I love working with nursing students, and find it one of the more satisfying parts of the job. I like the idea of enabling them and helping them learn and gain the most out of their prac placement. I guess it gives me a warm, fuzzy feeling. I have absolutely no time for shonky nurses and the practise of shonky nursing; and have no intention of uninspiring the students that I work with to a career of apathy and substandard provision of care.

Surprise, surprise, though… I’ve often found that the shonkier the nurse, the worse they are with students. On the flip side, the nurses that I have worked with over the years, whom I admire and respect, are generally excellent when it comes to providing a welcoming and supportive learning environment for students and new grads.

So as part of my ongoing efforts to be the kind of nurse that I respect and admire, I present my guide to surviving a student prac placement.

The information presented is pretty-much the same as I used to provide my students, and comes from the perspective of a first or second year placement on an acute surgical ward in an Australian tertiary facility, but the principles are transferable.

Welcome

As a first or second year student, you will gain exposure to what it is like to practise as a Registered Nurse in an acute care environment. You are there to learn. This means working with your buddy RN, and taking every opportunity to learn, whether it be by observing procedures, assisting your buddy RN, or participating in in-service sessions. There is a lot to take in, and there is no denying that this can be a challenging and scary experience. Just remember that everyone that you see working on the ward was once a student, like you. You can do it.

Out of the avalanche of information that you have had to take in, in your first week, just try and remember the following and you shouldn’t go wrong:

Smile & introduce yourself

If you smile and appear enthusiastic about being there, the nurses that you woke with are far more likely to take an interest in teaching you their craft. No-one likes working with the angry/disinterested student. Do not be that student.

When you meet a patient, make sure that you introduce yourself and tell them your name and that you are a nursing student. To the often uninitiated patient, everyone looks the same. Apart form that, it is simple common courtesy. The added bonus is that if you appear confident in your introduction, you should hopefully make a good first impression with your patients and staff.

Prioritise

If it is mad busy and you feel swamped, remember your priorities:

• Safety

• Your own safety – use universal precautions, be careful with sharps, and use your goggles when there’s a good chance of projectile mucus / body fluids.
• Your patients’ safety – watch out for falls (patients like to do that a lot) and do what you can to prevent them – restraints, rails, avoiding TEDS on slippery floors, and proper supervision of patients in the toilet or shower.

• Observations

• Its always a good idea to make sure your patient is alive at the beginning of your shift.
• Obs before meds (especially if giving anti-hypertensives / insulin).
• Document the actual time that you do your obs.
• You can waste a heap of time on the never-ending search for the one working Dynamap on the ward (legend has it that there were originally three Dynamaps) – use your judgement – if it is not essential that you measure the patient’s SpO2, then go medieval and do it the old-fashioned way with a sphygmo and a axilla thermometer.
• Never put a thermometer in a patient’s mouth – some patients will eat them (and your fingers if your put them in there too).

• Meds

• Take your time – remember your 5 rights.
• If a medication is ordered for 0800hrs – don’t obsess about the time – in most cases, giving the medication within an hour either side is generally OK.
• You will never remember every detail about all of the medications that can be ordered for a patient. This is normal. Try not to feel overwhelmed. If you don’t know what a medication is, look it up. Only shonky nurses give out unknown meds. You do not want to be a shonky nurse. There should be plenty of MIMS around the ward. Use them.

• Nutrition

• If your patient needs to be fed (ie if there arms don’t work properly), make sure that they get fed.
• All the tablets in the world are of no use if the patient isn’t getting adequate nutrition. Without food the body doesn’t have the resources to heal itself
• Unless contraindicated, make sure your patients have plenty to drink.

• Washes

• Showers can wait – nursing is a 24-hour job.
• Try not to feel pressured into getting all your showers done before morning tea. Although it is nice, it’s a dumb idea, if you haven’t done your obs, meds, and the other more important things.

You are still a student

• Scope of practice

• Remember your scope of practice, and do not work outside of this. This is a huge point when it comes to assessing your perforance.

• Supervision by your buddy RN

• Always make sure you are supervised by an RN when administering any form of medication (including topical medication) or undertaking a clinical skill.

• Medication administration

• Again – direct supervision by an RN (note: not an EEN).
• Remember your ‘5 rights’.
• If you are dispensing a medication, and you do not know what it is, ensure that you check a MIMS before administering it to your patient. It is extremely poor form to be handing out drugs without knowing what they are.

• Take every opportunity to learn

• You only have two weeks to learn as much as you can. If you don’t know something, ask. If there is something in particular that you want to go through, let you facilitator know.

Staff Assist Button

If something happens and you need help quickly, use the staff assist button.

Examples of when you might use it include:

• Patient fall
• Patient unresponsive / not breathing / no heartbeat
• Patient having a seizure
• Patient ripped their own trachy out
• Anything else where you or your patient are in immediate risk and you need help quickly

Remember that no-one will think badly of you for using the button, if it is a false alarm.

If in doubt – hit the button.

DRABC

If something happens to a patient, remember the basics – DRABC. In an emergency situation, ensuring that your patient has a patent airway is often the most important thing you can do while you wait for the cavalry to arrive.

Emergency Equipment

At the beginning of you shift, always check that your wall suction and O2 is working and that you have masks, tubing, etc. There is nothing worse than not having this stuff ready and working when you need it.

If you make a mistake

If you make a mistake, don’t beat yourself up. Everyone makes mistakes. It will happen. Just make sure you learn from your mistakes.

Lessons learned the hard way are lessons not soon forgotten.

? Best Practice

Everyone does things differently. Watch your colleagues and buddy RNs. See how they do things. If they do something well – learn from them and apply it to your own practice.

As long as you apply the basic principles of an activity and adhere to hospital policy, it doesn’t matter how you skin a cat.

Ask questions

There are no stupid questions. If you don’t know – ask. You are there to learn.

Documentation

Make sure your documentation is top-shelf. It is a legal record of what you have done. Consider the following format when charting:

Start with: “Nursing: Neurologically GCS=13 (E3,V4 ,M6 ), MSQ = 6, PEARL, Pt afebrile, Other obs as charted….”
Work through your body systems, etc:

• Nervous (GCS, AOx3, seizures, muscle weakness, etc)
• Pain issues – “Pt c/o headache – rated 7/10 at 0950hrs – given PRN Endone 10mg PO – with good effect”
• Respiratory (trachy, suctioning, O2 requirements, SpO2, dyspnoea, etc) Cardiovascular (hyper/hypotension, venous access, ECGs, capillary refill, etc)
• Gastrointestinal / Urinary (input & output, bowel sounds & movement, appetite, nausea)
• Integumentary (wounds, pressure areas, rashes, drains, etc)
• Psycho-social (visitors, concerns, etc)
• Behavioural (aggression, abusiveness, non-compliance with treatment. If your patient has been abusive, make sure you document it.

Write legibly – there is no point documenting if no one can read your chicken scrawl.
Always make sure that your documentation has been checked and counter-signed by your buddy RN.
Check out your facility’s documentation policy.

Punctuality

Be on time.

Again – be on time. Being late will not be tolerated by your wards when you are working as an RN. It won’t be tolerated while you are a student, either.

If handover for the AM shift starts at 0700hrs, make sure that you are ready (bag away, handover sheet in hand, bum on seat) for handover no later that 0655hrs.

If you are going to be unavoidably late, or are sick, then make sure that you have the common courtesy to inform your facilitator/ward.

Take care of yourself

Your time on prac is likely to be pretty stressful. Make sure you eat well and get plenty of sleep. Try and have fun.

Some days are diamonds, some days are stone

Always treat your colleagues the way you would like to be treated by them. Some days can be crazy busy. We all have bad days, and can sometimes be short, forgetful or appear to be rude. Just remember this and be prepared to give people the benefit of the doubt. At the end of the day, we are lucky to be working with good people.

Over the last few weeks, I’ve had quite a few patients that were cactus. They were circling the drain, waiting for the inevitable, with nothing short of a miracle able to alter their fates. As fantastic as mondern medicine is, there are simply some things that cannot be fixed.

As I was performing a post-mortem wash on a recent patient and preping them for their trip to the morgue, I was struck by the reaction of one of the wardies who came to help me roll the deceased and place them in their body bag. The wardie had never seen a dead body before, and was a little nervous about the whole experience.

He didn’t seem concerned that that the dead might rise and that we would be forced to fight a zombie (although I’m sure it was in the back of his mind). His main concern was how to handle the body respectfully, and how the patient’s family were. After reassuring him that my patient had had a dignified death, where her family loved her enough to let her go, rather than insisting that we violate her with every piece of high-tech equipment that we can bring to bare, the wardie was fine. A dignified death, that lacked tragedy and highly-strung grief was somehow OK, and not scarey at all.

This got me thinking about the nature of death and it’s associated grief; and how death, itself, doesn’t affect me, but the grief felt by families does. At the same time, Ten out of Ten wrote an entry on his blog that describes what I was going to write (though much better that I reckon I would have):

I am not saddened by death. It’s just part of my workday, occurring sporadically, occasionally in tragic fashion though much more typically the end result of too many years or poor health decisions. I used to feel a sense of disquiet, but this has long been displaced by ambivalence through emotion-numbing repetition. I remain unfazed, and simply move on to the next task at hand.

I am saddened by grief. I dread telling people a loved one has died, all the more so when they are unprepared. I dread the reactions, the sadness and anguish and tears and while I can’t comprehend the full extent of their pain, I feel a small part of it course through me.

I wonder if I’ll be numb to this someday too.

Original post here.

I hope that I don’t become numb to this pain.

So… you’ve discharged yourself, against medical advice, from intensive care.

You truly are a fucktard.

Solomf yoyo.

I love our hospital’s security officers. They make my job easier. They make my job safer.

When a patient start screaming, throwing stuff and threatening staff, it is always comforting to notice a wall of grey shirts appear. When verbal de-esculation fails and fists of fury start flying, there are few things that I like more than knowing security is there to help.

Last night, when my patient went nuts, screaming their tits off and spraying blood everywhere from a ripped out large-bore IV site, it was great to see the boys in grey rock up - response time: less than 2 minutes.

The delivery of health care is a team sport. I’m thankful to have the boys in security on my team.

They shall grow not old, as we that are left grow old;
Age shall not weary them, nor the years condemn.
At the going down of the sun and in the morning
We will remember them.

Lest we forget.

I like mnemonics. I find that they make it easier for me to remember things. One of the most useful that I’ve found as a nurse is PQRST - the systematic way to assess a patient’s complaint of pain.

By going through the process systematically, it often gives you a pretty good idea of what is causing the pain, which then guides what you are going to do about it.

And for the novice nurse: always remember to treat chest pain as cardiac in origin until otherwise ruled out. Why? Because heart stuff will kill you a hell of a lot quicker than reflux. That generally means an ECG.

And for some unknown reason, you can bet that when a patient reports experiencing chest pain, right as you’re about to clock off, that it’s going to end up being something significant…

If you are my patient and you are a smoker, then be well aware of the following:

• I do not escort gambling addicts to the casino for a bet.
• I do not escort alcoholics to the pub for a drink.
• I sure as hell do not escort smokers outside to the smokers’ area for a smoke.

I will not hesitate to offer you nicotine patches; but at the end of the day, your addiction is your problem. Don’t attempt to guilt trip me or resort to threats.

I will not compromise your care, or the care of other patients, to pander to your desire to light up.

If you’re too sick to go outside unescorted, you’re too sick to smoke.

Deal with it.

They were the odd couple - two patients who, to all appearances, had nothing in common; but together formed a friendship that made us all smile.

Fred was in his early seventies, a funny old bloke who’d taken a tumble down some stairs resulting in a SDH. He was old, confused, and was as funny as a frog in a sock. Put simply, he was a lovely old man. He was also a wanderer.

Greg was a young bloke in his thirties - MVA with all of the associated injuries - initially combative, but once the swelling went down, turned out to be a sweety. AOx1, and still in PTA, Greg was pleasantly confused. Although he couldn’t be trusted to go off the ward by himself (he too was a wanderer), he would always keep an eye out for the other wanderers, alerting staff to any problems and helping other confused patients back to their beds.

In the course of their extended stay with us, Greg and Fred struck up a friendship - watching out for each other, keeping each other company, and keeping each other from wandering off.

One day they were playing cards on Fred’s bed while the wife of the patient in the next bed was coming to terms with the newly delivered news that he husband was going to die soon. She had been crying and the two boys came over to me and asked what was wrong with the patient.

“Guys, I’m sorry but I can’t go into the details of another patient”, I responded.

“But he’s going to die, isn’t he?” Fred asked in hushed tones.

I could see the concern on the two boys’ faces and let them know that their roommate was going die and that he probably didn’t have very long.

Things got a bit busy on the floor after that, and about an hour later I noticed them loitering at the front reception desk. They looked pretty suss, trying to play it cool and look incognito, but it was clear that they were up to something.

They were trying to hide something between them as they inched back to their room. The ’something’ was a beautiful bunch of flowers that had just been left in a vase on the front desk by a patient’s relatives. Although the vase was still at reception, a trail of dripping water on the floor lead to Fred and Greg’s feet. I kept an eye on them as they made their getaway. They were trying not to grin, and I’m sure that the felt that they were pulling off the perfect crime. I knew that they had been pinching the occasional chocolate from the front desk, but couldn’t work out why they had decided to shift to Grand Theft Floral.

After being distracted by another patient, I made my way down towards Fred & Greg’s room to find the wife of the dying patient while giving them both a hug before she left for the night. In her right hand was a bunch of flowers that looked remarkably familiar…

She said good night to me on her way out, and let me know how much she appreciated the kind words from Fred and Greg, and how they had gone and bought her some beautiful flowers that they insisted she take home with her to brighten her house up. I didn’t have the heart to set her straight and wished her a safe drive home.

When I went to see the boys, they realised that they were sprung when I held up the empty vase with a raised eyebrow.

They sheepishly looked at each other and Greg turned to me and said, “That lady was so sad that her husband is going to die. We had to do something to make her feel better…”

It is always a thing of beauty to see compassion and kindness in an environment where abusiveness, generalised rudeness, and a sense of entitlement is the norm with many patients.

Last week I was lucky enough to win Volume 2 of NY Emergengy Medicine’s quizzER.

The cool thing is that there is a prize, which I’m looking forward to receiving - a copy of Adam Rosh’s Emergency Medicine: PreTest Self-Assessment and Review.

So check out the NY Emergency Medicine blog and have a go at the quizER and VizD quizes.

Make sure that you read this story - it serves to highlight that not all patients are drug-seekers and scumbags.