New Scrubs

Today I spent a shift at the skilled nursing facility I referenced in a previous post. I got up early to make it in time for Morning Report, after sleeping for only four hours. I have a bad habit of doing this, for some reason my habitual reaction to "something important" happening the next day is to stay out all night with my friends. I was relatively good, I got home before 2AM ;p . I bought new scrubs for the occasion, the only other pair I own are the white scrubs I wore to the pinning ceremony. I ended up going to three different uniform shops before I found a pair that complimented my eyes just so.

I didn't feel all that great about how my interview went last week, on reflection I noticed that the director of nursing did all the talking. In other interviews, the interviewer took the opportunity to grill me on my knowledge and auger for the appropriate interview buzzwords. Then again, after several interviews where the interviewer did all the talking and several interviews where there was a more equal give-and-take between me and the interviewer, I haven't gotten -any- jobs, so who's to say?

Anyway, I absolutely love this place. I didn't think I would be so enthusiastic about entering into practice at a skilled nursing facility, but this place would be fine, just fine.

I wish there was a camera crew recording my day there from several angles, it was like TV show The Office but in a nursing home. I'll try to reproduce as much of the hilarity here as I can.

When I arrived, I greeted the director of nursing and followed her around for a little bit, exchanging pleasantries and getting some info about the census to prepare for Report. We were in the documentation room next to the nurse's station. In the distance, we started hearing people yell the director's name. A chorus of all of the staff members started to bubble up from the halls and into the small room we were occupying. Her expression shifted suddenly when the words "The State is here!" could be heard.

She quickly beckoned me to follow her into the break room, where she told me to sit with a nurse there who was going over documentation. This nurse is an LPN, but due to her lengthy experience in long-term care, she acts as Charge Nurse. I ended up following her for most of the day. While the inspectors from the State were closing in on the nurse's station, we busily set out un-propping all the doors and scouring the halls and charts for things the facility could get slapped with a "Deficiency" for. This facility has a great record, the only deficiency they received in the past year was for a single I/O entry being left blank. Not bad considering all of the things that -can- go wrong.

When I finally arrived at Report, I got to meet the Executive Director, the Director of Recreational Therapy, the Director of Physical Therapy, the Director of Admissions and the Lead CNA. The LPN I was following conducted the report, which was interesting to listen to. It basically contained everything they needed to know about 38ish people in a concise way. Everyone was friendly and seemed to tolerate my presence well.

The side conversations and flurry of activity that was going on around me was priceless, I felt like I was in a mockumentary the whole time. The CNAs were friendly and fun to be around, the Lead CNA was a fiery woman with a thick Scottish accent and a sharp wit. She joked that the inspectors kept trying to interview her but gave up when they couldn't understand what she was saying.

I observed one of the State inspectors conducting a staff interview with the LPN I was following. The sense that I was in a mockumentary intensified a thousandfold. He asked a series of questions about five patients, the same questions for each. Are they catheterized? Are they receiving a nutritional supplement? Do they have bedrails up? Are they able to get out of bed independently? Have they fallen or fractured a bone in the past 30 days? Each of the four inspectors typed with a single-finger hunt-and-peck method and wielded their laptops clumsily, as if they were unfamiliar objects. I later found that the laptops were a new addition to their survey routine. I corrected the inspector's spelling of HEEL, he spelled it HEAL. I just couldn't let it slide. I spent some time chatting with the inspector about QIS surveys and Medicaid while the LPN retrieved charts on the rare occasions she couldn't produce the information from memory.

After I had a chance to enjoy several hours of witty repartee between the LPNs and the Minimum Data Set Nurse, the LPN I was following excused herself to take care of a personal matter. She suggested I pop in to the office of the Assistant (Associate?) Director, after warning me that once I did he might "talk my ear off".

"Sweet," I reasoned, "I didn't feel so great about how my interview went last week, so maybe getting some face-time with an administrator will help my chances". I was hesitant at first because he seemed busy, but I was assured he always seemed busy, and that it would be fine to drop by his office.

They weren't kidding that he liked to talk, but I saw this as a good thing. Something I first noticed while I was in Japan was that administrative types are often the people who have the most control over what they do with their time, which allows them to invest a good couple hours here or there to talk, give a tour, or play a board game, as the case may be.

In this case, we talked. I could see why the other nurses "warned" me that he was a talker, but I viewed it positively. The art of conversation is a dying one, and I got the sense that maybe he enjoyed having an intelligent conversation partner as much as I did. He's a very interesting guy, he has a graduate degree in public health and our conversation covered a wide range of topics; health care, insurance, the role of nursing in the healthcare delivery system, electronic charting, the economy (of health care and otherwise), long-term care, family caregivers, we even discussed our personal histories and ambitions. The conversation had a slightly paternalistic ring to it, which I didn't mind. He was, after all, in a leadership role, and I was one of two non-patient males besides him in the building. I engaged him in conversation until -he- had to excuse himself to get back to work, and when I emerged from his office I noticed that most of the rest of the shift had gone by.

I stuck around to hear the CNAs report off to the next shift, catching the tail end of the Scottish Lead CNA rolling through her patient load in a brisk, efficient lilt. Afterward the director of nursing introduced me to another RN who was "previewing" the facility (oh no, competition!), and told me to call back later to let them know if this job was something I would be interested in. I immediately assured her that, yes, I was definately interested. She told me to call back Friday "when the State is gone", and we can discuss "what the next step is". I kinda felt like she was trying to get rid of me.

On the walk back to the car, the Scottish CNA told me that the behavior I observed from the director of nursing wasn't necessarily a bad sign, just how she was, and that spending the time chatting with the administrator was the right thing to do. She wished me luck, bummed me a cigarette (I know, I'm trying to quit, really), and I headed home.

As I left I was suprised by how badly I wanted to work there. Not just because it pays almost $30 an hour; I enjoyed the pacing of the place, the relatively small number of coworkers I had to interact with compared to the beehive of hospital life, the offbeat humor and warm acceptance of those coworkers, the opportunity to develop longer-lasting therapeutic relationships with the patients, the eventual option of traveling within the company, it's a good match on a lot of different levels. The acuity isn't very high, and I still want to get into emergency someday, but this looks like a good place to enter into practice, even if they still chart everything by hand (for now).

Internet Search Query Highlights

I really get a kick out of seeing what people were searching for on the internet that lead them to this blog. I don't get quite the level of hilarity as some of my healthcare blogger compatriots, but I still occasionally run across something that makes me larf.

"normal trombonin values"
-I think you meant "Troponin". I do mention "trombonin" quite a few times on this blog, though, so good try.

-I busted out with this once when the child abuse specialists came to talk to our nursing class. I think I blew a few minds when the presenter was struggling to remember this word and I knew it immediately.

"eupnic in a sentance"
-I did, in fact, use eupnic in a sentance..but why not just look up the word eupnic?

""There Is No Friend Anywhere""
-This one sent shivers down my spine, it's from a Robert Anton Wilson book called the Illuminatus! Trilogy. I searched for this phrase myself on google, and there I was, on the second page of two pages of search results. Oh, what have I wrought.


Podcast, Podcast, Podcast

The new version of Winamp got me hooked on podcasts. In addition to my usual favorites of BBC world news and NPR, I've been subscribing to health care professional podcasts. Check out some of the healthcare podcasts I'm listening to:

The Dr. Anonymous Show
The Nursing Show
Travel Nurse Talk
EMS Live: Articles
EMS Live: Blogs
EMS Garage
Dr. Pod
Nursing Education on the Go!
Nursing Radio
Vital Signs
Persiflager's Infectious Disease Puscast

Am I missing any good ones? Let me know!



I had an interview at a nursing home a couple of towns away from home. It was a pleasant experience, so far this has been the most desirable place to work out of all of the ones I've interviewed at so far.

It's a nursing home nestled in a retirement community, a sort of swanky cruise-ship-on-land, where there's an in-house VNA, the previously mentioned skilled nursing facility, and all sorts of other services like physical therapy, a huge swimming pool, you name it. It reminded me of the integrative model of health care that I saw in the state mental hospital, making a health care facility seem less like a health care facility and more like a community.

Even better, the job pays 29/hr instead of the 24-25/hr that all the hospital jobs I applied for pay, and the corporation that owns the retirement community, home nursing agency and skilled nursing facility have similar integrative retirement communities all over the country, so there's opportunities for being an in-company traveling nurse, without the need for an agency. They do a lot of in-service training, and there's lots of opportunities to get experience in wound care, EKGs, ortho, neuro, all the stuff I'd get to do in a med/surg environment. Being able to develop long-term therapeutic relationships with the patients also sounds like a good idea to me.

So, I have to go back up there with my completed application and hang out for a shift to get a feel for the unit and show my interest, I hope I get the job. They said they DO hire new grads, so that's something at least.

On the ride back from the interview (about 20 minutes ago) I got a phone call from an unfamiliar area code. The woman on the other end wanted to know if I was available to work on October 13th, and that she had found my resume on Monster.com. She offered me a 1-day position providing first aid at a home improvement store. 27 dollars an hour, 7:30AM to 3:30PM. I balked at first, explaining that I didn't have any experience and am still looking for my first RN position. She said all I had to do was first aid, and that having previous health care experience was enough. So, why not! I told her yes. I'm going to do a bunch of reviewing before the job. I feel pretty solid in my first aid skills, but this will be my first paid nursing position, so I want to walk in confident that I can handle anything from scrapes to shock in a first-aid capacity. Even though it's only a one-day gig, I'm pretty excited about it. She said to wear scrubs or street clothes and a labcoat. She also said not to mention that I'm a new grad, it might "make them nervous". Heh.


I vow...

During my second and third semesters of clinicals, I stayed overnight between clinical days at the home of an RN and his father, the brother and father of one of my classmates. The experience was just as valuable as any during that time, being able to quiz and be quizzed while the iron of clinical preparation was still hot is something I recommend. Labs, pillow arrangements, care planning were all discussed, but maybe even more valuable was "how things really work in the field". After several years in Hemodialysis and some time in ICU, he had plenty of stories to tell. His father, too, after a long military career and tenure as a spanish teacher in urban public schools, could spin quite a yarn. I often wished I could take some video or audio of these stories, but it's difficult to do without making people uncomfortable.

Anyway, one of the most puzzling things this RN related to me involved ongoing harassment and discrimination from his coworkers for describing himself as a buddhist (he's of european descent, not that that matters). They would condescend and speak derisively about his "imaginary friend", and engage in all sorts of subtle psychological intraprofessional violence against him. These coworkers were universally christianist, and felt strongly that christianism was deeply connected to the profession of Nursing. I wonder how those same nurses treated their muslim, hindu, buddhist, etc. patients!

A different classmate who dropped out of the program half-way told me he suffered some of that same lateral violence from faculty memebers because of his atheism. This also seemed strange to me, mainly because questions about my religiosity never came up, even during those two semesters in a catholic hospital (which was -much- easier going than I anticipated). Later on, during a scandalous fling with a classmate, I learned that there was a rumor circulating through the class (and also through the faculty, by association) that I was jewish. I was amused by this, since all three of my names are irish.

I strongly resist any "ist's" or "ism's" being applied to me, especially when they denote any particular school of religious or metaphysical thought (preferring instead to borrow the ideas I like from all of them), and at the same time I was always aware of the reality-tunnels of the patients and coworkers around me. I made a joke once to one of my patients at the catholic hospital about how yoga and acupuncture are great, but here "it's the eucharist or nothin'". The classmate assisting me (who was catholic) looked horrified, but the patient laughed. A combination of prior conversations and a quick glance at the reading material at his bedside confirmed it was a safe joke to make.

Anyway, It's clear that despite employers and schools working to increase diversity in the nursing population, a monoculture still exists. Nurses are predominantly female (90-95%), middle-aged (mid 40's) and overwhelmingly subscribe to one of the three abrahamic religions (islam, judaism, xtianity). I think there's still a sort of "nurses eat their young" effect going on that counterbalances institutional drives for diversity, but even still, the percentage of men in nursing has increased over 200% since the 70's, so the trend seems to be towards greater diversity anyhow.

What troubles me most is the correlation that abrahamists (christianists in particular) perceive between their faith, their work and their morality/ethics. In true abrahamic style, many of these people slip down the path of believing that they have the market cornered on morality and compassion, even in the face of overwhelming evidence that, in fact, they could use a little work in that area.

The case they make against buddhism is possibly more asinine than average, since they view it as more of a religion than a set of techniques, and that's not entirely accurate, especially for people who adopted it outside of the cultures it arose from. I've tried and failed numerous times to explain to christianists (especially) that the practice of meditation does not, in fact, contradict anything in their faith or religion.

So it's for these people that I present the four great vows of buddhism. We chant this before zazen when we train in Aikido (it's a traditional style dojo). I present it as something to ponder for people who think that nurse=christian. First in some asian language or other, and then in english (maybe not the most accurate translation, but the one that appears in our chant-a-long booklets).


Sentient beings are innumerable, I vow to care for them all.
Self-delusions are inexhaustible, I vow to relinquish them all.
Gateways to truth are immeasurable, I vow to enter them all.
The buddha way is complete wakefulness, I vow to manifest it.

I haven't seen a better mantra for nursing in any other religion, that's for sure.


Musings over an issue of AJN

Ever since I graduated from nursing school, I've been getting copies of the American Journal of Nursing in the mail. I generally don't have much use for print media nowadays, the content-to-advertising ratio never seems very good, the printed materials themselves take up space, and then of course there's subscription fees.

After 3 or 4 monthly issues piled up in my mail "inbox" area I decided to grab a couple on my way to the coffee shop. I have to admit, it's not that bad. Most of my typical gripes with the magazine format still apply, but there were things about it that I enjoyed. There was a good mixture of scholarly articles (it was refreshing to read something a little closer to my reading level after all of the dumbed-down reading that was foisted on me in nursing school) and interesting musings, interspersed with cut-out charts and assessment tools and the occasional ad that I actually found interesting. It dawned on me, thumbing through an issue...I've become a target market! Weird.

There was an insert with this month's issue that focused on the role of the family caregiver, a person who, with or without a license or medical training, is in the position of providing direct care for a family member at home. There were a lot of articles about how Registered Nurses can assess and support families' home-care efforts, issues surrounding Nurse Practitioners' current inability to initiate home health services, and some interesting accounts of how insurance considers "skilled nursing" as something focused more on machines rather than hands-on skilled nursing care (pulmonary toileting isn't covered, but suctioning is, for example).

Anyway, the reason I'm rambling on about all of this was that thumbing through the issue gave me an idea, and it's this:

When someone takes on the responsibility for caring for a family member at home, there's a lot of information that needs to get across. Medications. Wound and ostomy care. Injections. Skin care. Pharmacological and non-pharmacological pain management. I've seen the overwhelmed looks on patients faces when they're receiving discharge instructions. Pamphlets written well above their reading ability. Dense discharge forms with scrawled addendums. It's a nursing responsibility to make sure the teaching is effective, but not all family caregiver roles are initiated in the hospital.

To support new family caregivers, I think it would be a good idea to set up a sort of distance learning system that can be accessed from home or a public computer. Take an individual patient's diagnoses and home care needs and customize a distance learning syllabus to provide a reference and learning aid for any family member who wants to get involved in care. This could be automated pretty easily, I've seen resources on hospital intranets that generate printable pamphlets for patient education, but I think this process could be improved upon by connecting family caregivers directly to resources like this.

Although my first impulse is to suggest that this should be some sort of freely available national resource (and I still think that's a good idea), it might be more realistic and workable to have this be a service of a particular hospital or system of hospitals. That way the learning aids served to the family caregiver can be customized not only with information pertinent to the patient's condition but also information specific to the patient's primary physician, like doctor's orders, dates of exams and appointments, etc.

Hell, you could even make it interactive, the module being served to the family caregiver could even allow for uploading pictures of wound healing, questions could be posted and answered, why not?

It seems to me that the more we support family caregivers, the more efficiently we'll be able to use our scarce health care resources. There's other issues in play, of course, like the availability of "attendant hours" and RNs for tasks family members can't provide, but it seems like there's definately room for improvement in how family caregivers are supported by the health care delivery system.

What I perceive to be the overarching problem, as I've mentioned before, is the quality of information technology resources employed by both educational and health care delivery systems. Maybe this is a job for Google, they're already getting their fingers in this particular pie anyway.


More Aikido

So, I didn't get the job I posted about last time I posted about a job interview. As it turns out, two of the other applicants had job references that worked at that same hospital. I was told that I "interviewed well", which I guess counts for something.

Being told that made me think of my references, and the hospitals they come from. They're from faculty members at the Nursing School I graduated from. Two of them come from the large community hospital in our state's capitol, the third comes from a state mental hospital which is in the middle of a hiring freeze. I was resisting applying at the big community hospital, but it just might be that I'll have to suck it up and resign myself to the 50-60 minute commute. Getting up at 5AM to haul myself up there was a huge chore a couple of semesters ago.

The other alternative is nursing homes, since I don't have an "in" at any of the other hospitals (although someone's working on something for me at the hospital closest to my home) and I've never worked in one before, I may just have to "pay my dues" for a year or two at an SNiF.

So anyway, in the meantime, I've been keeping myself busy with Aikido. If I can't make money I can at least get some exercise, right?

My home dojo hosted a seminar this past weekend, with a great guest teacher. I was injured, so I couldn't train, but I took a bunch of great pictures and video.

From Aiki Farms Seminar 2008


The Swear Jar

I've just been invited to write for my friend's blog, The Swear Jar. I'm immensely flattered, since the person who invited me is a fantastic writer, someone I met in the trombone section back at the state university that I couldn't help but think "damn, someone should be filming this dude" 90% of the time, he was that funny. Anyway, the blog is going to be about a bunch of random things like current events, politics, technology, random musings, etc. Basically all of the things I stopped blogging about in my personal (non-nursing) blog long ago. I don't think I'll crosspost at all between the swear jar and here, but check it out and add it to your RSS readers.