Me: What is your background?

PS: I’m a nontraditional student going back with an existing degree. My degrees are in anthropology, sociology, and mass media. What I loved about being an assignment editor was having to become an expert in something overnight.

Me: What made you decide to become a nurse?

PS: I wanted a stable and flexible career that could guarantee a certain minimum pay and might have options no matter where I moved or what my family situation was. The idea of 3–4 days off per week is also tremendously attractive. I loved my career in journalism—but I couldn’t afford it. I was drowning in debt, unemployed, and pregnant (after a decade of being a student and broke). I want some security (health insurance) for me and my son. I think that was the number one factor. I also love medicine, but more than anything, I want to work with people, and I want a challenging job that doesn’t allow me to walk along in autopilot.

I wanted a job degree that I could get quickly (I was promised many things when looking into an accelerated bachelor’s program that ran 11 months and then let you stay another 18 months to earn an NP or RN-midwife). My thinking (as naive as I know it to be) was this: as an RN with some experience, I could work in a hospital. If I am injured or lose my eyesight or life just happens, there are phone/desk nurse/office jobs to transition into. If the worst happened, there are certificates in forensic nursing that can be earned in a few months (I have some legal background), and I could even work for an insurance company.

Me: Are you worried about the stories of new grads being unable to find jobs?

PS: Yes! That is a huge concern. I was lulled into thinking there were lots and lots of jobs. But I also see people in tough industries who always have jobs. I know how to network and take every opportunity I get. I am starting my first semester with an internship in a free women’s clinic. It’s idealistic, and I won’t always do it, but I try to keep in mind that the professor I try to blow off or the class I want to float through or the patient I least want to deal with may be my next job connection.

Me: What are some unanticipated roadblocks you would caution would-be nursing students about—things you didn’t know to worry about beforehand?

PS: Everything in this process feels like a catch–22. I am just dealing with the automated service my school uses to clear background checks for clinical readiness now. The requirements for vaccinations/titers are actually impossible to meet. It cannot be done (the paperwork they ask for just does not exist).

The hardest part has been the layout of funds. I have learned that every promise will be broken. Even when you think you’ve planned for everything, you hit new financial walls. I am doing a background check now which was supposed to run $100. But there are additional fees for every state (let alone country) you have had residence in. It’s that type of surprise every day. I talk to people at schools and get amounts that things will run, but there are always things (large things) they don’t mention.

I got my acceptance letter to my first school 2 months before I expected to. That is great, but they wanted a large deposit (I had to get accepted and then file an appeal with my grant committee to get my accepted school approved), and they gave me less than 10 days to accept with a tuition deposit.

— Part 2 will appear later this week, so check back! —

• You can forward or bounce e-mail from school or work to your personal Gmail account, yet have a Gmail account profile that makes it looks as if you responded from the original account. That way you don’t have to log in to multiple places to check your e-mail.
• You can set up complicated filters (they are easy to set up but do complicated things) to make sure that “fluff” e-mail goes to a label (think of Gmail labels as folders) that you check only once in a while. For example, I don’t need to know what the cafeteria specials are at work every day, but they go to my work e-mail anyway. With a Gmail bounce/filter system set up, I never have to deal with them.
• If you’re forwarding everything to Gmail, you are in luck if you ever need to find an e-mail again. Gmail quietly archives everything away and searches it all. Quickly. No more searching through multiple e-mail accounts to find that confirmation for your NCLEX date.

Here’s how to get started.

• Figure out how to bounce your e-mail from school or work to your Gmail account. It has to be done from the other account, and you may need a geek to figure out it for you. Generally it involves a filter. You’ll want a “bounce” or a “redirect” instead of a “forward” to avoid all the frontmatter and “>” symbols before your e-mail.
• Log in to your Gmail account (get one if you don’t have one at http://gmail.com, and find your settings under the wheel at the top right corner of your inbox screen. (None of this will work from a client; you have to set it up from the Web interface.)
  
• Under Settings, go to Accounts and Import. Pick “Add another e-mail address you own,” add the e-mail address(es), and choose the “Reply from the same address the message was sent to” button.” If you’re not able to bounce messages from your other account, you can have Gmail pull them in with the POP3 option, but use that only if you can’t get a bounce to work. These options are what allow you to get all your e-mail through Gmail but have it look as though you’re checking external accounts and responding from there. Your e-mail will still be in the other accounts unless you take extra steps to delete it.

  

• Now you will get your Gmail e-mail and e-mail from all the accounts you’re sucking into it, and that’s no good, so set up a filter (from the same Settings screen, pick “Filters”). Google provides powerful and complicated search operators. Here’s the one I use for work:

  E-mails from any address at my work domain (*mywork.org) except for all the people in the curly braces (because I need to get e-mails from my bosses, the director of nursing, and so on) go to a Gmail label called “Bulk work.” They bypass the inbox without passing Go or collecting $200, but they never go to spam. And because I use the setup described previously with responding from the account from which the e-mail arrived, if I reply to my boss it appears I used my hospital e-mail account.

These tricks should get you started. Once you consolidate e-mail accounts and never have to delete dozens of e-mails a day that do not apply to you, you’ll wonder how you ever lived without doing this.

These are all questions and comments I have heard. In general, anecdotally, patients are concerned that long shifts for nurses will make their care unsafe. Do they? It seems that the answer is yes, and working long hours is actually unsafe for nurses too.

Problems for patients

Fatigue in nurses is a problem. The ANA wrote a position statement[1] in 2006 specifically addressing this issue. In the statement it reminds nurses that they are ethically bound to consider their fatigue level and capacity to safely work when accepting additional hours or shifts. It acknowledges “the health care system has lagged behind in recognizing that fatigued health care providers endanger not only themselves, but also the patients for whom they care.” (The ANA also issued a position statement[2] for employers reminding them of their responsibilities in this area.)

A study in Health Affairs with a relatively large sample size found that more hours equaled more errors, and the risk increased after consecutive work longer than 12.5 hours (a not-unusual shift length for an RN).[3] This study found that “the likelihood of making an error increased with longer work hours and was three times higher when nurses worked shifts lasting 12.5 hours or more.” Three times higher is a lot higher. A different study found that the risk of making an error only doubled after 12.5 hours,[4] but still. Concerned patients seem to have a point.

Problems for nurses

Long shifts are not a problem only for patients; they also may hurt nurses. The 3-day work week is an advantage to the 12-hour shift, but not all nurses are happy with their schedules. Twelve hours is a long time to work hard, which nurses do, and “there are already hints that the fatigue associated with working twelve-hour shifts is contributing to absenteeism and job dissatisfaction among RNs.”[3] We are apparently also more likely to hurt ourselves between our 8th and 12th hours of work by means of needlesticks and musculoskeletal injuries.[5] Medical residents have had their weekly work hours capped for some time because they were making egregious errors and/or driving off the road on the way home from the hospital, but the same kinds of restrictions are only now beginning for nurses (my hospital just recently began requiring a certain number of hours between successive shifts).

What to do

According to the ANA, we should refuse assignments that would push us over the edge. Whether that will fly in the workplace remains to be seen. We can, however, be aware toward the ends of our shifts that both we and our patients are at a higher risk of getting hurt and can exert increased diligence. We can also cooperate with institutional efforts to help us out by limiting our overtime, number of hours worked per week, and number of hours worked per shift, and we can object as a profession to mandatory overtime.

• Several e-mails from professional organizations, each containing links to articles of interest to you
• Facebook links posted by friends or “liked” organizations that you would like to read
• Links posted by Twitter contacts whose judgment you trust
• Articles and blog posts from your RSS feeds, Flipboard interest groups, or other content curation tools
• Newsletters from your school or employer

It is not always convenient to stop and read each item as you become aware of it. The usual temptations are initially to start bookmarking blog posts and articles in some way through your browser, starring or flagging e-mails that contain items of interest, starring or flagging RSS feed items, and/or e-mailing articles back to yourself (possibly also with a star or flag) for later viewing. The problem with these methods, particularly in combination, is that they disperse reading material over several “things that have to be checked.” In combination with a routine that includes checking e-mail, Facebook, Twitter, Pinterest, Tumblr, and so on, it makes sense to consolidate the number of “things that have to be checked.”

This is a common issue, and multiple solutions exist. One is Evernote, a comprehensive cross-platform system that holds text, photos, PDFs, and, depending on whether you pay for the service, movies and other formats. Evernote has Web bookmarklets and clippers for most browsers and allows items to be e-mailed in or dragged and dropped (depending on the platform). The main issue with Evernote is that if you plan to use a system that allows you to view material on the go, Evernote does not sync and allow offline viewing without a paid plan.

Therefore, if you do need a system that allows offline viewing, consider Instapaper, Readability, or Pocket (formerly the aptly named “Read It Later”). The unifying factor for all three is that they allow collection of items you don’t time to read right now but want to keep in a unified place to read when you do have time, whether that be at your desktop, in line at Wal-Mart, or on the treadmill at the gym. The way this works is that you zoom through all the things you look at daily: e-mail (forward the e-mail to the service of your choice or open enclosed links in a browser and bookmark them), Twitter (these services are options in many popular Twitter clients), Facebook (bookmark from browser), and RSS (bookmark from browser). Then open the app on your portable device and sync; you’ll be able to read everything anywhere, as you have time. Read up on all three and consider your needs before committing to one.

• Instapaper is the most sophisticated, including features such as folders, social media involvement, and curated links
• Readability and Pocket have mobile applications for both iOS and Android, whereas Instapaper is iOS only
• Instapaper and Readability have text-only formatting options for articles and blog posts that remove distracting sidebars and leave, well, only the text
• Pocket allows the saving and viewing of photos and video as well as text, thus overcoming a major limitation of the text-only Instapaper and Readability
• Instapaper and Pocket allow organization with either folders or tags for archiving or follow-up, whereas Readability goes only as far as starring items

All three have points in their favor, and it is worth learning how to use one of these systems. It saves time and results in you spending more time productively reading material you wanted to read at some point and less time trying to organize yourself.

Now nursing schools are requiring students to have PDAs (generally iPod Touches these days), and the (slowly developing) trend is toward decreasing the number of large textbooks nursing students need to have constantly and instead moving this information to the smaller devices. Currently the handheld devices hold drug references and clinical snippets as opposed to entire textbooks, because it would be more laborious to read a textbook on an iPod Touch than to carry around the book, but as more students have Kindles or iPads, options increase for the purchase or even rental of electronic textbooks.

The Amazon Kindle, in its various incarnations, has become extremely popular, as has the Apple iPad. Both now offer textbooks as part of their catalogs, and the Kindle now offers textbook rentals.

The list of textbooks available on the Amazon Kindle is available here. The textbook rental program details can be found here. For students with an iPad or a larger Kindle such as Kindle DX, these options may be compelling. Avoiding back strain by having textbooks all on a tablet offers immediate benefits, and Kindle technology allows highlighting and notetaking as in a paper textbook and additionally syncs the notes and highlights across devices. The electronic version prices are cheaper, although not always as much as the 60% discount touted by Amazon, and the rental prices even more so.

However, Amazon provides no easy method of finding rentals as a group. You have to pick the book you want and look under the Versions section to see if it is available as a rental or even as an electronic textbook at all. Issues may arise with some devices with page numbering, because although some Kindle devices and applications reflect the page number of the physical book, others do not—a major issue in lecture when the professor says “turn to page 984.” And although purchasing an electronic textbook has immediate benefits, including the environmental ones, in the end the cost savings may be negligible because the book cannot be sold back.

iTunes now offers texbooks for iBooks as well, but a brief perusal of the selection reveals this new offering to have little for the nursing student. The Amazon selections do have nursing textbooks for the Kindle, although I could find none available for rental. The rental section may be handier for students enrolled in nursing school prerequisites, as many broader subjects are well represented there.

In short, nursing programs are starting to inch toward electronic education, but this change is slow to leave the ground because of the paucity of options. Students interested in the use of electronic textbooks should write to publishers of nursing textbooks and urge them to create e-book versions and should initiate discussions with their nursing school faculty over their use to see whether advantages justify a trial.

Can anyone do it? No. I’ve met nurses who just aren’t biologically able to stay up all night and function. Before I tried it, I would have bet good money there was zero possibility I could do it either. I used to get up at 5am and go running before editing all morning. I was done with my day by 2pm. Now I’m rarely out of bed before 2pm, and I feel fine about it. I sleep better during the day, and it turns out if left to my own devices I naturally stay up late and sleep in. When I switched shifts, all the things that should happen to nightshifters happened to me: I got depressed, my skin broke out, I gained weight, I could never sleep, and I never had any energy. Aside from avoiding all that, there are benefits if you turn out to be a nightshifter.

It pays better, you gain seniority quickly if you just don’t quit or die, you often have greater autonomy, and you have a 50/50 chance of the pace taking it easy on you. The other 50/50 chance is that all heck will break loose, but it breaks loose in a different way on nightshift. It is not the case that nightshift works less than dayshift. We work hard in different ways. I have never been able to describe the differences very well between dayshift and nightshift, but they exist.

So, if you find yourself on the brink of working nights, here is my advice on how to pull it off.

• If you have to “flip” (have a day schedule except when you work), you won’t be able to sleep the day before your night shift. If you make it until noon, consider yourself lucky. Do not despair. You will be able to stay awake for one shift. After that, you WILL be able to sleep the next day.
• If you need to “flip” after a night shift, you must “short-sleep,” which is just what it sounds like. Make yourself get up before you want to so that you will be able to sleep the next night. (Astute readers have probably noticed that all of this means nursing students basically can never sleep, and that’s true.)
• Try to do most of the major eating for a given 24-hour period during daylight hours. Get up early and make a big dinner/breakfast before work, and eat something after work before bed. Eating the junk that nightshifters leave lying around guarantees queasiness, drowsiness, and possibly weight gain. Eat small snacks throughout the night instead of meals.
• Accept that coffee will stop keeping you awake but that you will drink it anyway.
• Create a sign for your front door that says “Day sleeper. Do not disturb” and turn off your phone if possible. Include in your voicemail message that you sleep during the day and your caller can expect a return call the following day. The world does not cater to nightshifters.
• Acquaint your friends and family with the concept that “if you switch AM and PM on the clock, you have your etiquette guide” (would they want a phone call at 1am? No?).
• If you hate working nights, at some point you can switch shifts. Just be patient.

If you just passed the NCLEX, that 2-year period may seem amazingly long, and happily, when you are a new nurse, accumulating CEUs is generally not a problem because you are offered and usually required to take many, many training classes that offer CEUs (also called "contact hours"). In many areas, you can select from a smorgasbord of BLS (Basic Life Support), ACLS (Advanced Cardiac Life Support), the NIHSS (NIH Stroke Scale), basic dysrhythmia classes, and others. Most of these offer CEU credits.

However, time flies in nursing as in all areas of life, and at some point you will realize, with a sinking feeling, that you need to get some CEUs and fast so you can renew your license. Even if you have renewed your ACLS certification or others from the AHA, check to see whether you can count CEUs from recertifications. Some agencies are starting to let you use CEUs from only the original certification, so check them all. Due diligence will ensure you don’t have to take the NCLEX again, so it’s worth the time.

As with many other situations, like studying for boards, I suggest a slow and steady approach to CEU accumulation rather than a marathon attempt to get all of them the night before your license renewal application is due. You’re required to get the CEUs, so you might as well plan ahead and use them for things that interest you or you have an actual interest in or need for. Hospitals invariably offer hundreds of presentations throughout a year that offer accredited CEUs. That hospital newsletter that you toss? Read it. It might seem dreadful to spend your Saturday sitting through a "Spanish for Medical Professionals" class, but if you do it, you’ll get a ton of CEUs, probably for free or at a reduced price, and hey, you’ll know some Spanish afterward.

If classes and lectures aren’t your thing, check out the nursing journals you have sitting in a big dusty pile next to your couch. Some have articles that offer CE credit if you read them and take a test that you send in. This is a pricey approach because you have to have a (usually expensive) journal subscription plus pay for each test that you send in.

A more convenient solution is to find online CEUs. The best resource I’ve found, hands down, is nurse.com, which charges $44.95 USD for "unlimited" CEUs (in quotes because the unlimited ones are only for CEUs worth 1.5 CEUs or less. If the course you want is more than 1.5 contact hours, you get a 50% discount, though. The site has a ton of 1-hour courses, and they make it simple. The price is a good deal because of the simplicity, and anyway many courses you attend charge that price for just one 2- or 3-hour CEU class.

Finally, you have to track these things somehow. I’ve tried everything from collecting my certificates in a file folder to using Evernote to using a spreadsheet, all of which resulted in me still having to scramble to get everything together, and lately I’m using the iPhone app Continuing Education Tracker. It’s got some shortcomings, but it’s a down-and-dirty way to see where you are in your count to the finish, and you can e-mail the data out of it for a handy list of courses. It lets you budget for CEUs and track expenses, too, if that is important to you. It’s available for iPhone and Android, so if you have a smartphone check it out.

I’ve blogged on this topic for years, including on this site. I write again about it because the topic is on an upswing in nursing media, which tells me we apparently aren’t doing any better. In some ways the topic has been a trend in our field for years; however, it has been pushed to the forefront by nurse managers looking desperately for the answers to nurse attrition. The nursezone.com blog post I cited suggests that this bullying issue is caused by ingrained culture in our field passed on from generation to generation (“I suffered, so you will too” [my interpretation]). Is it worse with the recession and increased stress on nurses, who are constrained by having to do more with less and the implication or outright statement that “if you don’t like it, too bad, because there are no jobs out there”? I think so, but that’s an opinion.

Generally before when I’ve written about workplace bullying I have focused on the work rather than the nurse, because my major point has been that bullying affects patient care. I haven’t really focused on how it affects nurses. It does, though; the more encompassing term “lateral violence” reflects this better. Most of the literature indicates that bullying causes decreased self-worth in the recipient and may cause insomnia and depression, all of which lead to decreased nurse retention. We, in short, get our feelings hurt just like everyone else.

I think, however, that we all need to just stop and think about our own behavior, as well as that of others; what if we invert the issue and start from the source—you and me? The nurse.com post recommends that a bullied nurse confront the bully directly. That would be rare enough in a hospital culture that you could successfully charge admission for it. Still, I’ve had managers or other nurses approach me on behalf of, usually, a new hire to whom I have been “scary” (I prefer “intimidating”), and when I recall the situation it has never been the case that I intended to scare the nurse, bully her, or hurt her feelings. I’ve always been in a high-stress situation in which immediate competent action is necessary for patient care, and in that situation I expect everyone, like me, to grow thick skin and take nothing personally. Expectations will get you every time.

My point is that possibly nurses are getting so focused on how things make us feel bad that we are missing the big picture. We really do need to confront people who upset us, because otherwise we can’t even know whether we’re actually being bullied, as with the nurses I am not trying to scare. Nursing is built solidly around the process of self-reflection and change, but others can help us out by handing us a mirror. Am I bullying people? Not intentionally, but if they feel bullied, does intention matter? If it is affecting patient care, and the literature says it does, then the answer is no.

I invite readers to observe their own behavior and repair any that may be construed as bullying or lateral violence. I still maintain that nurses with issues are responsible for voicing them to find out whether the issue actually exists, but in reality that happens very rarely. The burst of articles on bullying and lateral violence tells me that nurses perceive a serious problem in this area, and this is one we can fix ourselves. Other authors suggest tactics for the bullied nurse, but I’m suggesting a solution that starts with everyone, including “mean” bullies.

What is it? Secondary trauma is just what it sounds like. You get traumatized second-hand, from trauma that isn’t even yours. How does it happen? Nurses do not work in the land of unicorns and rainbows, despite the ads from the Johnson & Johnson “Discover Nursing” campaign. Sometimes we do take care of cute babies who aren’t very sick, and on occasion we make a huge difference by rearranging someone’s pillow or doling out warm blankets. Mostly, however, we wade around in tragedy at least part of the time. Depending on our specialty, it can be most of the time. Nurses like me who work in emergency departments and those who work in critical care areas or hospice may be particularly susceptible to secondary trauma.

Some situations or types of situations are more obvious than others as candidates for causing secondary trauma. For example, nurses who work closely with patients (and let’s not forget their affected family members) who have been raped, brutalized, or disabled by trauma would seem obviously likely to be affected by the ongoing despair. However, nurses who do not work in trauma or critical care areas still witness personal tragedy regularly. What of the stream of elderly who have been abandoned by their families and fall into the social-work black hole where they cannot receive the care they need? What of the parade of terminally ill patients? These situations are tragic and draining as well, even if they are not trauma in technicolor.

Do you find yourself wishing more often you were somewhere else at work? Do you dread going to work at all? Are you sick more often than you used to be? Do you see specific patients or scenes behind your eyelids when you are trying to fall asleep? Are you unable to stop thinking about certain situations you have witnessed at work? Do you feel yourself putting the brakes on your compassion because you just have nothing left to give?

These are all signs of secondary trauma (and compassion fatigue, the fastest and most common result of it), and if you don’t address it, it will just get worse. Hospitals often have formal debriefing systems set up for huge obvious traumatic situations (take advantage of those when they’re offered, please), but they fall down on the job when it comes to this creeping secondary trauma which builds from multiple episodes of lesser drama and obviousness. They do often offer EAP (employee assistance program) benefits, and I don’t see a downside to taking advantage of help when it’s there waiting to be used.

It is every individual nurse’s responsibility to notice and address potential secondary trauma in ourselves, because it affects our health and our patient care. It may even eventually render us unable to do our jobs at all. The culture of nursing can sway us toward thinking that asking for help shows weakness, but we can decide to change that. Secondary trauma is unarguably an issue in our field, and it is our duty to address it.

Her issue of interest to me was that her boss and the HR folks in her institution had written her up on at least a half-dozen social media–related offenses, none of which were legitimate offenses according to my column. The one I want to focus on right now is time-stamped social media entries. This CNA was in hot water because she had posted entries on Facebook during the time she was clocked in and therefore “on duty.” Her side? She was on break or in the bathroom, not Facebooking at the bedside.

Those of us nurses who use social media or even SMS messaging are “toilet tweeters,” meaning often the only time we have to tap around on our phones is in the bathroom or, if we’re lucky, on break. Are we clocked in? Yeah. Does that mean we can’t post anything anywhere during that time? I don’t think so. I’m not talking about posting patient information or anything that violates patient or company privacy. I’m just talking about anything posted while you’re clocked in. If you work a 12-hour shift, you theoretically get two 15-minute breaks and a 30-minute lunch, which is a solid hour of “on the clock but not on the clock” time.

Privacy and HIPAA aside, other issues arise. I admit that I have been extremely annoyed during busy shifts to find social media entries time-stamped during the shift by other nurses who should have been working. Have I taken the time to find out whether they made those entries while on break? No, of course not. I just got mad and assumed they were lazy, on the computer instead of working like everyone else (meaning “me”). They could, however, easily have been on break, in the bathroom, or otherwise legitimately able to text, tweet, or Facebook to their heart’s content. I don’t know. And neither does HR.

Is it really necessary to have a rule, externally or internally imposed, stating that employees should not leave electronic breadcrumbs behind them during the time they are at work? I say “internally imposed” because we are adult professionals and can self-govern if we decide it’s best. I initially say no, because we are adults and should be allowed to use our own judgment as to when we can safely and reasonably engage in our own activities. But I have to admit that it can look bad. What if

• Your time zone is set wrong and it looks like you were repinning a recipe on Pinterest while someone was coding?
• What if you WERE repinning a recipe on Pinterest while someone was coding—because you were legitimately off the floor on your own time?
• You post a photo of your workplace with no patient information visible but people can figure out where you were and when?

Those are just a few examples. This CNA, happily, had all of her issues dropped and has moved on in her career. I’m glad she brought these to my attention, though, because although I have published on them before, there are always new angles to consider. For what it’s worth, I am adopting the hallowed middle ground by including disclaimers when I tweet at work (“On break. Blah blah blah” or similar).