Change Your Attitude, Change Your Workplace

Nurses have a deserved reputation of being difficult to work with: we eat our young, and we are a bunch of back-stabbing, squabbling, whining folks. Is it because we are still a female-dominated profession? Because of the fierce competition for jobs themselves, not to mention preferred schedules and shifts? Because of a culture of blaming and looking out for number one?

The answer is probably a combination of those things, plus personal ambition, personal shortcomings, and individual personalities. One nurse cannot change an entire culture, but these individual traits are entirely subject to being addressed and changed.

To that end, it is truly difficult to change your attitude when you are tired, overworked, and surrounded by negative people who are also tired and overworked. Still, here are some ideas to counteract a negative workplace, starting with yourself:

  • Fake it till you make it. When all else fails, this isn’t a horrible idea. Just as smiling when you’re sad will, studies say, eventually make you feel happier, acting relaxed and satisfied with your job does make the situation feel more relaxed. Bonus: coworkers pick up on one another’s nonverbal signals, so just as a bad attitude travels from person to person, so does a relaxed one.
  • Bring food. It may be a little grade school–ish, but few things perk up nurses more than gratuitously brought junk food. Don’t bring a vegetable tray. Bring donuts or cookies, or have pizza delivered. Being around happy people for an entire shift is worth $20 sometimes.
  • Do stuff you don’t have to do. There are always things not on your assigned task list that you can do. Think how happy you are when you drag yourself in to go through rooms and look for expired gauze and find that someone already did it. Look for the expired gauze when you don’t have to.
  • Facilitate breaks. It is amazing how an entire shift will perk up when nurses team up to give each other breaks. Adopt an “I’ll cover you and then you cover me” plan and watch satisfaction go up.
  • Bite your tongue. When you’re tired and mad and everyone else is whining and complaining, it feels temporarily good to join in and let out your own frustrations. The emphasis is on temporarily. In the long term, a group of angry people letting out negative energy just makes everyone feel more negative.
  • Put a moratorium on work talk when you are not at work. Your family doesn’t want to hear it. Your friends don’t want to hear it. Also, the way I look at it, if I’m not at work, I’m not getting paid, so I shouldn’t be doing anything related to work. Carrying the negativity home just ruins your time off as well. Resist the urge.

Conversely, as with most things, there is a gray area, a fine line, an on the other hand. Keeping things bottled up and becoming a fake Polyanna is not a long-term solution. EAPs (employee assistance programs), available at many jobs, can provide names of therapists who can be sounding boards. I make a point of befriending the chaplains anywhere I work. I just find that they are generally open, nonjudgmental people who are fantastic listeners and don’t take anything personally. Finally, an idea I see used too seldom is the “timed complaining session.” The unit where I was a CNA had monthly no-holds-barred meetings with the department director. Anyone could go, we took turns talking, and there was no retribution. The director met with people later if necessary. It cut down the muttering and whining nearly to zero because we knew we could go to the meeting and have our complaints heard. I thought it was a pretty good idea, but I’ve never seen it used elsewhere. Maybe it should be.

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Which Is Better: 8- or 12-Hour Shifts?

Most nurses work 12-hour shifts these days, but this practice is coming under fire. Nurses in some specialties and those who do not work in hospitals generally work 8-hour shifts. I worked 12′s until December and have been working 8′s since then, so people have been asking which is better. The short answer is that the data are showing that 8-hour shifts are better for both nurses and patients, yet nurses’ experiences and preferences could swing the balance either way.

The 12-hour shift paradigm has cropped up relatively recently in our profession, and it is the norm for hospital nursing. Unless you wear a tie, you will work 12′s in almost any hospital setting except, occasionally, rehab. This scheduling framework is increasingly being targeted and questioned both regarding patient and nurse safety. For brevity, I won’t include a bunch of links, but perform a Web search for “12-hour shifts safety” or similar for your own curiosity. The summary is that nurses make more and worse errors with longer shifts and don’t sleep enough between shifts.

Still, mention to most nurses currently working a three–12-hour-shift schedule the possibility of working five 8-hour shifts, and fur will fly. Nurses enjoy those 4 days off.

Here are my own thoughts and experiences.

The 12-hour shift

Pros

  • Four days off every week
  • Ability to “stack” shifts and get a long string of days off without using vacation days
  • Greater continuity of care (two changes of shift involve fewer communication errors and less chance of dropping the ball with patient care)
  • If you commute, there are three drives instead of five

Cons

  • No time: by the time you get ready for work, work, and get home from work, there is very little time into which to fit anything else, like sleep, exercise, cooking, family time, or leisure
  • Tired all the time: see above. To get enough sleep working 12-hour shifts, you would basically have to only work and sleep. Realistically, adults cannot do this. This assumes successive shifts. “Singles” remove the attraction of 4 days off because working every other day or “two and one” involves more recovery days
  • You can get stuck: if you get a horrible patient load or are working with your least favorite coworkers, you’re going to spend a third of your work week with them
  • Driving after working for 12+ hours is truly unsafe and also unpleasant

The 8-hour shift

Pros

  • A weekend. When I worked in hospitals, not only did I work nights most of the time, but also I had to work weekends, either sometimes or all the time; furthermore, when I had time off, normal people were working. It is gratifying to have time off when my other friends do
  • After working 12′s for so long, I don’t feel like I’m really at work for very long
  • A bad day (from my attitude, the patients, or my coworkers) is not that long
  • Commutes are much less painful after a shorter shift
  • More time to sleep and do other things even on work days
  • I get to work a shift (2-10p) that biologically suits me

Cons

  • Only 2 days off per week
  • Five commutes instead of three
  • Fragmentation: I feel like I miss things more with shorter shifts because there are more shift changes

Clearly, for me, the 8-hour shift wins right now. Still, the 12-hour shift has definite benefits. I wouldn’t kick and scream if I found I had to return to them.

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Nursing Will Change You

Becoming a nurse will change your life. At first it will be in big and obvious ways, and then after a few years you will look back and realize that you are not the same person who decided, “Gee, I want to go to nursing school.”

You will see the most horrifying things you’ve ever seen, and you will see people enter and leave the world. This changes a person in stages. I used to be stunned and horrified by some of the things I saw, and then I was concerned when I stopped being stunned and horrified, and now I’ve arrived at a more reasonable “death and illness are part of life” stance. I’d still rather they part of other people’s lives, but there you are.

Your schedule will become odd. Eventually you will realize that you have increasingly less in common with your old friends. You may find your circle of friends changing. Most nurses do not work 8 to 5 Monday through Friday jobs. Many work overnight or evening shifts, and some have to be at work at 6am. This kind of schedule makes people stop calling (“she’ll be asleep/at work/otherwise too busy”).

You may lose significant others (particularly in nursing school). Spouses and other types of partners do like to see their other halves, and opposite schedules and changes in interests can break up a relationship fairly quickly. Dinnertime conversations get gory, and things go downhill. It happened to me, and I’ve seen it dozens of times.

Keeping and forming healthy habits and dropping bad ones may be more challenging than previously. Nursing schedules complicate forming habits like exercise and healthy eating. Working nights is particularly vicious. Who wants to wake up at 4pm and go jogging? Even other shifts necessitate eating at times that do not necessarily fit circadian rhythms, because nurses have to eat when they have time and not when they are hungry. After work they are so tired they resort to eating junk.

Your basic personality will change; you will develop a new core and a new sense of confidence. After you have done the hard, hard work of being a nurse and come out the other side, you will find a steely center you never knew you had. With that will come a type of self-confidence that cannot be forged in any way other than by fire.

Perhaps the most important difference will be that, bureaucratic nightmares aside, after almost every shift as a nurse, you can come home with at least one example of truly making a difference in someone’s life. As trite as that sounds, it truly contributes to Maslow-ian self-actualization. If you can seek meaning in your life while earning a paycheck, well, that’s a real bonus to the job.

Do nurses come home after back-breaking shifts and throw their stethoscopes down, resolving that they’ve had it with the paperwork, the back-stabbing, and the patronizing physicians? Constantly. However, people with number-crunching jobs come home after work just as angry and have nothing to show for it. It’s a difference.

Nursing is not just a job. Being one will change you, and some of the changes are challenging. Some are fantastic. It is always better to know what you’re getting into, either way.

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Consider Correctional Nursing

Correctional nursing contains bits and pieces of every nursing specialty. Correctional nursing also is its own specialty, complete with a certification (Certified Correctional Health Professional–RN), just like pediatrics, oncology, and critical care.

Yet, typically, this work environment remains overlooked and therefore underappreciated. In this post, I hope to put correctional nursing on the radar because it is a rewarding and challenging environment that nurses may not initially consider during a job hunt.

The defining characteristic of correctional nursing is diversity: in the patient population, in the nursing experience and skills required, in situations that pop up on every shift, and in working environments. Correctional nurses work in small county jails, juvenile detention centers and prisons, enormous Federal prisons, smaller state prisons, and everywhere in between.

Inmates have the same health care problems and needs as patients outside bars, including chronic conditions such as asthma and diabetes, but they also bring a smorgasbord of health concerns to the table caused by less-than-optimal lifestyles. They may have a long history of drug and alcohol abuse, they may have severe and persistent mental illness, and they may have a lifelong history of extremely poor self-care.

Nurses who work with the corrections population must be knowledgeable about disease processes and how they may be complicated by lifestyle issues such as extensive drug use, poor hygiene, and promiscuous sexual activity. They must be experienced mental health nurses as well, in most cases, because unfortunately people with mental illnesses are increasingly gravitating toward the correctional system. Those who work in juvenile prisons (like me) need to be good with kids.

Triage and assessment skills are vital. Corrections is not an environment for new graduates, in my opinion. Nursing autonomy, a hallmark of correctional nursing, necessitates quick and accurate decision-making with, often, a minimal amount of information. “Sick call” is a big deal in the correctional setting, and inmates may not be ill at all or may present symptoms that are not the concerning ones. An experienced and discerning eye is absolutely necessary, and typically correctional nurses have access to a huge variety of standing orders and the ability to at least initiate treatment on the spot.

What of safety? Working with a patient population in which many of the inmates have a known history of battery or even murder does present risk. However, a surprising percentage of offenders are incarcerated for nonviolent crimes (they wrote bad checks or sold drugs, for example). Violence does occur daily in correctional settings, but unlike in other settings where it occurs frequently, such as emergency departments, the institutions expect this and contain it. Ironically, I think the prison is the safest place I’ve ever worked, simply because my environment is designed for my safety, whereas in other jobs it has not emphasized nurse safety. Danger lurks, but it should not be a deterrent.

Nurses who are easily bored will like corrections; you never know what will happen. There is the occasional all-out catastrophe, but also inmates will show up with strange or rare issues that need to be assessed and treated, and because of the nature of the setting, even basic care coordination is challenging and requires resourcefulness from nurses.

Prisons are not sitting empty these days, so I would bet that more and more nurses will be needed to care for the inmates. Prison inmates have cancer and need hospice and anything else nurses do elsewhere; if you need a change, corrections may just be the niche you’re looking for.

Photo credit http://www.flickr.com/photos/vxla/ by Creative Commons license

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“Impaired” Coworkers

Nurses have an obligation to report impaired coworkers. Impaired, however, means much more than “smelling like alcohol” or “reeking of marijuana.” It also means impaired from prescription medications, overly tired, or just not making connections. The nurse who makes scary mistakes and does not remember simple things may be developing dementia and is impaired even if she has never touched a drug in her life. Nurses with head injuries, psychosis, and so on still are impaired, and we have to protect patients.

Still, in every workplace I’ve been involved with even peripherally, that nurse goes unreported. People cover for her or collaborate to keep her away from actual patient care. Why?

Ironically, when otherwise nurses are perfectly willing to band together and bully someone, they are reluctant to report someone who actually probably should receive some intervention. Nobody wants to be a tattletale with these issues, which again I find absurd given the nearly universal propensity for nurses to run to the boss and complain about the most minor of issues with their coworkers.

Two jobs ago, a nurse came to work smelling of alcohol. All the time. Everyone complicitly made sure she treated sprains and sore throats, and I actually heard more than once, “she works better when she’s drunk, actually; when she’s sober she shakes so bad she can’t do anything.” Eventually a charge nurse smelled her, Breathalyzed her, and fired her on the spot. That charge nurse threw a prizewinning fit and said she ought to write up every nurse who hadn’t reported her. I was brand new at the time and felt this was an overreaction; now I’m not so sure. The reason the charge nurse smelled her breath was that they were both assisting with a lumbar puncture on a child.

At my job once removed there is a nurse who is probably on drugs, according to the reports I hear of her behavior. Nobody wants to say anything because there is no proof, and besides “the DON won’t want to do anything.” That is probably true. Everyone collaborates to keep this nurse high.

Those are more clear-cut examples. What about that nurse who does things that make you think, “what?” She doesn’t remember relatively major occurrences, and she is not able to remember how to perform tasks that have to be done multiple times per shift. She makes the same repeated mistakes. She doesn’t seem chemically impaired, but she isn’t quite right either. Should concern be relayed? It should.

It is this type of impairment that really makes nurses dig their heels in. “I wouldn’t want someone to get me fired just for getting old.” “She’s just not too bright, poor thing.” “I’ll look vindictive if I say anything.” “I don’t want to work her shifts if they get rid of her.” “I don’t want to call attention to myself.”

Again, these are the same nurses who have no problem running off to the boss if you forget to fill out a relatively unimportant piece of paperwork. I don’t understand this dynamic, but I know that it exists.

Reporting concern about a possibly impaired nurse should not be done lightly or to cause problems, certainly. However, true concern should be shared. It is a supervisor’s responsibility to follow up. All we can do is keep them informed.

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Stop! Do You Have Consent?

Consent in medicine is one of the many issues that initially seem obvious and clear-cut and turn out to be minefields.

For example,

  • Has an extremely intoxicated or high person lost the right to consent?
  • If a lucid 14-year-old says “no,” should medical professionals really go as far as to hold him down for an injection if his parents want him to have it?
  • If an adult’s significant other says she told him she wanted to die, is that enough for the police to go get her and for the hospital to detain her for hours for a mental health screen?
  • If a 98-year-old patient states, “I don’t want any more treatment; I’m ready to die,” should she be allowed to do so?
  • If we know a coding patient has a DNR status and living will stating that no extraordinary measures should be taken, but the family present say, “No, do everything,” do we code the patient?

    These are just a few examples I have seen that rose to mind off the cuff. Sometimes I feel as if I have spent most of my career doing things to people that they don’t want, for their own good. I’ve said “I’m sorry” so often that it’s depressing.

    Particularly as I look back on my ER experience, I largely see a blur of struggling with people to accept treatments they don’t want, even if they arrived there under their own power for help, but also including a lot of starting IVs and giving injections to screaming and restrained patients.

    In the ER I could pass the buck because a physician was always standing there and we had a special form to cover our backsides with. However, that simply sidesteps the issues of forced treatment and patient autonomy. How often are we operating legally appropriately but being shady with our ethics? As nurses, we are bound to advocate for our patients, but do we advocate for what they need or what they want? Who decides what they need?

    The systems in place are hugely deficient. Nurses can hold down a screaming, protesting adult and sedate her, but before a physician can start a central line on an emergently septic patient, we have to get a stack of consents and paperwork filled out. I have heard a dozen physicians say, “Coming to be seen is implied consent in itself.” It isn’t, and this paternalistic attitude totally dispenses with patients’ right to collaborate in their own treatment.

    Complicating these issues is the fact that many patients are not aware that they can refuse treatments. Particularly elderly patients operate under the “doctor knows best” umbrella and quietly accept whatever is ordered. The ones who do know they can refuse are generally the ones who need treatment the most: the intoxicated person found unconscious with signs of a skull fracture is the one who will threaten to sue you if you lay a hand on him.

    Even informed consent with a specialized form is dicey. Physicians will tell nurses to get consent signed before they’ve talked to the patient, or they talk so fast the patient has no idea what they’ve said.

    Nurses have ethical dilemmas daily in this area because two of the ethical principles that are supposed to guide our practice are often incompatible: doing what is best for the patient and allowing patient autonomy. I have no answers other than each nurse should be aware of these conflicts and document thoroughly, as always.

    Photo credit http://www.flickr.com/photos/raptortheangel/ by Creative Commons license

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    Learning Can Never Move Backward

    Nurses are probably doing more than it looks like at any given moment. To an outside observer, it may sometimes seem as if nurses are doing things a non-nurse could do, but we are like ducks. We appear to be gliding along the surface, but what others don’t see is our busy little webbed feet churning like crazy.

    We are not just giving a bed bath because the CNA is lazy; we are doing a skilled skin assessment. We are not just popping medications out of a blister pack; we are pondering why this or that medication changed and wondering if our patient’s new symptoms are medication-related, and we are filing away our ponderings for easy retrieval when things go wrong.

    In my job-shopping adventures lately, I have moved from pediatric long-term psychiatric nursing to juvenile corrections. Apparently, my patient population of choice is kids with issues, in various nursing environments. I chalk this up to another thing on the long, long list of things I never would have experienced or known had I not entered that life adventure called nursing.

    These are, by design, very different environments from the critical care hospital environments I spent the first 5 years of my career pursuing. In my interview for my current prison job, the Director of Nursing said, “Tell me your thoughts about the fact you will feel as if you are moving backward sometimes in your learning and career after the excitement of critical care.”

    I responded without hesitation. “No learning is ‘backward.’ By definition, learning new things is moving forward.”

    Yes, we chart all on paper. Yes, there is a lot of red tape. It’s a prison. Yes, there is a lot of low-acuity silliness.

    When it comes down it, though, aside from the high-tech toys in the ER, there too I dealt with a similar amount of ridiculous paperwork (even though it was online) and arguably even worse low-acuity silliness. At least in the prison, no one is claiming that his acne is suddenly an emergency.

    By the time I left the ER, I faced serious, concerning burnout because of the number of patients flooding in with totally bogus chief complaints. In the last month before I left, I triaged a patient who had sore feet because her shoes were too tight and was kicked hard by a patient who did not get Percocet for her mildly infected “spider bite.” In the ER, you have to see these people and worry about patient satisfaction and reimbursement. In the prison, I have autonomy to triage these complaints.

    It apparently seems as if I have moved backward from shiny machines that go “ping” to being a med monkey, judging from the comments I receive from former coworkers, and I decided to write this post to encourage other nurses to try new things despite those attitudes. On analysis, stories like the tight shoes show that these jobs are often not very different at all.

    I am definitely using my extensive critical care experiences, even if I look like a sedate duck. Yes, most of the things I see are low acuity; however, because I am a triage ninja, I can zero in on things that may be serious. You never know when an emergency will happen, either, and I can handle those. A kid coded at the psych facility I briefly worked at, and it was their first emergency in the history of the place. Critical care skills: used.

    My objective is to make people think before judging themselves or others. If you are a good nurse, you can be an asset in any setting, regardless of your or others’ preconceived notions.

    Photo credit http://www.flickr.com/photos/bithead/ via Creative Commons license

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    Importance of Neutrality in Nurses

    Nurses (and other healthcare professionals) tend to overlook the importance of neutrality when we interact with patients. However, neutrality and a nonjudgmental approach are not only ethically necessary, but also professionally and medically vital.

    The necessity of a neutral and nonjudgmental increases exponentially in environments where the patient cannot choose healthcare providers. Such situations could include temporary ones, such as a clinic visit with only one physician and nurse on duty at a time, where the patient takes who is available or has to return another day, or more permanent ones, such as institutional stays, where the patient may be stuck with an extremely small staff for months or years. In such cases, adopting an attitude of acceptance is necessary 100% of the time, because patients generally do not have the option to choose another provider.

    Think of the sinking feeling you would get if you were locked up against your will, for whatever reason, and your nurse treated you like a bottom-dweller. Would you feel confident in approaching that nurse for your healthcare needs? I wouldn’t. I probably would also do what I could to get back at her for putting me in that position.

    Nurses should not be involved in disciplinary actions against patients, restraining patients, and so on, with one disclaimer: if a patient assaults or batters you, by all means hold that patient accountable and file charges. Nurses deserve respect. Otherwise, consider what your actions are saying.

    This idea is a major change for my approach to nursing. In the emergency room, all the nurses regularly participated in restraining patients, and neither nurses nor physicians considered the importance of neutrality during patient interactions. “The biggest problem in finding a diagnosis is a previous diagnosis,” said the one physician there who declined to fall in with this culture. Extrapolate this idea to each patient interaction; interpreting current behavior on the basis of known past misdeeds can cloud professional judgment.

    Initially the idea that nurses should never participate in patient restraints mainly just perked me up because wrestling with violent, angry patients is a good way to get hurt, and I’m tired of getting hurt at work. I thought, “Finally, someone is thinking of nurse safety.” That may be part of it, but the reason is really that if you are a patient and your nurse has just helped hold you down and restrain you, your relationship is pretty much over. No matter what that nurse does to try to help you from there on out, you, as the patient, have at the forefront of your mind that this person helped tie you down.

    Assisting with restraints or any other discipline simply does not fit with our commitment to providing appropriate medical care. Nurses are medical providers and not disciplinarians; we are patient advocates, not judges. How can we tell patients in good conscience that we are their advocates if we have just held their legs for a restraint or filled out a form to revoke privileges and so on? Those are not healthcare-related activities.

    These ideas should not be revolutionary, but I bet I’m not the only nurse thinking, “I never thought of it that way.” I’ve always unquestioningly jumped into the fray and helped out, and I’ve always been a proponent of logical consequences, so I have had no problem participating in disciplinary actions against patients, residents, or inmates. Most nurses I know are the same. Therefore, let’s consider how we can stand back and provide unbiased healthcare and leave the restraints and write-ups to the people with badges.

    Photo credit: http://www.flickr.com/photos/gsofv/, via Creative Commons license

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    Do Health Exchange Policies Change the Game for Full-Time Nurses?

    It just occurred to me that the new health exchange insurance policies could change the nursing career marketplace and give nurses a lot of new employment options: we can play job Tetris. Why? Read on.

    Before the individual policies were available, nurses without spouses or another source of health insurance were bound to full-time work with benefits unless they opted to live dangerously. Individual policies were just totally unaffordable (I used to pay about $1,000 per month for an individual policy when I was self-employed). Now they are affordable, and they are particularly so if you consider the salary differential between full-time and PRN hourly wages. It is usually significant.

    This one factor allows some mix-and-match in job searches. Perhaps your dream job has a part-time position available, so you take that and pick up PRN shifts somewhere else. Perhaps you have interests in two areas, so you find PRN positions in both. Perhaps it even works out financially for you to work full-time hours as a PRN nurse where you already are, if you work at one of the hospitals where PRN nurses can always pick and choose hours (this plan will not work if PRN hours are what they were intended to be and not guaranteed).

    Disclaimer: this does not include other benefits such as retirement contributions and term life insurance that are generally offered, nor does it generally offer paid time off. Speaking as someone who was self-employed for a decade, I can readily state that employer matching for retirement and paid time off are benefits worth accepting a lower hourly rate than I would get for PRN status. However, I know that for many people health insurance is the sticking point, and for those people a whole new world may have just opened up.

    Of course, your mileage may vary with the exchange policies versus a group insurance policy with an employer. I have found so far that with mine, the benefits are either similar to or better than the group policy I used to have, and I even bought a lower-tier policy because I thought it would be much more temporary than it has ended up being. They really do cover preventive screens and such at 100%. They really do pay what they say they will for copays and prescriptions, and this was not the case for my group policy. There was always an exception. As I say, this is my mileage only.

    Just think, though, of the possibilities. This is important given the tight job market for nurses right now. What if you were not tied to benefits? Do you have a hobby or a sideline you could monetize and be a nurse two shifts per week? Do you have a previous career you could still put to use part time and pick up shifts now and then as a nurse?

    Thinking of job opportunities this way opens up a new range of options if you are willing to, I hate to say it, think outside the box. Just keep in mind the question, “What if I didn’t have to look just in the full-time section?”

    Photo credit: http://www.flickr.com/photos/jarbo/ via Creative Commons license

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    Prepare for Clinicals Like a Pro



    Students: have you been to a a few clinicals now and gotten your piles of paperwork back with less-than-exciting grades? Here is your guide to being an ace student in clinicals and getting your money’s worth as well.

    Leave Your Ego at the Door

    Even if you’ve worked as a nurse for years and are bridging, you still don’t know anything. Even if you’re a classroom book-learning wizard, even if you’re a paramedic or an EMT or anything else that causes you to know more than your preceptor, you still don’t know anything. In a perfect world, preceptors would all want to learn from their students, but this is not that world, and things will go much easier on you if you are a sponge only.

    Prepare, Prepare, Prepare

    Use your preclinical visits, if you have the opportunity to go the day before and read your chart. Write down every single drug your patient takes, every single diagnosis he’s ever had, and every weird lab result from the recent past. Then go home and write all of that stuff down in one column and write down information about each one in another column. This will go a long way toward installing the information in your head, it will make you wonder how A connects to B, and it will allow you to jump in to patient care and use your time better at the clinical site. Major bonus: you will have answers to bust out when your clinical instructor says, “So…tell me why Mr. Jones is receiving albumin and Lasix?”

    Suit Up

    Look professional. I know, school uniforms usually look silly, but don’t slit the bottoms of your pants or otherwise modify them. Please do not wear a black thong under your white scrub pants. Just do what they say. You can fight fashion battles when you get a job.

    Show Up

    Never miss a clinical. IV poles have wheels, so you can still go even if you’re really sick. Tell your instructor you’re sick if you are, because if you get sent home, that’s different from not going at all. Missing a clinical is a huge deal to be avoided at all costs.

    Paperwork Tips

    If you followed my advice for preclinical work, you are about half done with the massive pile of postclinical paperwork you will no doubt have to do. Have the right tools at hand, with this as with anything else. I’ve bought one of the folding clipboards from MDpocket that I reviewed here for all the nursing students I know, and they love them. (MDpocket is not paying me to say this.) Find some way to contain your paperwork in a way you can easily access it, at any rate.

    Find some good mind-mapping software for your computer. You can find free programs. They allow easy creation of impressive-looking care plans and save a huge amount of time; I find they also help for thinking my way through things at the same time.

    Do not refer to any previous experience unless asked to do so. Remember, you know nothing except what you’re learning at this clinical.

    Emphasize how each patient has contributed to your development as a nurse. This is the goal of clinicals, so address it directly.

    Finally

    Pretend you’re the nurse! Do not trail around after your preceptor and watch. Do. If you have a nervous preceptor, address it. You need to have your hands on medications and patients and IV kits. Remember that sooner than you can imagine, you will be the nurse. This is your chance to practice.

    Photo credit: http://www.flickr.com/photos/clemsonunivlibrary/ via Creative Commons license

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