Team

You need a team.

If you’re a nurse, you need a good team. There is no way to survive on any unit without team work.

When you interview for a position, ask about the team work. How well do the nurses work together? How is bullying handled?

You’ll want to know these things. A unit that isn’t a team is a unit headed to hell in a hand basket. It can’t function effectively. Trust me, I’ve worked on units where it was every nurse for themselves. It was horrible. There were nurses that wouldn’t help with the new admission. It took an act of congress to get someone to help clean up a patient. Gossip spread like wild fire. Nurses ate their young for fun. It was two years of nursing that I never want to experience again. From that point on I decided I would not waste time on units like that.

That’s why finding about the team mentality is so important. You want to work somewhere with nurses that work together. You want to work in an environment that is not toxic. Regardless of how the shift is going, you want to know your coworkers have your back.

Nursing isn’t a solo job. We aren’t super heroes that can handle everything on our own. We have to depend on each other to get through the day. When the shift is nuts, you want someone you can vent to. When you aren’t able to save the patient, you want someone that understands the pain. You’ll want someone you can ask questions to that won’t make you feel like you’re stupid. You’ll want a team.

Do yourself a favor, find a good place to work.

Consent and ethics

Nursing is fully aware of consent. We know that we need to have documentation that the patient accepts this treatment. It’s a no brainer. But, what if the patient doesn’t want treatment and the power of attorney does?

Prime example, you have an elderly patient that is obviously letting the family talk them into surgery. To no one’s surprise, it doesn’t go well. They end up sick. They have to remain intubated. They need an art line, central line, pressors, the works. Even on the ventilator they are adamantly shaking their head no to all the things you’re trying to do. They are fighting. They keep trying to pull away. They don’t want this.

Their family does.

The POA is who the doctors decide to ask for consent to treat. They completely bypass the patient. They’re intubated, they can’t answer for themselves right? If course the family wants everything done… So, everything is done. Is that fair to the patient?

Shouldn’t the patient be allowed to say no without having someone else choose otherwise? What is the fine line that decides when a patient no longer has the capacity to make their own decisions? Does intubation automatically take away that right? Does having a POA take away that right? If a patient is clearly communicating, even in the vent, shouldn’t we respect their wishes?

The nurse in me says yes. The nurse in me says to respect my patient’s dignity.

The nurse that’s been at the bedside for almost 8 years knows that that is normally not the case.

I have seen advanced directives ignored because the patient is unconscious and the family isn’t ready to let go. I’ve seen cases like the one mentioned above. I’ve seen doctors watch as the family is almost forcing a patient to go along with treatment and the doc just goes along with it as well. I’ve had to be a part of “moral distress” meetings because nurses were stressed over the ethical dilemmas involved in certain cases. When do we stop?

Know your meds

Nursing school will lead you to believe you need to know every medication, ever. You should have your pharmacology book memorized.

That’s a damn lie.

There are new medications being advertised every month. There’s no way you can possibly keep up. There absolutely nothing wrong with that. However, know the medications you are giving to your patient!

Before passing meds take a moment to look and see if you know what medication you are giving and why. If you don’t know a med, look it up. Medscape, Epocrates , even Google are only a few clicks away. Your pharmacy is only a phone call away.

Let’s say you notice that your patient is on midodrine and propranolol. You know the midodrine is to help your patient maintain their blood pressure since they tend to run lower. You’re not familiar with propranolol but you know that suffix. You remember that “olol” was rammed into your head as a beta blocker for hypertension. Wait, what? Why is your patient on meds to raise and lower their blood pressure?! Better hold that propanolol right? This is the perfect moment to stop and look up your meds. A few minutes of research and you learn that propanolol is also used for tremors. Nevermind, guess that med might need to be given.

This is why I keep Medscape on my phone. I take a few moments and look up a med I don’t know just to make sure I know what and why I’m giving something. It doesn’t take much time at all and I feel safer giving my meds. Also, if you have that family member in the room that questions everything, you look like a genius when you can answer each question they throw at you about what you’re giving. They don’t need to know that you just looked all of this up before walking into the room! A few moments of pause can make you much safer.

Speak up when it doesn’t feel right

You are your patient’s last line of defense.  Whether it’s meds, bedside procedures, trips off the unit, or just care in general, you are the person that can potentially save a patient.

I know, medical shows would have you believe that doctors are the saviors. Doctors are the last hope. Doctors save the world! Yeah, most of the doctors I know can’t start an IV sooo…

You are the one at the bedside for 12 hours. You are the one that has had them for three shifts straight and don’t even need report anymore. You are the one that knows that patient. You are the one that may notice something wrong.

Perhaps you come in for your shift and notice that Mr. B, who is typically trying to crawl out of the low bed and get back to his “bus”, it far too chill. His vitals have been great all day. The team doesn’t order labs for him daily anymore but the ones from two days ago look fine. In your gut you know something isn’t right. You talk to the doc, who isn’t impressed. You give it all you got and at least convince the doc to order a set of labs for now. You get those labs and anxiously wait to see if they can help you figure out why Mr. B hasn’t tried to kick you in the face tonight.

And then the lab results come back AND THEY ARE A SHIT SHOW! His WBC’s are almost 30. His H&H has dropped by 3. His BUN and creatinine are climbing. All of his electrolytes are out of wack. But once again, his vitals have been good all day.

You just saved your patient. You knew something wasn’t right, even if you couldn’t pinpoint it. By being a patient advocate you may be the reason he’s alive.

Maybe it’s less dramatic than that. Maybe they have ordered a medication for your patient that seems like it just might be contraindicated at this point. His platelets are low. His INR is going up, not down. One of the teams wants you to give heparin. You aren’t comfortable with that, especially since the primary team (or doc) purposefully stopped it because of his labs. You try and talk to the ordering provider and rather than listen he yells “just do it!“.  Do NOT just do it. Healthcare was not designed by Nike and that rarely works out. You can take another step. You can talk to the primary team or doc about a consulting team or doc restarting what they’ve stopped. So you do just that. Primary agrees with your hesitation and they talk to the consult to let them know heparin has been discontinued and why. Turns out, consult didn’t actually look at any labs before ordering it.

Looks at you walking around saving the day, like you have an “S” on your chest! You know what you are doing. You know when something isn’t quite right. You know your patient. Trust yourself and speak up when you feel like it is necessary.