I'll keep this short because I was on a weird shift last night at the ER to try and cover the peak times, and then I went to my other job today, and I'm trying to catch up on sleep before my 0800 class tomorrow.

It's crazy to look at my syllabi and see all 400-level courses.

This fall semester is my final lecture-based term; Jan-Feb is my consolidation and then Mar-Apr is my PRECEPTORSHIP!

I put in my preceptorship placement requests yesterday after a lot of serious thought. Basically, after much deliberation and longing to try every specialty but being restricted to only 3 choices, I finally decided on Oncology, Cardiology, and Corrections.

A few that fell on the cutting room floor were PACU, ICU of all types including CCU, public health particularly women's sexual health, and a brief daydream of something extra crazy like OR. I also didn't consider asking for Emergency since I wanted to try something new.

Why not critical care? Although I'm tremendously interested in it, and I KNOW I'd learn a lot, I spent a lot of time reflecting on the criteria to excel in my preceptorship. Some of those things include initiative, the ever-elusive "critical thought", and transitioning to a grad nurse role. I honestly don't think I'd be able to excel in those criteria in ICU. Yeah, a 10-week preceptorship would be an awesome orientation to the floor, but really, it would just be an introduction. In my final preceptorship I'm expected to be a grad nurse. I feel like I'd spend so much time being a fly on the wall, I'd be too afraid to get in and get my hands dirty, so to speak.

The choices I picked are ones that I think have opportunities as a newbie nurse to actually show some initiative and capability as a health care provider.

We had to provide some rationales for our choices, and these were mine:

1. Oncology: My interest in Oncology stems from both the prevalence of cancer diagnoses across all patient populations as well as my family’s experiences with cancer. I feel uniquely prepared for a preceptorship in oncology nursing as I am currently completing the ONDEC course through the Alberta Cancer Board. I am also a student member of the Canadian Association of Nurses in Oncology (CANO) and will be attending the CANO conference** in Halifax this September to learn more from dedicated Oncology Nurses about their specialty. In return for receiving a travel grant, I have agreed to write a journal article for one of CANO’s publications and I am hoping to write about my preceptorship experience and transition from theoretical knowledge into practice as a graduate nurse.

2. Cardiology: I have worked as an undergraduate nurse in the Emergency setting over the past summer. I have tremendously enjoyed working in the ER and have found that one of our major patient populations are either experiencing acute cardiac changes or have a history of cardiac/vascular pathophysiology. Having worked closely with several former Cardiology nurses, I admire their extensive knowledge of this specialty. As I have been invited to stay with the ER after I graduate, getting first-hand experience with this specific population will be extremely educational and give me confidence when working with new-onset cardiac concerns in the ER. My RN coworkers have commented on my willingness to get involved and ask questions to further my understanding, so I believe I could meet the required objectives to excel in this placement.

3. Corrections: My first post-secondary program was in Policing, of which I completed 50% of the course credits. I still have a strong interest in law enforcement although I am geared more towards prevention and rehabilitation rather than apprehension. At the ER we also had several inmates transferred to our facility for treatment. I believe that with my educational background and ability to respect and work with corrections patients without judging their histories, corrections nursing would be a unique opportunity to make a positive impact in an underserved population.

**In other news, as you read, I am going to yet another conference! There are just so many opportunities for students to get involved in Nursing. I have some other projects I'm excited to tell you about. But that post will have to wait until, at least, I get a decent night's sleep :)

WaHOOOOoooOOO FOURTH YEAR!!!!!!

Firstly, THANK YOU for all of the kind words re: my summer placement.

Since Zazzy asked, I'll define UNE - "undergraduate nursing employee" is my province's designation for a 3rd year student nurse; since BSN was made entry-to-practice for RNs in this country, it's how we can get paid experience working in an RN-type role before we graduate.

The UNE position does not fall under the auspices of our regulatory college or union; rather, it is a protected position that is only available to regular-entry BSN third year students (not LPN-RN bridging students, or accelerated BSN students) and it is designed to be temporary (cannot work full-time for more than 3 months, less a day, per UNA guidelines - this is to make sure that a UNE does not take the place of an RN or LPN position).

The UNE takes on a lighter load than an RN, with lower acuity, and is responsible for patient care for anything he or she has been trained to do already in school. For example I can do anything I have done in clinical before - foleys, wound dressings, IMs, bladder scans, etc. Things I have not done before I can watch and learn, such as placing NGs. Things that are outside of my clinical scope I cannot do as a UNE. Such as IV push meds or defibrillation - which is totally okay, I'm in no hurry for that kind of responsibility.... lol

Otherwise I function in my full clinical scope. I can do planning, teaching, skills, and nearly everything an RN would do. I'm not totally sure what I *can't* do, yet, because I think that's probably specific to the type of environment I will be working in. I've never had a rotation in Emerg, or spent any significant time there outside of my volunteer position (which never exposed me to much except where the supplies were, really). It won't be like my med-surg experiences with paging the docs and stuff. I like this particular environment because the nursing station is combined with the physician desks. It will be an excellent opportunity to learn by eavesdropping on everybody, especially because curtains aren't particularly soundproof! :)

So yes, I will be working 0.5 FTE from May through August (that's about 20 hours a week) and mainly evenings and nights. I have never worked overnight before. I've worked late-as-hell (6 PM to 2 AM) and early-as-hell (6 AM to 2 PM) but never crossed that barrier. If you have any tips please share. I am concerned that I will turn into a surly, cheerless, friendless prickle. My plan to also work 3 days per week at my desk job, likely in midmorning-afternoon, kind of hinders the idea of turning full-on vampire. I'm not sure how this will work out. If something has to give, I will stick with Emerg.

Oh! That reminds me. I was going to write up some of the interview questions in case that helps any of you out in the future. I have them scrawled on a notepad somewhere...

At any rate, as per the title of my post, I am technically supposed to be writing a ten-page critique of a research report right now. It's a self-imposed deadline for the research class I'm taking by correspondence. Knowing myself and how I am, I booked the final well before I finished any of the projects, so that I would HAVE to finish it. So now I HAVE to finish it, or fail the course, by Thursday April 28............ but it's only the 17th, and of course you see my temptation :)

Before I get back to the slog excitement of critiquing research, I guess I should also update you about my clinicals, which are (surprise!) still going on until the end of this week.

Yeah! Bet you thought I was done, based on the crappy posting of late...

Nope, I am 4 weeks out of 5 from being finished my Community/Public Health rotation.

Tuesday is our oral report about the agency placement with the preschool kids, and our teaching plan re: toothbrushing and washing hands. Wednesday is our actual presentation to the kids. Thursday is our final evaluation, and Friday is a long weekend, my last before I go back to work.

(For the record, I took a leave of absence from my desk job for the months of March and April in order to focus on clinical, and it was the BEST THING I EVER DID for myself in school. Hands down. Last year my hair was literally falling out. This year I am able to attend my horse-riding classes, work out, make healthy food choices, take on 2 correspondence classes, AND do a decent job on my clinical projects)

In regards to Community Health, well... I have felt like I could fit into every clinical placement I've had so far. Even postpartum which I honestly thought I would hate (thanks CC for helping me consider otherwise :)

But, man, Community Health has absolutely NO appeal to me. It could be that I've worked desk jobs for about 6 years now and I'm numb to the pride I once had about having my very own cubicle. I can't stand office work or office gossip. I hate photocopiers and water coolers and I REALLY hate getting emails from people who don't know what Reply All means. I realize that there is a hands-on component in public health, i.e. when you actually go out and assess babies or teach college kids about STIs or do an immunization clinic for Grade 5 kids.... but that seems to be only 10% of the job. The good 10%, IMO. The other 90% of the time seems to be spent in the office, trying to round up resources and liaise with other people and hammer out meeting times and set up appointments, etc, etc.

Maybe CHN/PHN will be appealing to me when/if I have family responsibilities or am tired of running around all day.... but for now, get me back in the hospital, stat.

I shadowed one day last week in the Hip & Knee Clinic, where people go for pre- and post-surgery teaching and assessment. It was actually a really cool experience, especially given my rotation in Orthopedic Surgery last year. I got to take out some staples and do a dressing change. Compared to the rest of my rotation, it was practically critical care in there! lol!

Okay okay, I'm going to go write a paper now. Honest....

So here I am, nearly 2 weeks into my Community/Public Health rotation.

My partner and I went to our assigned community agency for the first time today. It is a small converted house in a poor residential neighborhood that supports a variety of programs including childcare, social work, and drop-in personal growth/social opportunities.

Our big project with this agency is to plan, develop, and implement a handwashing/hygiene presentation for preschoolers and their parents. We will have about 6 days total to come up with the lesson plan and resources. Everything will be documented into a presentation for our peers, since different students are assigned to different agencies.

So while my partner and I were brainstorming ideas for a short presentation on handwashing, my phone rang. I didn't recognize the number, but it looked like my instructor, so I sighed as I reached for my phone and rolled my eyes because she had just called me......

.....until I realized it was the hiring manager for the local Emergency Department!!! Yep, the one I volunteer at :) And the one that is literally across the street from me.

I had applied for a UNE position (Alberta Health Service's position for Undergraduate Nursing Employees on a summer/temp basis) last year as well but I didn't realize how many skills I was lacking. And I went to Thailand - no shocker they didn't hire me! So this year I was really pumped when I sent in my application at the beginning of this month.

My interview is on April 14! So excited.

The core reasons I'm interested in working Emerg over the summer are because (in this particular ED, anyway) of the high degree of collaboration between physicians and nurses, and amongst the nurses themselves, the population will be all ages and sizes and socioeconomic statuses, I will see a high volume of presenting conditions and learn about how to prioritize/plan for them, and I will get to use plenty of skills.

Did I mention I was excited? :)

I started this post several times over the past few days. Friday was the last day of my acute care rotation, where I have been stationed on a Vascular Surgery unit.

You may recall that my instructor quit halfway through my rotation due to family issues, and we got a new instructor. Not just any instructor, but my Patho instructor from last year. I wasn't sure how changing instructors halfway through could possibly give either instructor a decent overview on how I did on this rotation. Especially considering how I was raked over the coals at my last evaluation. My confidence was so shaken and it's been nearly a year since my last acute care placement.

Wow. I take back almost everything I said about my Patho instructor last year. It actually pains me to read how harshly I critiqued her. I still remember how it felt, though, to be in her class and be absolutely boggled by how she would jump from one topic to the next without clear linear relationships between disease processes. It made me absolutely crazy and I learned Patho from a textbook because her teaching style didn't resonate with me.

But - as a nurse? As a clinical instructor?

I have been SO privileged to be under her care and direction for the past few weeks.

I even wrote on my course evaluation that she should be promoted to teaching other clinical instructors, she's that good. It's hard to put into words what exactly worked for me, but I'll try, so that one day I can remember what it took to make me feel like I have it in me, somewhere, to become a great nurse:

1. Greet every student with a warm genuine smile, and a holistic appraisal of who we are and what we want to be. Even if that thing isn't in Nursing.
2. Collaborate with students and encourage us to use our theoretical knowledge in practice. That knowledge is in there, somewhere - draw it out! Get us talking!
3. Have high, high expectations for us. Expect that we will be safe, compassionate, knowledgeable caregivers. Have faith in our education. We will rise up to your high expectations and we might even exceed them.
4. Once the plan of care has been decided, ask us to explain what we're about to do, and then leave us to it. We can and will do a much better job without an instructor breathing down our necks (such as priming TPN lines, choosing appropriate IV med tubing, choosing appropriate needles/syringes and drawing up meds). Follow up after to check our work. We will feel the weight of surveillance float right off our backs.
5. Get involved in the patient's perspective and demonstrate how easy and spontaneous therapeutic communication can be! Segue seamlessly into those tough questions like suicide risk and spirituality! Show us how it's done!
6. Give instant feedback. Good and bad.
7. Treat us like adults. We are.
8. Be excited for us. Be happy for us. Share in our accomplishments and celebrations. Encourage us liberally.
9. Be fair, honest, and genuine in your appraisals.
10. Come with us for a drink after the last evaluation. We all worked hard, dammit! We won't judge you. See #7.

So I hope I'm not sounding too sappy, but I absolutely, 100%, believed in, respected, and wanted her feedback on everything. She is a Great Nurse, and a Great Educator, and an Inspiring Leader, and how many times do you meet someone like that?

I can't tell you how many times former-students-now-RNs would come and find her on our unit, with tears in their eyes, and thank her for her contribution to their lives. Doubtless, I'll be the same way.

"UgRN," she said, reaching for my lapel;

"I wish there was a higher grade to give you than A+. You are caring, skilled, and holistic. This hospital is practically run by former students of mine. In my 15 years of teaching, I have developed an instinct for people who are Going Places. I can honestly say that you are one of them."

She pinned a small angel to my lapel.

"This is to remind you of 3 things.

"One, to remind you to connect to your spirituality if you find yourself in a situation that overwhelms you. If you are doing postmortem care for a recently-passed patient, and they moan as you turn them [I had told her about my possible interest in Oncology]. Connect it back to your spirituality, and I don't care if that's God, Buddha, Mohammed, or the Circle of Life. Once you do that, you will remember who you are and the importance of what you are doing.

"Two, you can be anything and go anywhere in nursing. I don't think you would like it, but you could be in management. You can be a Nurse Practitioner. You can excel at anything you put your mind to.

"Three, if you need me to vouch for you - and I don't care if it's 15 years from now - call me anytime. I might need you to send me your picture. But do that, and I will remember you, and you will have an excellent reference."

She smiled at me with tears in her eyes. I did the same. I have never felt that someone Got Me in the way that my instructor Got Me. She totally understood who I am and where I am coming from. She could see how much I love this work.

I am so very honored that she gave me the angel pin. I am not much of an "angel" person, but the significance of it outshines anything else I may ever get from an instructor. Every time I look down at my uniform, I will smile and remember what she said to me.

A quick story because I am heading out to clinical soon -

Patient has been in hospital for several weeks now, post op for a diabetes-related amputation. Side effect is HUGELY swollen genitals with some really awful skin breakdown. Guy is in a lot of pain. He is both needy and withdrawn. He is not handling the patient role very well. He wants his control back.

He's had a student with him for several shifts. Student has the time to be with him constantly. Student talks to him, gets to know him, works to understand and resolve his concerns. Turns out there's a lot of underlying stuff about him that no one knew about. Patient is super grateful for the care. Patient calls student (note - I'm not the student!) an "angel from heaven".

Next shift, staff balks at allowing a student in his room anymore, stating that the 1:1 care of a student is "making them look bad".

What say you?

It was right around 1800 and I was in the middle of spiking new bags of TPN and lipids. I had forgotten the PICC IV adapter and was halfway out the door to grab one when her visitor peeked around the corner.

Before me stood a woman about the same age as Mary, my patient. She held her purse with both hands and peered at me questioningly. I paused and smiled at her, told her she was welcome in the room - Mary was awake for a change and watching TV.

She hesitated and looked at me again, eyes darting briefly between me and the room behind me.

Eyes wide, she asked it:

So... how's she doing?

Whoa, loaded question.

My mind lurched briefly and then started racing. Who are you? What do you get to know? How much do you already know? What do I know? Where's the line supposed to be, and how do I draw it?

Mary was not doing particularly well. She was currently weak but stable. The severe ischemic colitis was a major complication; if it turned gangrenous, the mortality rate could be as high as 50-75%. At this point it was a wait and see game, to determine whether she'd recover some bowel function and be able to live a normal life, or perhaps her bowel might perforate and she would have to be treated for life-threatening peritonitis. Surgery could entail resecting the bowel, or even removing it entirely, and creating an ileostomy. Mary was also experiencing some mental status changes, had pitting edema to one leg, and was becoming increasingly gaunt.

So *I* knew all of this. But I was also acutely aware that this visitor would hang on every word I said, and I would have to be as diplomatic as possible, but there was no time to really think about what I would say because every moment I hesitated she grew ever more concerned. There were also concerns of who was she, and what was she entitled to know. What was I entitled to share? How could I put it?

So, with my heart pounding in my chest, I asked the visitor who she was. Mary's best friend since we were in high school, she told me. We go way back.

'Okay,' my mind raced, 'a friend. Good friends, by the sounds of it.'

I took a deep breath.

"Mary's surgery is healing well, but she has developed a complication with her GI system." Her eyebrows raised and I cringed internally. GI? Who the hell says that?

"Her, uh, bowels are having some problems, and we are, uh, keeping an eye on her." I winced inside. It was extremely hard for me to find the right words that would simultaneously protect Mary's privacy, avoid false reassurance, and also respect the friendship of these two women; made harder still as she watched me, nodding carefully and hanging on every word I said. "She is doing well today and you are welcome to go and visit her."

"So, when will she be able to leave the hospital?"

Good question, I thought, I have no idea either. "When the doctors feel she is strong enough."

"So we are just waiting for her to get strong enough, and then she can leave?"

Yes, if she doesn't perforate and go septic... or lose her bowel function entirely and need major abdominal surgery to create an ileostomy... and if that surgery doesn't develop complications too--
"Pretty much. She should be discharged then."

"Okay, thank you." She smiled at me, and I smiled weakly back at her as she walked into the room and gave Mary a big hug.

I let out a huge exhale. My heart was pounding. They never taught us how to deal with that in school...

Today's evening shift marks my 6th day on the unit (Only? Wow!). It would have been 7 except I had to miss a day for flu-related conditions. This week has been interesting.

I've been assigned one patient for the last few days - a lady in her 70s who presented to Emerg with a big DVT in her leg. A CT found AAA as well as an aneurysm on her common iliac. They decided to remove the clot and repair the aneurysms at the same time, landing her on my unit after some time in Intermediate Care. Turns out she has developed a major complication from the AAA repair, ischemic colitis. They put pictures from the scope into the chart.... that was a sight to see. The colon is pale and there are patches of necrotic tissue. There are what seems like grey perforations in the bowel and a lot of mucousy yellow slough. It's crazy to think that's going on inside her body.

Right now, I think they are managing her symptoms and trying to ride it out and see if the bowel will recover some function. She's on TPN and a couple of antibiotics; pretty much everything else is from pre-existing conditions.

So, she's a pretty sick patient, and it's been a busy few days for me. I have been able to hang IV meds & TPN to my heart's content and provide pretty much total care for her, which I have been enjoying immensely. It's like all the good stuff from 1st and 2nd year, plus being able to do almost everything for my patient, with a cosign of course.

"Can I have a shower today?" she asked, squinting up at me in the afternoon sun.

She had been looking kind of, uh, smarmy and I was elated to hear her awake enough to request a shower. It was a hell of a production. The primary nurse and I (despite my protests - I definitely could have managed, but she wanted to be there too) brought the patient into the shower room along with her smart pump. We cling-wrapped her PICC and peripheral IV. We put bags over the pump. 20 sweaty, humid minutes later, we had her scrubbing under the showerhead, and her relief and sighs of satisfaction made the whole thing absolutely worth it. She said it was the best shower she'd ever had. lol :)

Unfortunately the pleasure of providing her with a much-needed shower was tampered by a very unfortunate mishap involving incontinent ischemic bowel... everywhere...

That makes my Code Tally 0 code blues and 2 code browns. They are smelly but no one dies.

So, after having such a crazy start to my shift, the rest was absolutely slow. My patient slept most of the evening, barely waking up for meds, and then zonking out again.

Finally, after I awoke her for 2200 meds and HS care, she popped back to life and asked me what was on the menu today. "Nothing," I smiled, "you've had quite a day; it's now 10 PM and it's night time."

"Oh. Were [unintelligible]?"

I leaned closer. Come again?

"Were those yard apes here?"

I laughed. Yes. "Your family was here. They watched Ellen."

She shook her head and smiled. She picked up her toothbrush and examined it. I waited patiently, watching her for signs of agnosia. She felt the handle and brought the bristles close to her glasses.

"Modern science!" she proclaimed appreciatively, and then proceeded to brush her teeth.

Just after I set up her sidestream nebulizer, and before I turned off her light, she turned to me and asked.... "So, any chance I can have that shower today?"

Second buddy shift down. I had the same RN to shadow. It was a great day, lots going on!

Tomorrow I am taking my first patient, an older guy with rectal cancer who had a new ileostomy created. It'll be the first ostomy I've cared for. My instructor doubles as an ICU nurse when she's not teaching and expects solid research from us about our patients. I am happy about that - patho doesn't REALLY make sense to me until I see it manifested in a patient.

So LOTS of research to do tonight on ostomy care, cancer disease processes, head to toe assessments, and meds. Sooooo many meds.

Whee!

Yesterday was my orientation onto the new unit, new instructor, new everything. It can be pretty challenging to change gears like we do as we move from one rotation immediately into the next. Especially given the circumstances from the last instructor, I found the adjustment a little difficult, but I think once I hit my stride with my own pt load I will be okay.

I wasn't sure what to expect with this unit, since my last surgery rotation was orthopedics. I think there will be a lot of similarities. Older patient population, multiple comorbidities, people who are more or less paying the price for a lifetime of unhealthy choices. Sure makes me re-evaluate my own healthy habits. There are amputations, bypasses, carotid endarterectomies, a whole plethora of vascular surgeries I don't yet know about, and general surgery.

My precepting nurse today was a new grad herself, class of 2010. I shadowed her and rounded with her on her 4 patients, getting a feel for the unit's flow and routine. I was pleased to see the teamwork dynamic on the unit - an AWESOME change from my maternity rotation, where the floor had some serious politics that they made no attempt to hide. Like the day I had to request a new nurse because mine spent the entire morning griping to me about other nurses and work environment instead of letting me care for my assigned patients - wow, awkward.

It was nice having a newer nurse to shadow today. It helps to give me a visual on where I would like to be when I graduate. Usually, when I shadow really experienced nurses, I get blown away by how much they know and what they know to expect. It can be intimidating when they are connecting dots long before the questions have even formed in my brain!

Today's patients included a middle-aged woman with a brand new ileostomy, a senior who'd had her gangrenous leg amputated, a patient with a gianormous gallstone and pancreatic issues, and a man in his 60s who was about a week post-op from a fem-pop bypass.

The unit is pretty old-school in terms of layout; it is a horseshoe with rooms around the perimeter and the nursing station at the opening. Being oldschool, there isn't really anywhere to chart comfortably or congregate with other students to do research. I got pretty used to that on my last rotation - couldn't go 10 feet without running into a charting station complete with computer and task chair :)

I am feeling good about this rotation EXCEPT my instructor will be leaving in a few weeks and will be replaced by someone, but we don't know who. So my current instructor will be doing my midterm evaluation and then a new instructor will be doing my final. This could play in my favor, as I have time to find my feet and then the new instructor will come in and see me being awesome, or it could go the other way.

I am looking forward to my leave of absence from my job; I will be off March-April so I can focus exclusively on clinical. This will be a first for me and I intend to take full advantage of it in terms of home study and knowing my stuff - I should get another 20-25 hours per week to myself! Unfortunately I will be completely broke for 2 months. :(

In other news, I attended my STTI chapter's executive meeting to offer my assistance with maintaining a web presence via The Circle. This kind of evolved into them asking me to give a presentation at the next meeting to show them how to use it. Ironically, the next item on the meeting agenda was succession planning. IMO, the single best way to recruit my digital generation into any role is to create accessible information and make it easy to become involved. Honestly, the first thing I did when I got invited to STTI was go to the website. Same with CNSA. Same with Alberta Health Services. I am probably a little more gung-ho than the average student in terms of finding information, and a little ballsy when it comes to getting involved, and I think more people would love to get involved if the process of becoming involved was straightforward and clear.

I believe we are at an awkward stage in terms of information accessibility; a lot of the areas in senior management that are responsible for coordinating information grew up in the era of newsletters and paper applications. Information was accessed days or weeks from the initial request in terms of fax or mail or answering machine. What you knew was directly related to who you knew, and "in person" was often a requirement. However, these outdated methods of Finding Out no longer meet our expectations. We want to find information in seconds. This dichotomy is causing tension between old methodology and what we've come to expect from online resources. It's no one's fault, of course, that we are taking our time getting information more freely accessible - healthcare is a little unique in terms of extremely important confidentiality issues. I definitely see a huge potential for information distributed almost exclusively through digital media. There really is no reason to have paper anything (unless you live in Canada and have paid attention to recent events involving Usage-Based Billing). It is my hope that I can do my part through CNSA and STTI Mu Sigma to encourage freely accessible information and improve involvement in these organizations.

By the way - I don't know if I mentioned it, but I was elected into an informatics position on the Board of Directors of CNSA! It is currently an Officer position which reports to Director of Communications, but informatics is a massive role in its own right and I see potential for the position could be expanded to Director of Informatics at the next National Assembly. Obviously it will take a whole lot of work on my part to make that happen. I am really excited about this opportunity. The website is going to improve a lot over the next year. It needs improved navigability, richer content, frequent updates, CNSA projects and involvement, and clear role descriptions for the BoD. There are some lacklustre forums on there which need better organization and spam filtering. There are opportunities for greater integration with CNA's NurseONE (I met the project lead at the conference) and hopefully nursingideas.ca. I have a lot of ideas and am hoping to get together soon with the webmaster to discuss the back end process for the website. My term doesn't officially begin until April 1 so no rush.

Wow, I had a lot more to say than I thought. I am so, so, so excited about all these possibilities. Going to bed with visions of awesome, engaging, easy-to-navigate websites dancing in my head. Second RN-shadowing shift tomorrow!

So after spending the entire weekend feeling sorry for myself and (involuntarily) lying awake pondering the intricacies of human nature, I feel mostly at peace with the events from Friday. I owe a lot of that to you guys for your support and kind words. Nobody gets it like another nurse does and I felt SO much better after seeing your comments and emails.

To answer the common question - I have decided that I will not pursue the matter against my instructor. I am heading into another full-time clinical rotation on Tuesday (vascular surgery, yay!) -- with a different instructor, thank god -- and I just don't have the fortitude to deal with ongoing illogical bullshit. Even if I did call for some kind of inquiry, it would be my word against hers, and how can you argue with someone like that?

I would prefer to be that person who stood up for the masses and blew the whistle... but my school has a history of blackballing, and I just don't see how I could win. One more year of this and I will be answering only to me: ugrn, RN. And CARNA. :)

I did submit anonymous feedback on my instructor before my evaluation. Our school asks for feedback on all instructors up to the day before final evaluations. I was extremely fair in my assessment and delivery, maybe TOO fair considering how she was with my evaluation, but I think my feedback is more likely to be taken seriously than someone who rants unintelligibly.

My mark isn't terrible. I got a B. I think I deserved much more than that, but it's acceptable. If I escalate my concerns with the ivory tower, it would be a whole lot of BS just for the sake of 'being right'. If my instructor had been someone I looked up to or wanted to emulate, I might care more, but frankly I think her bedside manner stinks. I don't need her to validate my hard work. I didn't then and I don't now.

FYI, because this past couple of posts have been pretty specific about one instructor (she'd obviously know it was about her), I have been carefully monitoring incoming traffic. If I feel like I may have been discovered I will be temporarily pulling down my blog or removing some posts.


Anyway, enough about that. Happy birthday to my blog! It turned 3 on February 3rd. I got it a birthday cake because it has grown so much since that first post. I really have to thank all of my readers for sticking around this long. It blows my mind to think of how far I've come since that day. One more year... one more year... then I will have to change my blog name!

In celebration of my blogiversary, I tweaked my page design a bit. I like it. It's a lot cleaner than the last one, which was the result of the various glare and texture filters in Artisteer being vomited all over the page... I also whipped up a slightly modified header since  I discovered the joy of Adobe Illustrator. Anyone else want a shiny logo? I'm having a great time with it, lol. Too bad it costs $1500 for a licence. I have 28 more days to enjoy the trial. :)

For some reason I have been getting a ton of visits from Israel coming to learn about cranial nerves. One of my friends is Israeli. She showed me some pictures of the homeland and I was amazed by how many sexy people live there. Wow. Hello, good looking people, and welcome.

I do have a post coming for the CNSA Conference recap. However I have a date with football, beers, and wings so I will have to catch you up later :) Happy Superbowl Sunday!

I originally started this post last night while I got ready for my final clinical evaluation today. Because I am having a total mindfuck of emotions right now, I'll break it into two parts: Part 1 was written last night and Part 2 written now.

Part 1 [Last night]:

Thank you all for your patience while I get back into the groove! I had an a-maz-ing week at the CNSA National Conference, as you can tell by my various phone updates, and I will recap it for you as soon as possible. I came home on Sunday and it has been a total whirlwind since then, which is pretty much my life during clinicals.

@Cartoon Characters: Thank you for your awesome supportive comments. I really appreciate you stopping by to say something! Especially given your career :)

Today marked the last day of my experience in Maternity. I have mixed emotions about it - since my final evaluation is tomorrow, I wanted to really reflect and consolidate my patient experiences before going into my eval. I don't feel especially confident in my instructor's appraisal of me, partly because I have NO IDEA what she thinks of my practice, and mostly because I have found her pretty hard to gauge.

A word about instructors... I think one of the most important traits to have is transparency in your opinion. If you think I did great, please say so. If you think my practice sucks, PLEASE say so. But even more than that, it is so important to have an instructor who is willing to share in my challenges and in my victories. I had a huge win yesterday - I'll explain in a bit - and I wanted to share that with SOMEBODY, and so I turned to my instructor. She gave no opinion at all and just stared at me with a blank face until I trailed off and awkwardly walked away. It didn't diminish my feelings of success because I KNOW that I did well and no one's lack of championing my actions can change that. But it would have been nice to have some external validation as well.

---

Part 2:

She slid the evaluation towards me.

"Do you have anything you want to say?" She asked, eyes glittering, lips in a tight smile.

My heart was pounding in my chest and tears blurred my vision. I had a lot to say, but I was too overwhelmed to get any words out without falling apart. I scrawled a signature accepting my grade and gathered my books quickly, charging towards the door before I lost control.

I was reeling from the evaluation. It felt like series of accusations. Fails to show professional behavior. Fails to maintain professional-social distance. Does not know what she should know. Incompetent. She told me that she didn't think it would be in my best interest to act as a reference for a undergrad nursing position this summer.

As she read these phrases out to me, it felt like she had to be talking about someone else. Fails to maintain professional distance? What could she possibly mean? I wanted to ask but could not; I didn't want to start an argument that I couldn't win. The grades had already been assigned.

I mulled it over and over, trying to pinpoint a time I may have breached that professional boundary - moreso, trying to imagine a time that she might have actually been around to witness it. The only moment I can think of is where she breached the professional boundary and made an off-color comment to one of my families, jokingly referring to their (first, miraculous) post-term baby as a "peeler" and asking the father if he had any stories about 'The Peelers'. He was mortified ("Uh, no, actually, I am not into that at all....") and so was I.

Incompetent? How could this be? I'll be the first to admit there's a lot I don't know. But I ask. I work within my scope of practice and I ask as I go. I practice safe care, I keep my eyes and ears open, and I study at home to try and learn something for next time.

Nothing made sense. My patients expressed nothing but gratitude for the care they got. I independently assessed a need for breastfeeding support on several of my patients and got them the help they needed. I coached new moms through that initial latch and encouraged them to listen for the swallows of their feeding infants. I intervened on a gagging baby and got him to burp the biggest burp he'd probably ever made in his short life. I talked a young couple through how they felt about their changing from a couple to new parents. I demonstrated initial baths to several proud dads and their cameras. I found twin heart beats for an NST on my first try. I palpated fundi, I provided comfort measures, and I once dug through a bag of nasty post-birth laundry to retrieve a pair of tiny baby socks when everyone told me they were as good as gone. And not once did anyone say anything less than thank you with that look that said they meant it.

About that big 'win' I mentioned earlier - I left the hospital on my second-last day knowing I did good for someone. I had spent the entire day providing postpartum care to a new family stuck up in Caseroom until a Postpartum bed opened.

The mom delivered at about 0600 and was still up in the caseroom at 1230. Baby had been showing early signs of hunger but was also quite sleepy. She was an anxious mom, asking about feeding her baby, and the L&D nurse assigned to her provided very vague answers about how to get started with breastfeeding. I stepped in when the L&D nurse deferred their questions, and they had lots of them, like new parents should. I hunted down a pillow and helped prop her up in bed. I stole some breastfeeding pamphlets from Postpartum and sat down with her for close to an hour of teaching.  I coached her on positions, and we finally settled on 'football'. I showed her how to get baby nice and awake, and ready to eat. Eventually, with plenty of teaching, patience, and false starts, mom and I got baby with a solid latch and feeding like a champion.

Elated, I went to find my instructor and show her, and further convince anxious mom that she was doing well. I found my instructor getting her hair trimmed by a service aide in the utility room, but I digress. Instructor came in and saw mom and baby feeding well and applauded mom. A few minutes later, at the desk, my instructor told my assigned RN that mom was successfully feeding babe despite all of the challenges and concerns she had before. The RN was happy and asked my instructor if 'we' did that. My instructor reiterated that mom was successfully feeding babe.

I was honestly crestfallen with that statement. I had, in my mind, been a huge advocate for this family; despite their staying up in the L&D caseroom all day, I made sure that they had the same quality Postpartum care (to the best of my ability) that they would have gotten on that unit. Nobody guided me to make these interventions. I saw the need for them to learn, so I stepped up my game and taught them. It was like opening flood gates: they asked about SIDS risks, carseats, skin-to-skin, jaundice, and the list went on. That family was so thankful and grateful for the time I took to spend with them, helping them transition into the role of new parents. That was the family who left their new baby's tiny socks on the birthing bed when they finally did get transferred to Postpartum - the ones I ran back upstairs and convinced Housekeeping to let me dig through dirty laundry bags to find.

So yes, I *did* do that - in the sense that if I hadn't intervened, that mom and baby might not have had the same outcome. They didn't transfer downstairs for another hour, and shift change wasn't for another 90 minutes after that, and I'd bet my stethoscope that poor baby would be screaming blue murder if he had to wait that long for his first meal. Screaming baby + already anxious mom = anxiety through the roof, and who knows, that anxiety could have shaken them so badly that baby would be on formula by now.

And where was my instructor? Selling me short, and telling me in my final evaluation that I was not knowledgeable and crossing professional boundaries.

To think that I started this clinical terrified that I was going to screw it up. If it wasn't for the incredible response I've received from my patients, peers, and especially the unit staff - who frequently expressed how glad they were to have us, and often gave me a high five or a hug at the end of the shift - I would finish this clinical convinced that I am a shitty nurse. If it wasn't for how I felt going home a few days ago, when I KNEW I'd made a lasting difference with my families, I would doubt myself. But I know I did well. One voice to the contrary can't change that.

One thing did jump out at me at my evaluation. Despite all of the bullshit incompetencies on my final evaluation, there was not one bad thing my instructor could say about the quality of care I gave. There was absolutely nothing wrong with my practice as a nurse. The angles she took to undermine me were personal and nebulous. I really wish I had asked for concrete examples of these incompetencies; I would have liked to hear her try to describe them as specific situations.... but I was just too upset with disbelief to argue the point.

I think of the few times she was around to witness my practical skills - Vitamin K injections, initial baths, newborn assessments. She said I did them fine. I even asked her for critique and she had none.

I think of all the times she was around me as a person, not as her student. Very clipped responses, sarcasm, awkward silences.

And I wonder - what on EARTH had I done to make her dislike me so much that she would want to attack me like this. I still draw a blank. Maybe I reminded her of someone.

The lasting damage has been done. Her appraisal of me as a future RN has been decided, written, and filed away somewhere to inevitably reappear when I want to apply for a cool opportunity at my school. I will not let this define me. I will continue to advocate for my patients and provide them with exemplary care, and I will not let personal grudges EVER get in the way of that.

As my peers told me later while I cried into a cup of coffee, I grew so much through this clinical and I did it without my instructor's guidance. I became a better nurse despite her instruction, not because of it.

Antepartum and L&D start tomorrow. Had my L&D orientation today.

I LOVED my last few days on postpartum. LOVED.

There is a post in the works about it; I want it to be thoughtful so I won't rush to finish it tonight.

I am SO tired. Exhausted. Run off my feet yesterday in clinical and then straight to a work shift, and a 5 hour sleep before I had to wake up to finish a 15-page review on fetal heart tracings, and back to the hospital to do it all over again.

Oh, nursing school.

Good night :)

First of all - THANK YOU to all the kind suggestions on counting apical pulses on infants. I started tapping it out and it helped me with the counting. Part of why I was so confused with the heart rate was, I think, because my stethoscope is so good. The Master Cardio picks up every little sound and I was hearing the lubbs AND the dubbs and I was having trouble initially telling them apart. I have got it now, though :) Also, when my instructor watched me do vitals, I saw her write in her little notepad that I was keeping a good count! Thanks again!

Let me see here -

Last Saturday, I was fortunate to attend a prenatal class at the hospital (it didn't feel very fortunate at 7 AM on my only day off, but I digress). The instructor was a PT, which surprised me, because she was so super knowledgeable I had her pegged as a RN/Midwife. It never occurred to me that PT/OT might actually function outside of the Ortho unit. Sorry, PT/OT, I was foolish to doubt you!

It was snowing like crazy here but luckily I made it and all of the expecting couples did too. The class was an excellent recap of pregnancy, labor, delivery, and postpartum. The instructor had some really good suggestions on mobility (PT shines through!) and pain relief. I was impressed to see her put the coaches to work. I always wondered how the dads felt in the delivery room. She gave them all jobs to do and made sure they understood! She provided LOTS of teaching on the pros and cons of epidural and c-sections. She made absolutely no doubt that labour was going to hurt but she also reinforced that she was giving the parents-to-be tools to deal with it too. She kept stating "You aren't SICK, you are HAVING A BABY. So, if the nurses tell you to do something for yourself, it's because you aren't SICK and you CAN!" We could have cheered :) It was a very good class to attend and I was grateful.

On Tuesday, we were back on the unit for another buddy shift (RN shadowing). I was assigned to the nursery, which is on the postpartum unit, and it's where the neonates come to be assessed after delivery before they rejoin their moms in their assigned rooms. The nursery was a very busy place. We had 2 or 3 infants in there all night. They come down from L&D "fresh from the oven", so to speak, and are weighed, measured, given initial assessments, Vitamin K, initial baths, and vital signs taken. I had just arrived in the room when someone parked a bassinet in front of me and told me to take the baby's vitals. Man - that was suuuuuch a gong show, I'm embarrassed to tell you about it.

Quick tangent - I upgraded my watch to the kind that pins on - which has been coming in extremely handy.

So I get the little bundle quasi-naked and get to work counting apical beats. I am excited to use my new pin watch. So there I am, stethoscope on this baby's chest, trying to count the heartbeats and remember which minute I started at and which "ten" I was on (90? 100? Wait, was that 80? I think it was 80). Of course when you take an infant's heart rate, you need to count for the full minute. So I kept having to start my minute over again and 5 minutes later I am proudly waving my notebook around saying I GOT IT!!! So the RN asks me for the vitals and I'm like.... oh.... I was so pumped about getting the HR that I forgot about all the other vitals. So another 5 minutes later I've got the axillary temp and I think I've managed to count resps but that baby kept making little noises and moving so who the hell knows. Then my instructor pops her head in and asks if those were within normal limits for neonatal vitals and I was so out of sorts I couldn't remember and I had to go check. FYI - they were! lol :)

My RN gave me an initial bath demo and then asked me for a return demonstration. The baby she gave me was a 9-10 lb behemoth (he was only 38 weeks! LGA? Um, yep) and, luckily, a total gem to work with. I had him stuck under an arm and he was so good in the bath - by good I mean screaming, but not too much - and omg my arm was getting so tired. Then I tried to get a C-hold around his scapula/neck/head and scrub some vernix with the other but he was so darn big that my hand started cramping. I have to say - washing vernixy baby was not my favorite nursing experience. Combing goopy mommy bits out of baby's hair was rating kind of high on my eeeeeeeuuuuuugggghhhhh scale. However I was very satisfied with the sweet smelling, cuddly result once he was clean and dry.

On Wednesday, I was assigned to my first patient - a mid-20s G5 P3 or something similar who was 3 days post C/S and due to be discharged the following morning. She didn't need much care at all, BUT I actually did get a chance to do some teaching. Probably two of my biggest hurdles to overcome were 1) actually touching and handling a neonate without dropping it, and 2) providing breastfeeding advice to a mom, having never been a mom myself.

This mom kept complaining of feeling engorged even though baby was feeding well. I managed to try some strategies with her including warm and cold compresses, manual expression, and pumping to a comfortable level. She actually listened to my advice, although it didn't work, and never made me feel like I was just some random student trying to tell her how it was (which is what I was worried about). I call that one a success. I am, however, having trouble assessing funduses (fundi?) on larger moms. Anyone have a tip for me?

Then I had my second assignment, Day 1 C/S first time parents. I was SO busy. I managed to do all kinds of things - my first initial bath witnessed by my instructor, infant assessment, Vitamin K injection. My patient family kept me busy too with PIH (pregnancy-induced hypertension) precautions (v/s q4h) and some voiding concerns. I got to d/c a foley, spike a new IV bag (3rd year skill, yippee!) and give teensy handful of meds including a Voltaren suppository, for which my instructor said I did a great job with good confidence(!). I did a full independent newborn assessment in the mother's room, which was scary because she kept asking me questions and she was a pretty intense first-time older mom, and I managed to provide some good teaching on Vitamin K and an overview of the infant assessment and things I am looking for. Then she wanted me to demo a swaddle. I think she was expecting some kind of pro-star super tight baby burrito but all I gave her was taco salad and I think she was a little disappointed, whoops :)

Today we had our first major project of the rotation, providing anticipatory teaching on various subjects and covering them from birth to adolescence. I did it last night, per usual, and was up all hours. My subject was on child learning and education in Alberta. It was an enjoyable topic, but like any project during clinical, effort is proportional to grade and the project was worth 10%, so... *shrug*

As an aside, I am still absolute crap at interpreting written orders. I don't know where physicians learned to use a pen but I don't understand how, if it takes close to the same amount of time to write legibly versus illegibly, this* isn't some kind of real patient care risk. I know it's kind of a laughable quirk for a lot of people, but it could really hurt somebody if they misread it. And I don't mean someone who's been practicing with that doc forever and knows what is ordered. I mean me, as a new RN in a year and change, coming onto a unit for the first time, or a float RN. Who the hell can read these? Don't we think that should matter a *tiny* bit more? Although it'll just be my fault if I fail to follow up with the doc. Because THAT takes so much less effort than just writing a tiny bit more legibly in the first place, right? {/soapbox}

*Add - I know this isn't a particularly bad example of illegible writing. But really, if I were to hand this in as charting, would my instructor call it okay and safe, best practice?

I am really happy with my clinical so far. I don't hate maternity. I don't know if I LOVE it, at least not yet, but it has definitely been a great experience for me. First day off since clinicals started tomorrow... we had a lot of snow fall here so I think it's a perfect day to go tobogganing! Have a great weekend, everyone :)

Wow, 2011. One year from now, it will be 2012, and I will be entering my final clinical placements. This has simultaneously been the longest and shortest 4 years of my life - mostly in that I haven't spent 4 years doing the same thing before.

I started my L&D rotation a few days ago. Okay, okay - despite how much I thought I would detest the idea of being an L&D nurse, I can see how it might grow on me... :)

We are placed at an inner-city hospital with a really nice new wing created specifically for maternity. It has assessment & induction, antepartum, L&D, postpartum, NICU, and obs surgery all in the same wing. I was surprised and pleased to see the focus on family-centered care. Most of the babies barely leave their moms, except for assessments and initial baths.

Being inner-city, the patient population reflects everything from wealthy, prepared, crunchy granola moms who have read every book on gestation published since 1980, all the way to homeless women with no prenatal care and whose babies are detoxing from street drugs. There are recent immigrants and teenagers and the physically and mentally ill. There are high-risk moms flown in from northern Canada. It is a MUCH more dynamic cross section of life than I expected - really.

On Wednesday, we attended Ye Olde Orientation at my school. It's the same stuff we've heard before. WHMIS videos and fire safety videos, per Alberta Health Services protocol. I then met up with my clinical group and instructor. She has been an L&D nurse for 10+ years (and is still!), which is super exciting, because my last 2 instructors haven't been at the bedside in 20 years.

We had our orientation onto the unit. We are starting on Postpartum. My orientating nurse was great! She was a younger RN and it was nice to be with someone who wasn't quite so practiced at it. Sometimes it is hard to pick up on techniques used by really experienced nurses. She was fun and really wanted to teach me, and with me being the sponge that I am, it was a very productive day.

There was a lot more teaching to be done than I ever expected. Some of the moms would ask question after question, especially just after the pediatricians rounded on them, so we could interpret med speak. Lots of questions about breastfeeding. LOTS of questions about breastfeeding. I have a lot of studying to do to, so I can answer all these questions with any degree of competency :)

We saw a mom who was afraid to supplement her 2 day old 37 weeker because she really wanted to breastfeed her, but her milk wasn't really coming in yet. However little babe was losing weight and was getting more lethargic, and sucking less. I saw my RN smoothly convince this nervous mom that she could supplement the baby without worrying about nipple confusion with just one resourceful remedy - the nurse cut the needle off a butterfly infusion set, leaving just the tubing, and used a 3 mL syringe to draw up some formula, and then she attached the tubing. Mom got baby on the breast and the nurse squeaked the tiny tubing into the corner of baby's mouth. She was then able to supplement the baby while the mom nursed. Baby got 10 mLs+ of formula and sucked with gusto once she realized she was getting the goods. Win-win-win - it was GENIUS. I am still telling everyone about it! I was so impressed! Even better, we taught dad to use the syringe at the next feeding. He really wanted to help and he did great. We worked ourselves out of a job in that room :)

Another mom got really sick. Failed vacuum, baby delivered with forceps, 3rd degree tearing and episiotomy. She spiked a 40° fever and raging infection and was put into an ice bath to bring down her temp (I didn't see any of this, but I heard about it in report). When we rounded on her, she was so, so, so tired and very apathetic about baby. Can't say I blame her. Her peri area looked really angry and the only thing she ever rang for was more ice packs.

Third mom was absent for most of my shift because she was up in the NICU with babies A and B.

We also toured the nursery area and I got to play with my very first baby, the tiny little girl who required supplementation. I listened to her heartbeat. I don't even know how you are supposed to count it....shiza.

Seriously, wrapping babies into a tiny parcel is harder than it looks. They stick their hands and feet all over the place. You swaddle one side and the other side escapes! I hope I get the hang of it, LOL :)

Lots of studying tonight, lecture tomorrow, and back on the unit with my own assignment on Tuesday!

I don't know if I have previously shared one of my guiding life philosophies, but I will now.

I've started this post about 5 times now on different days but kept having to try again later. My days are just sooooo busy. I guess having too few hours in the day is a good thing, given the alternative!

My second rotation started in mid-February just before the Reading Week break (that's our Canuck version of Spring Break... only it's in the winter and less associated with drunken bingeing ;) Man, let me tell you, at the end of my first rotation on Medicine I felt a degree of competency I could hardly believe. The nurses on that unit trusted us to do good work. I assumed all aspects of care for my patients and at the end of the rotation I had three. I was pouring meds independently (although we had to get an RN to cosign narcotics and insulin, and our instructor to cosign Coumadin/Heparin). Basically the only time I saw my instructor was a daily check-in to verify my assignment. I felt very comfortable with my patients and their needs and saw and did a lot.

So I had a certain expectation that I would only be improving on the skills, independence, and decision-making that I had been developing over the past 5 weeks.... well, not exactly.

My instructor for the second rotation was an older nurse who'd had her masters for longer than I've been alive! She had been a nurse manager/administrator for more than a decade. Compare that to 3L where my instructor was maybe 10 years older than me and was still in bedside care in the CCU.

This new instructor had a totally different attitude towards teaching. She considered herself more of a facilitator and did not give concrete expectations about anything. It drove us CRAZY. We'd ask what she needed to directly observe, or what meds we could pour, or what expectations she had for the care plan.

Her answer to everything? "It's not about me. It's about your learning."

Um, thanks. Wait, what?

Anyway it ended up that my I-think-I-can attitude from 3L was completely shot because for the entire 5 weeks she insisted on watching every med poured, every dressing change, every bladder scan, every foley/straight cath/IV line prime/etc, (almost) every assessment, and so on. The real problem with that was that we were split between 2 units she would take FOREVER getting from one unit to the other to observe all of these things.

The big difference between the two rotations, I guess, is that on 3L it felt like we were actually somewhat useful to the unit. Handy to have around.

On 6R we were just a pain in the ass. Because she insisted on watching *everything*, that meant a lot of things had to wait. Sometimes hours. Sometimes those things were meds. Some days I didn't pass 0800 meds until 0930. A lot of times I had to ask my buddy nurse to do things that should be Really Freaking Basic because I didn't have permission from the instructor to do them without her and it was something that was urgent.... perhaps a fresh post-op was at 8/10 pain, or the initial dressing was not holding, or something like that. Boy, did I feel great making excuses all the time for why my patient care seemed so crappy. Luckily the patients were really understanding. The nurses? Not so much. Apparently the charge RN took it to the dean (not sure) of my school saying that it was unethical for patients in pain to wait for morphine because the instructor wanted to see it. Especially because school policy says that all we need is ANY nurse to cosign - RN, LPN, whoever is handy! I totally agreed with the charge's opinion. Complete BS, IMO. No patients should have to suffer in pain for ANY length of time just because they have a student assigned to them.

I will say, though, that as much as the instructor's (ahem) 'teaching' style grated on me, she had really valuable insight into people and behaviors. At my midterm evaluation, I was amazed at all the things she had noticed about me. She had things written down from the first day on the unit. She was incredibly perceptive and it was actually really good to hear what she had to say. She said I was a good nurse and that she would hire me if she were still a unit manager. I was completely honored, given her background.

Well! Venting aside, let me describe the unit :)

I think we usually had 19 beds open. The patient population was mostly 60+ and in for elective hip and knee arthroplasties. MOST of the time they were post-op but we did have a few people come in before their surgeries. WOW, what a difference from Medicine! These patients' average lengths of stay were less than 5 days. We would get a post-op in at about 1400, often still numb from the spinal block, and by 1900 physio would have them up walking. I COULD NOT believe how fast their recoveries were. I guess I still had the perception that there was a certain period of convalescing after a major surgery like that - not so, at least not for joint replacements.

Patient care usually consisted of neurovascular assessments and vitals q shift (depending on how recent their operation had been), hygiene, encouraging mobility, assisting with transfers, pain assessments and interventions, and prophylactic meds like Fragmin. And drains. And dressing changes... omg! Dressing changes! Part of me thinks wound care is SO AWESOME!!

I took a picture of the giant Wall O' Dressing Stuff. That was a HUGE learning curve for me. There are dressings for every type of wound. Occlusive, silver nitrate, hypotonic, absorbent, moist packing, protective, nonadhesive... the list goes on and on. I spent literally hours in here (this is the clean utility room) going through all the bins and researching what type of dressing was best for what type of wound. I absolutely loved it. Most patients with a healthy surgical wound, typically and depending on drainage, got their wound aseptically cleaned and dried with normal saline, a layer of Adaptic to prevent adhesion, Cavilon to protect the surrounding skin, and either gauze and abd pads taped down with the sheet tape or Mepore all-in-one bandages. Sometimes I had to get creative and splice together bandages to fit. My instructor had her own ideas about how I should do it, and I usually followed her advice, but when I started sneakily doing dressing changes on my own I did it my way and it looked (and lasted) much better. My sterile technique is completely second nature now. I worked a sterile field sometimes 2 or more times per shift, and it was often awkward as hell with a huge pile of dressing packages and a tiiiiiny little dressing tray for space... I also got to do a dressing change on a central line. The patient thought I did such a great job, he wrote me a letter of commendation! *sniff*

The drains were also pretty cool! I drained and primed a lot of hemovacs. It's amazing to see just how much post-operative goo can come out of someone. The pic on the right was about 300 mLs, I think, drained only about 4 hours after I had already drained 400. She was a fresh post op and quite the bleeder. It looks like straight blood but it isn't; there are tiny bits of bone in there and lipids and lymph. It's quite the cocktail ;) Strange smell to it, too. It smells very strong and very chemical, like a hair perm might.

6R was all about teamwork. All us students got letters when we orientated, stating the rules of the unit. One of the big ones was that we were to NEVER risk our backs. All lifting and heavy patient care was to be done in teams. I was totally impressed with how well everyone worked together. There was always someone ready to help you. The NAs seemed to be everywhere at once.

One of the NAs was a dear older Brit who used to nurse in England. When she came to Canada, her licence did not transfer, so she chose to work as an NA instead of upgrading to LPN/RN. She said she loved patient care more than anything else a nurse was expected to do, and she was really, really good at it. She appeared at my patient's bedside on the first day and helped me give a bed bath, just because. She then instructed me on how to give a really freaking good bed bath. My pt was just about purring by the time she was done. She said that chances were excellent that if you give really excellent nursing care in the morning, patients would be feeling very content and not likely to ring their callbells for the rest of the day. She also said it was very therapeutic for the family as well to see their loved one comfortable and cared for. I completely appreciated her help all throughout the rotation. She was great. I wish SHE was my instructor...

It was amazing how the whole unit acted as a team. EVERYONE went to report, including the unit clerks, NAs, manager, staff nurses, students...

Really the only 'downer' during my stay on 6R was my instructor's desire to see and do everything even though that wasn't physically possible. I'm a pretty gung-ho student. I keep my eyes and ears open for opportunities and make the most out of my rotations. I really liked the unit itself. It seemed like a great place to work, given the helping atmosphere and the fact that most of the patients were there for elective surgery and WANTED to get better and get the hell out of there so they were very motivated and active in their own recoveries. Don't get me wrong, Medicine had its moments, but Surgery didn't have the same atmosphere most of the time.

The other negative about the unit, and it really wasn't about the unit at all, was regarding one of the patients. I really should call him a resident. Actually, I'll call him Mark ;) He was a 60-something man with some severe congenital cognitive impairments. He yelled inappropriate things and was aggressive and immobile. Apparently he had a fall at his group home, fractured his hip, and was sent to our unit after surgery. This was OVER A YEAR ago. The group home refused to take him back (!) because he was so difficult for the staff to handle. Because no one could find him a place to go, he stayed right there on Orthopaedics, probably one of the most ill-equipped units to have a guy like Mark. Everything was so busy that there was no time to just sit and spend time with him and give him the quality care he needed to reintegrate him back into a group home. He was just strapped into a Broda chair most days. You could hear him yelling obscenities from the other unit, and my heart cringed every time I saw a child pass near his chair with no one to make sure he wasn't going to strike out. The hospital did the best it could by assigning an NA to be with him 1:1 as much as possible... but really, he shouldn't be there. Mark is a perfect example of a guy who just fell through the cracks.

I saw a couple of interesting cases during my last week on the unit:

• One pt was a trauma who was flown in from very, very north (~200 km north of the Arctic Circle). He was, like, the embodiment of the Determinants of Health. He was remote, poor, uneducated, male, and Aboriginal. My Foundations in Health class would have had a field day. He had gotten into some kind of snowmobile accident and shattered his tibia. I was trying to do a thorough neurovascular assessment on him (big risk for compartment syndrome - challenging because of the cast he had on his leg), and there was a whole freaking med team in there discussing his surgery, and the surgeon was pushing consent forms in his face, and my primary nurse was attempting a dressing change. He was a pretty neat guy though. He told me about hunting polar bears and seals and carving traditional bows and knives. He had some epically beautiful pictures on his laptop too. Wow. Kinda makes me want to be a Northern nurse................. lol, yeah right. Maybe if they had sun 12 months a year ;)

• One of my few sub-60 year old patients was a younger mom with a spindle cell sarcoma in her upper arm. She was in for her second resection to try and remove the tumor. She had gotten a skin graft taken from her ventral thigh, and that was pretty awesome. I couldn't believe how much fluid wept from it. No wonder people with burns are at such a high risk for dehydration! I had to do a dressing change on it because the one done 3 hours prior had already sprung a leak. I ended up putting a medium-sized Tegaderm on it, taping it all around, and then putting a huge Tegaderm over that and taping that all around too to try & seal it up tight. My dressing held quite well actually! She had it on still after I was done my rotation. I was very proud of myself :) I also had a really awesome Nursing Intervention moment. She had her initial dressing on her upper arm for over 5 days. Well, by the end of the 5th day she had a crazy case of the itchies. She looked really uncomfortable. I noticed she had Benadryl ordered for nausea so, with the consent of my instructor, I gave her 50 mg of that. Lo and behold, it worked! Total self high five! No more itching, and she pretty much loved me from then on.

• My other Really Cool patient ended up being the guy I wrote my care plan on. I got to go into the OR and follow one person through the entire hospital experience. I got to Same Day Admit at about 0800. The first thing that struck me was how young he looked. Comparatively, I mean. He appeared in his late 60s and he was in for a total hip replacement. Turns out he was actually nearly 80!! He had been very physically active for his entire life and now was getting joint replacements because of the osteoarthritis from his sports-filled past. The guy was seriously the fountain of youth. He lived in the mountains and biked 5km every day. He and his wife were adeptly maintaining their home. He looked decades younger than my own grandfather. No lie.

Wow, the operation!!! That was so cool! He was awake through the procedure. I followed him down from SDA to the operating room where I changed into OR scrubs and a hair net. We wheeled him into the theatre and slid him onto the table, and the anesthetist gave him a spinal block (SO COOL - the catheter was massive!!). The anesthetist threaded the needle between the disks and into the spinal column while the pt was sitting leaning forward. Then they laid him down while he could still move, put in a foley, and proceeded to drape the hell out of him. The surgeon was very particular about pressure points from the catheter tubing and clamps etc, which I approved of. I got to stand about 5 feet away throughout the operation so that was very exciting for me. I wanted to be as "in" the action as they'd let me and if I were any closer I'd have contaminated their sterile field :)

They rolled the pt onto his side and clamped him, so to speak, in that position. Then they cut through his skin and down to the acetabulum. And then, oh my god, the surgeon and the resident grabbed onto the pt's leg and popped the head of the femur out!!! It made this nasty thwwwwwwwOP sound that just hit the pit of my stomach and made it churn. Nothing else in the entire surgery hit me quite like that. Once the femur was out (shudder) the surgeon took a bigass bone saw and cut the head of the femur off. I mean off. He plucked it out of the wound and plopped it onto the instrument table. Mmmmmmmmm ;)

Oh! The instrument table! MASSIVE! I was amazed at how the scrub nurse knew what to get and when. There were about 3 tables pushed together, all covered with sterile drills and bits and screws and saline and cloths, oh my!

It truly was like being at a mechanic's shop. The surgeon and the resident and the product suppliers were all talking about the pt's leg and fitting different-sized cups and heads into him. They were moving his leg all around and using power tools on him. It was kind of surreal.

The thing that really got me, though, was how the OR was not really about the patient at all. At that point he was just a Hip that needed fixing. No one talked to him throughout the procedure and really no one censored their conversation to accommodate him. The scrub nurses and the surgeons were talking about some kind of masochistic x-rated somethings at one point. I kind of thought the surgeon was a dick, actually, but he was kind enough in teaching me various things. He was only a little chauvinistic towards me ;)

They sewed up the pt without putting a drain him because he didn't bleed very much, and then I got to care for him for the rest of the week, and I wrote my care plan on him as well. It was great, actually, for both of us. I think he appreciated knowing that I would be there when he woke up in the morning and I knew all of the ins and outs of his surgery given that I had seen it with my own eyes.

Well I guess I'd better wrap up this rambling. Feels like I've been typing forever!

Summary: I definitely liked my surgery rotation. If there's one phrase to describe me, it is Morphine Fairy. I loved giving people pain medications to control acute moderate-severe pain. I loved seeing them grit their teeth while I prepped them for a sub-Q or IM injection and then watching them drift off to sleep within half an hour. I'm not sure if I'm a med/surg nurse, but I learned a TON. Really, I've enjoyed all of my rotations because I'm the kind of person who goes into an experience with an open mind and a humble, 'teach me' kind of attitude. Not like some of the ice queens in my class, but that's a story for another day. Good night, nurses and nurses to be :)

Wow, after finishing up that post yesterday, I realized how much I had to talk about! There is a lot so I needed to think about how best to split up my thoughts. This term (since January 4) has been straight clinicals. 5 week rotations at different sites here in the city. So I'll give an overview of my week and then delve into my experience in each rotation afterwards.

So, my week. Wow. I am absolutely INSANE for working as much as I do. My job with the City (and the associated union contract) stipulates that I must work a minimum of 21 hours per week. Unfortunately my clinical rotation hours were all over the map between 0700 and 2300 so I couldn't work during the week. This meant that I worked full 8 hour shifts on Saturday and Sunday and worked another 5 hours on Monday after my lecture time on campus.

This means that I have been working 7 days a week since January with the odd singleton day off every few weeks from clinical schedule adjustments or school holidays.

In order to have some semblance of a day off I chose to work Saturdays from 1800 - 0200 and Sundays from 1600 - 0000 before lecture time at 0800 on Monday. That way I'd at least get the weekend days to myself. However that meant that Friday night was my only "night off" to go out with friends and have a life.

The stress has been eating at me though. I've always been the kind of person who thrives on busting my ass during the week and then utterly recharging on my days off. I haven't been able to do that every week or even every two weeks. I'm gaining weight (like 10 pounds, QQ) and losing my hair, and I wish I was joking about that. It's been falling out all over my head for the past few months and it's way thinner than I've ever seen it. My apartment looks like hell and my car looks like it ate a hurricane, and I've been sweet talking my mom into doing all my laundry. I feel like Marge Simpson in that episode when her hair starts falling out and she goes batshit crazy.

Happily, I am now in the final stretch of this clinical term. I am on the second week out of five in my last rotation and I will be done on April 24! I have never wanted anything as badly as I want to just go back to regular work with regular weekends. I don't even know what I'll do with myself. Sleep? :)

So, to any curious about whether they could pull off fulltime clinicals and a solid work commitment... it was a dumb move. I mean, I'm technically DOING it and I'm still alive, but I hate every second. Clinicals are my time to roll up my sleeves and be excited about nursing! But I'm so exhausted from never getting a rest day that I just can't wait to go home all the time and don't want to put in more than the bare minimum of effort. I haven't done something 'just for me' in months. Hobbies? What are those?

Next year, if I am still with my job with the City (I'm considering picking up a brainless job with no commitment required), I am going to apply for a leave of absence from January to April. Seriously. I can't do both again.

My first rotation was on 3L, an 20-bed medicine unit at a hospital about 40 minutes from my house. My instructor was a younger nurse, maybe in her late 30s. She came from a critical care background which is something that interests me. We were her first clinical group so it was new for both of us! Our schedule rotated 8-hr shifts with days one week and evenings the next. Mondays from 0800-1000 were classroom time at the school, with all students doing that rotation (not just our clinical group). After that we'd head down to the hospital to get our patient assignments for the week and do the research. Typically I'd go through my pt's chart to find out admitting dx, medical hx, health determinant information, plan of care, relevant lab values, interdisciplinary care from OT/PT/dieticians, and I'd copy down the laundry list of medications for research at home or at work.

Monday lecture was a joke. Attendance was mandatory or else we'd have to put in extra time to "make up" the missed lecture. Ridiculous. Our instructor (the same facepalmingly awful instructor from Nursing) claimed that we were not allowed to cover new material so all we did was rehash bitterly boring discussions about caring and stuff. How would I have chosen to spend this time? How about talking with the whole group about their clinical experience? It seems clear to me that the lecture time SHOULD be about getting as much shared information as possible. What did we actually do? Well, one class was spent reviewing some acronyms found in patient charts. Two hours. One class was spent role playing how we'd teach different groups about choking. Another two hours. FML. May I add that I was working until midnight the night before these "lectures"? I determined that it was actually less effort to go to class and space out for two hours versus skipping it and having to show some kind of "research" instead. Sad...

Anyway, about the clinical! The unit was similar to the one I was on in first year, being a med unit. However the hospital had a very different setup and it was positively spacious and well-organized in comparison. At report on the first day we were assigned two to a buddy nurse. It was a way better experience than first year, IMO, because we had the initial OMGAPATIENT freakout out of the way and we could just watch and learn the routine. Wow, were there a lot of meds being dished out. Our nurse, Michelle, had 6 patients with at least 5 pills each. It seemed like by the time she finished passing 0800 meds it was time for the 1000 ones. Sheesh.

We did 2 buddy shifts like that and then we were responsible for one patient from Tuesday through Friday. We did all patient care, charting, and most meds (PO, sub Q, and IM, including all narcotics). In fact the only thing we did not do was IV anything including saline flushes.

Over the 5 weeks I worked my way up to caring for 2 patients. I had some really interesting cases and I thought it was a great experience. I managed to do almost every procedure at least once. The nurses thought I was great because I'm the type to find opportunities for myself. "What's that, a patient in 77-3 needs an intermittent cath? I'll do it!"

A brief summary of my more memorable patients:

• A middle-aged man with CHF, gross edema his lower abdomen & scrotum, pitting edema to his arms and legs, kidney and liver failure. He was one sick guy. It was amazing because I started with him and had to do med teaching for obvious things like potassium supplements (he was on Lasix) and he was really kind and patient. However I was able to observe his very subtle decline and I charted about him "seeming slow to respond to commands" which made me feel silly. Boy was I ever glad because 2 days later he was acutely delirious and he came very close to being transferred to the ICU. I had to do neuro assessments on him q15 and the rapid response team was in and out asking questions. I got to observe his CAT Scan [Photo Credit]. I got a ton of interaction with the physicians and I was very assertive and sure of my observations, and they listened to me. It was a very, very good experience. I felt like a Real Nurse for the whole week. His family asked me many questions and they were very glad I was there to look out for him. I also got to do my first foley on him with the son present (aahh!). In addition this particular patient had phimosis and I wasn't even able to see his urethra. I was kind of shooting blind, so to speak...

• An older lady with dementia who suffered a fall at a nursing home - she had been on the unit for some time and was having a lot of changes in mental status. She would swing from drowsy spells to moments of complete lucidity. Sometimes she would be very confused about what procedures I was doing. She swung at me while I was trying to palpate her abdomen. I asked what the matter was and she yelled "It's not appropriate!!!" Other times though she'd be pleasantly confused. I caught her once trying to get out of bed. I asked her why. "I left a bag around here, somewhere," she told me. I went through the motions of looking around her bed and table and asked her to describe the bag. She looked at me pityingly as if I were a complete moron and said "It's got urine in it!" ..... she meant the foley ..... uh, yep, it's right here.

• Another elderly woman battling depression, awaiting transfer to LTC. Wow, older people and depression... I'd no idea how common it is until I started my psych rotation. She'd just lie in bed and "sleep" the entire day. She'd do the bare minimum and that was it. She was SO hard to engage and part of me just about cried every time I thought about it.

• A 70-something male who was on heparin and had massive nosebleeds. He had foam stuck up his nose the whole week and he was so angry about it. It was up there for ages while the med team decided whether to cauterize or not. He started refusing his heparin. I don't blame him. He was also incredibly constipated and the twice-daily Senokot and Colace weren't doing anything for him. He was the recipient of my first glycerine suppository, he had the world's largest BM, and he was SO HAPPY after that (nose foam and all!), it still makes me smile :)

• A little old lady (seeing a trend here with the ages? lol) who was blind in one eye and deaf in one ear, who's children had all died, who's husband had died, who lost all her family, and had just found out she was terminal with lung cancer. She was incredibly plucky in spite of all she'd lost and she told me, as I was changing her chest tube dressing, how she was born under a lucky star... I don't even know how she managed such a positive outlook. For all her losses, she was hilarious. My classmate was giving her peri care and she burst out with such quips as Hey! be careful with my 'jewel'! and Bedbath, eh? You gonna wash my pussy? An octogenarian... I also got to watch her chest tube insertion. Wow, that was awesome! They aren't gentle at all! An NP put it in. They cut through her chest wall into the pleural space and shoved their fingers in her to make sure it was clear. Then they inserted the tube. Nothing came out so we rolled her onto her back. Woosh! 1.5L of serosang pleural effusion drained within a matter of seconds and we had to clamp it to prevent too much drainage at once. It was remarkable. She was so tiny! Where was all that fluid being stored??

• Another patient who impacted me a lot wasn't technically assigned to me. He was in his 90s and was close to death. There wasn't much to him - he was just a skeleton! One morning, his breath was harsh and rattling. His eyes were so scared. He looked like a man drowning in his own lungs. He was lying in his bed, gasping for breath, with each arm out straight in a white-knuckle grip of the bloodied side rails. 4 hours later, I had the privilege of being at his bedside, with his family, when he died. His chest rose slower and slower and finally did not rise again. The resident checked his apical pulse and pupillary reflex - nothing. When it struck me that he had passed away, I was very thoughtful. I'd never seen a dead person before, much less the transition from life to death. It was very odd for me, and I kept expecting him to breathe suddenly and sit up. I wondered if I should be sad; I wasn't. If anything, I was relieved. He wasn't suffering anymore. It was a very sombre experience but very, very inspiring - the nurses were so respectful of him. They talked to him and addressed him by name as they took off his brief, disconnected his IV, and gave him a final bed bath. I really felt like they upheld the CNA Code of Ethics:
  
  
  

  "When a person receiving care is terminally ill or dying, nurses foster comfort, alleviate suffering, advocate for adequate relief of discomfort and pain and support a dignified and peaceful death. This includes support for the family during and following the death, and care of the person’s body after death."