Constipated and on bowel protocol, etc.). Some nurses I work with have a mini-summary of their assessment like above and some are more bare-bones, but still in a "dot phrase" or "smart phrase" that lets them quickly toss in the start of their narrative note. If you're required to have PIE formatted charting, you can also create specific "smart phrases" for the common problems of particular type of patient. a .KNEEPIE would include problems of pain, skin integrity (both for the incision and for PU), altered mobility, elimination (if foley in or DTV), and neurovascular (as most have q4h neurovascular assessments ordered). Most of the interventions for my knee patients were the same across the board. Yes, there were minor tweaks that needed to be made to customize for a specific patient. But having a .KNEEPIE note makes is so that I don't have to type up the problem or the interventions and just have to jot down a one sentence evaluation. What a time saver! (I use EPIC at both of my jobs.)

I think I have similar learning opportunities on nights as on days - with more time at night for looking up something that I want to know more about, often the same shift rather than doing it at home later (e.g. what's this condition noted in my patient's history of which I've never heard or reviewing the finer details of a policy after getting a quick verbal primer from the off-going RN on a seldom used skill) and, as you mentioned, I usually also have more time to read a bit more into my patient's backgrounds to get a bigger picture of what's going on with them. On the other hand, my time management isn't getting honed to a fine point as is require to be able to manage the hustle & bustle of days: all the patients being admitted (post-procedure), being discharged, and those being sent off the unit for tests that aren't (generally) done at night. It's not that my time management hasn't improved while working nights, it definitely has, but it seems like maybe mine is improving a little more slowly without the crucible of the time crunch that busy days put on a nurse. I'm sure that someday I will move on to days, but for now, I enjoy the (usually) slower pace of nights where there's often at least a couple hour break for charting in the middle of the night. Another benefit of working nights as a newer nurse interested in changing units every couple of years for a broader experience is that it's easier for me to find posts for open positions on units that interest me. Often the open positions that are posted (even internally) are on nights because any open day positions were snatched up by night nurses on that unit moving to days. I know a surprising number of day RNs who want to change units, but don't want to go to nights, so they are waiting and waiting (and waiting!) for a unit that interests them to post a full-time, day position. (In some facilities, it may be easier to change units and keep a day position, but in the two facilities that I work in, it's a lot easier to change units if you're willing to work nights... at least for a while.) If you decide to try nights, I hope you enjoy it as much as I do. Either way, day or nights, be patient with yourself. You're probably doing better than you think!