1.29.2008

"They've already had one judge, they don't need another."

So, I was mistaken about a few things in my last entry. My cohort is actually 8 people (including myself), the rest were students who are rotating in to this facility later in the semester. The 7 people with me will be the same 7 people with me in acute med/surg, which is nice. We get to spend some time together in a more relaxed environment before what I assume will be a relatively chaotic assignment in acute med/surg.

Today consisted of more orientation and no patient contact, which disappointed me. We were told the purpose of this is to ease the transition into the psych setting and reduce anxiety, which in the past has rattled students enough to prevent them from learning anything. I can understand that, but what about the students who want to get right to it?

Having said that, it was an extremely pleasant day. We began by introducing ourselves, describing our previous experiences with mental health (and it's various alternatives), and stating what our expectations for this setting were. Lots of great conversations came out of this, which continued through the day as we walked past crumbling asylum facades and sturdy, state-of-the-art facilities.

The conversations were really the highlight of the day, between the instructor, other staff, the occasional patient and each other we covered a lot of ground, shared a lot of ideas and told a lot of stories.

Something interesting that occurred to me while I was listening to the instructor was the similarity between some of the patient's stories and things I've read about shamanism. Without being too specific, one story involved a person living with mental illness who was shunned by his community. He became depressed and tried to kill himself by throwing himself underneath a heavy moving vehicle. He was "run over", but had no serious injuries or broken skin. He earned the name "speed-bump" because of this, which brought him a measure of happiness because he had never had a nick-name before. The experience may not have completely cured him, but it resulted in some measure of healing.

This sequence of events may seem familiar to someone interested in shamanism, indigenous peoples and things of that nature. A person becomes sick, faces death, and survives unexpectedly. The person is then selected to learn that culture's shamanistic tradition. In various cultures the sickness might be a mental illness, surviving a snake-bite, or being struck by lightening. The idea that a person who becomes ill and through fate or dumb luck heals themselves can then heal others seems to be a pervasive one in many regions. Outside these naturalistic traditions there is still the somewhat gnostic point of view that facing one's own death imparts an augmented view of reality that strips away a lot of the linguistic noise that masks the natures of things. Or else it just makes you crazy. Or maybe both, depending.

Speaking of the social context for "psychopathology", another great tidbit that arose from those conversation was the instructor's observations on the role of the extended family in mental illness. In the midst of a long career in acute forensic psych nursing, she traveled somewhere pleasant and tropical to continue practice for a while in a more idyllic setting. In this place, she knew an agoraphobe who could not leave her house. Rather than treating this as a horrible tragedy of mental illness, the family simply left the children with her when they needed childcare, because she was always home. The instructor said she was the happiest agoraphobe she had ever met. A powerful example of how the social context for mental illness can shape the lives of the people who live with it, and how sometimes a successful thereputic outcome doesn't involve remission of symptoms or "normal behavior".

It was brought up that I would be "good for the system" somehow because...I dunno..I'm outspoken and/or articulate or something. Someone thought I might be good as a delegate for the Union, which "needs people like me". A strange paradox was raised. How did it come to be that Nurses, a group of people who tend to be assertive, highly educated and well-trained, keep getting the shaft when it comes to legislation? The answer, I'm told, is that Nurses as a group aren't very politically mobilized. I can hardly blame them, why -should- they be? They're here to take care of people, let people with other jobs figure out the whys and where-fors...but no, no, that's not how it works. If we don't get in there and shape policy, policy will be shaped for us in ways that will make us very unhappy. I guess that's just how it works. I've been getting my feet wet a little with our local branches of the National League for Nursing and the American Nurse's Association, and that kind of thing seems more my speed, I can't see myself fighting with management over a $.50 raise..I realize those issues are important but they don't motivate me the same way as plumbing the intricacies of practice acts and license regulation. At the very least I can help prepare other people to take on those issues, I think. For now, I'd be happy to just take care of patients.

So, anyway, "forensic nursing" is apparently a relatively new field, although I've met a few people who were doing forensic nursing before it was called forensic nursing. A friend of mine recently told me she got hired as a forensic nurse and I was all like "a what now?". One of the reasons for its surge in prevalence seems to be the growth of the population of people who require forensic nursing care. Forensic nursing involves care of patients who have been found not-guilty of a crime by reason of insanity, by the way. Our instructor, with 20 or so years of experience with this population, had some interesting insights into the field, where it's headed, and how it got here. She described how, in the past, it was easy to get in to a psych facility but hard to get out (the proper way, I mean, this isn't a commentary on the security schema). Today, it's hard to get in and easy to get out, partially because there aren't enough beds. As a consequence of this, beds in inpatient psych facilities tend to be reserved for people who are a) a danger to themselves, b) a danger to others, or c) unable to care for themselves due to mental illness. In effect, people who suffer from mental illness and feel that they need treatment have been "taught" by the system that they must commit a crime to be recognized as ill. No wonder the demand for forensic psych services has been increasing!

During our tour of the facilities, we walked around the greenhouses, where we saw patients working on the flower sale (which is the largest contributer to the patient's fund). At the treatment mall we saw a meditation room, expressive therapy facilities, an impressive physical therapy department complete with gym, an equally impressive library, a beauty parlor and a couple thrift shops, all of which employed patients. I'm hard pressed to identify a single area of the hospitals where patients weren't therapeutically employed (and making minimum wage, a vast improvement over the slave-labor I witnessed in the mental retardation racket). We didn't get to see any actual units today because of the hardship tromping all 10 of us through the living areas would cause, but we saw the lobbies of the buildings housing the medium and maximum security forensic units (we're assigned to the medium flavor), the general units, the TBI (traumatic brain injury) and ABI (acquired brain injury) units, the women's shelter and various facilities for patients and staff alike. It's a big place! We got a lot of walking in, filled with pleasant and interesting conversation.

The use of the phrase "patients" caught me off-guard, since in our other sites we had been trained to say "consumers" or "clients" variably, but here the word is "patients". I'm not one to quibble (about this anyway), as long as it doesn't offend -them- I'm game.

Towards the very back of the facility we were shown an abomination of a juvenile detention facility, designed as if it were meant to house factory-farmed chickens or something. Apparently it was built in secret and housed juveniles in it's stark, windowless desolation until one of our instructor's colleagues called one of the child-protection agencies. The appearance of the building from the outside was enough, it would seem, as it's now slated to be dismantled, and the children imprisoned inside are going to be relocated to smaller facilities integrated into their home communities. A no-bid pork-barrel project, we're told. Pay attention, we're told. If we observed our leaders and captains of industry as intently as we do our mentally ill, we'd be a lot better off, I'd wager.

Everyone we met in our meanderings was pleasant, welcoming and friendly, staff and patient alike. Everyone seemed very interested in recruiting us, and it's definitely tempting. I just can't resign myself to working towards retirement just yet, though. If I was, this place would be top of my list, for sure.

At the end of the day, the instructor "committed" us to four directives. It was a sort of informal swearing ceremony, where we raised our hands and swore that 1) we would treat the patients well (because if we don't treat one of her patients well, she'll find out and extract revenge) 2) that we treated our fellow students well 3) that we treated the staff well and 4) that we do something good for ourselves for one hour for every clinical shift. We have to back this up by writing an additional journal entry about this hour. The way this night is going I don't think that's likely to happen soon. My car broke down and I'm stranded with school in 6 hours.

1.28.2008

The Milieu

Today was orientation day for psych clinicals. My Cohort includes 24 people, including myself. We've been assigned to a medium-security forensic nursing unit, which means that the consumers have all either been committed by the court system or have some kind of court judgement awaiting them.

It's a pretty large campus. I got there a half-hour early and went to a few buildings before wandering in to the HR department to ask for directions. No one seemed to know anything about my cohort, so I convinced them to let me use a computer to check our courseware, where I could check a forum posting that contained the location. I was suprised how easy it was to gain unsupervised access to their computers. What if I had been a consumer?

The orientation day was a lot like those timeshare meetings you can go to in exchange for free lift tickets at a ski resort. We were actually being sold positions there through three hours or so of explanations of the benefits of working for this facility specifically, and the state department of mental health and addiction services in general.

It wasn't a bad sell, really. After three years they pay up to 24 hours of your schedule to go to school and further your education, and offer reasonable benefits. My gripes were the amount of paid leave they offer and the lack of vision insurance. That aside, working for the state in a job that's considered "hazardous duty" can be a pretty sweet deal. Some of my misconceptions about psychiatric nursing were dispelled as well, since psych nurses DO seem to do quite a bit of health assessments outside of psych issues. Still, though, although I could do psych right out of school, it doesn't seem like it would count very much towards getting into the acute-care setting, so I'll leave it as something to try out later.

The campus has a great cafe that's open to the public, eating breakfast and lunch there for the next few weeks will be a delight. Cheap, too, you can get a decent breakfast for a buck-fifty. The rest of the campus ain't bad either. We're getting the full walking tour tomorrow (along with our first patient care day), but we've been told it includes greenhouses, a radio station, a beauty parlor, gyms in every building, and a relatively new idea (so we're told) in psych treatment called a "treatment mall". Consumers have to leave their units to undergo treatments instead of having everything done in the same unit. That's how it works for most of them, anyway. There are higher degrees of security where everything's still done on the unit. We took a walk through this mall today, it's kind of like a mini shopping mall, where consumers can work in the shops under the supervision of job-coaches. It's intended to prevent the consumers from becoming institutionalized, they say. The campus also boasts a huge library. It still reeks of the "institutional setting" in some places, but I haven't seen the actual unit yet and..hey, it's the State, what do you expect? I expect I'll enjoy my rotation there, for sure.

A friend of mine used to work at this facility years ago as a psych RN, she seemed thrilled when I told her I'd be doing my rotation there. According to her, she's the reason that facility stopped using straightjackets all those years ago. She had to stop practicing because she developed MS. I told her I was a little bummed that I'd have to wait a few weeks before I got back to acute med/surg, so she let me administer her duoneb inhalation treatment and her baclofen. What a sweetie.

1.25.2008

Yawngasm

Copied directly from my pharmacology for nursing care text:

"Yawngasm. Rarely, patients taking clomipramine [Anafranil] experience yawngasm. Experience what? A spontaneous orgasm while yawning. Honest. This unusual side effect, which affects both males and females, may be considered adverse or beneficial, depending on one's view of such things. In at least one documented case, yawngasms strongly influenced adherence, as evidenced by the patient asking how long she would be "allowed" to continue treatment. Although data are scarce, one might guess that the occasional yawngasm would help relieve depression."

I seem to remember reading something about an anti-yawning drug that had this same effect, but it's name eludes me.

1.24.2008

Beginning of the End of the Beginning

Yesterday was my first day of the last semester of nursing school. I got to reconnect with some old friends who dropped out two semesters ago, returning with a year of PCA experience under their belts. I got to look around the cramped lecture space to see who made it and who didn't. Attrition this semester seems lower than in the previous semesters. It's the point of no return, I suppose, with only one semester left you might as well just finish.



My clinical cohort is starting with acute psych. After an orientation day on Monday, we'll do 3 weeks of client contacts at a large inpatient psychiatric facility. I think my favorite part of this will be not having to wear the rediculous uniforms they issue us. From what I hear, we'll rotate through geriatric, forensic and peds/adolescents. We won't be passing meds or applying treatments, but we'll be doing assessments, which is always a good time.



Many of my classmates are nervous about psych because they don't feel safe and don't feel that they can reasonably predict the clients' behavior. Others are anxious about it because psychiatric diagnoses give them the heebie-jeebies. I'm looking forward to the psych rotation, I've always found the population interesting. I found working with adults with mental retardation and autism very rewarding in the Unlicensed role, and I think I'd be pretty good at psych nursing. Most of the day's activities were centered around alleviating my classmate's anxiety about psych by playing videos and being spoken to in a generally soothing manner. Then, there was the Show.



At the end of the day, we had a theater group come in to do a series of skits about living with mental illness. I took along a pre-nursing student I'm more than a little sweet on. I didn't know what to expect, at first. From what I heard about them I was expecting adults with MR, maybe that's because that's where my experience lies. The troupe was made up exclusively of adults who have been diagnosed with psychiatric disorders. Most had been hospitalized, most were currently on medication, all were in recovery and had symptoms managed well enough to travel and perform throughout our region. The skits they did were hilarious, touching on subjects like guilt, denial and substance abuse. They sat on stage afterward and answered our questions about their diagnoses and their experiences with the health care system. When asked what aspects of nursing care benefited them the most, the things that came up again and again were respect, listening, and support. We watched a video they produced called "All Better", in which a gentleman with schizophrenia is declared "all better" by his case worker and ejected into the workforce after over a decade of institutionalization. The fact that these plays, musicals and stories were constructed start-to-finish by people with psych Dxs is encouraging and empowering. Although I realize this will narrow down the possibilities concerning my geographical location, I was impressed enough with these people to link to them. http://www.artreachheals.org/. If this sort of thing appeals to you, gentle reader, visit http://www.autistics.org/. There you'll find some powerful writings from people with Autism.





Although I enjoy this population and think I'd be good at psych nursing (probably because I identify with them, having been an inpatient once myself as an adolescent, and still exhibit a lot of the characteristics of asperger's), it's not presently compatible with my intermediate range goals. Maybe some day in the future I'll give psych a whirl, but for now the plan is still to build assessment skills on the general units, maybe dabble in hemodialysis, and eventually get into ED/ICU while going for my Family NP. There are plenty of other things I think I would enjoy doing, like Home Care, but I want to avoid becoming too specialized too early on, and I want to preserve the technical skill I've nurtured so far in school.

Speaking of, the following Friday is my orientation day for acute medical/surgical. I'm pretty excited about this, if a little anxious. I've heard fantastic things about my new clinical instructor, and she's also one of the course coordinators for my last semester. It's an evening shift, which is more compatible with my sleep schedule. The IV pump situation is kind of funny, actually. First semester, I learned how to operate a volumetric pump, but didn't have any opportunities to apply this knowledge. Second semester I was in a hospital that was almost exclusively gravity drip. Third semester I was in that same hospital, but having to figure out on-the-fly how to use ancient peristaltic pumps that we didn't have mock-ups of in the Lab. Now, for my last semester, I'm going back to the volumetric pump. I stopped by the lab and had one of the tutors run me through the pump's operation, just to be sure I got it.

This semester we're also doing a "trends in nursing" class, mostly online, with three seminar days in the lecture hall. In the past this class has involved an lengthy paper, but the paper has been dropped from the syllabus. I'm somewhat cynical about this, it seems as though we're being let off the hook. Most of my classmates are relieved, but I'm annoyed. I just hate it when things get dumbed down. Anyway, this class will involve coming up with 150-200 word responses to questions on the online class' message board. The sample question put up on the screen during orientation was something to the effect of

"given the definition of leadership in the text, what aspects of leadership are most important to you and why?"

We were then told that we had to support our answers with APA style citations. My hand immediately shot up.

"What sources can we use to answer questions that are asking us for our personal opinion of something?" I said, or something to that effect.

The instructor smoothly answered that we could use nursing journals, interviews with nurses, or nursing blogs, to name a few options.

My hand shot up again.

"Can I cite my own nursing blog?"

This stumped them, they all exchanged glances before the first instructor explained that I could, if the content was appropriate, nursing related, and universally accessable.

1.12.2008

respite

I have about two weeks of vacation left. All attempts to find a PCA/PCT job with area hospitals have met with complete failure. It's around that time where I should be looking for GN (graduate nurse) positions instead, so I suppose I'll just focus on that and hope one of those potential employers has some PCA or PCT positions open.

In a couple of days I have a speaking engagement. I love this sort of thing. I'm supposed to visit one of the other community colleges in this state to talk to their nursing students about setting up a Student Nurses Association chapter there. I'll try to remember to bring a camera and a tripod. I'm not going to come with a powerpoint slideshow, as I mentioned previously I'm not a big fan of them. I might put together a short handout with some relevant information (web links, etc), along with the chapter toolkit booklets I scored at our last convention in Kansas City, MO.

Some time this coming semester we're planning on visiting area middle schools to get younger students interested in nursing by educating them about who we are and what we do. I'm still trying to think of techniques we could demo for them. Bandage wrapping would fly, straight-caths not so much. Heh. Anyone have some good ideas of nursing skills to demo that are non-invasive?

When I do this sort of thing, I tend to speak extemporaneously. Having note cards or an outline to work off of cuts me off from the audience in a way I find disruptive. As a result, I tend to ramble, forget something, move on to another topic and then reintroduce what I forgot when something else reminds me of it, but as long as the audience is listening to me and not taking notes, that tends to work out just fine.

This seemed to be a powerful tactic during our last annual NSNA convention. During the debates on resolutions, people stepped up to the microphones to deliver their Pro or Con statements armed with notecards. The first time I stepped up to that microphone and saw thousands of student nurses staring at me, the rationale for this was clear: it's intimidating! Waiting in line to deliver your canned statement, however, didn't take into account the dynamic nature of a debate, and people routinely found themselves wasting their time on the microphone delivering statements that have either already been argued or made irrelevant by the flow of the discussion. I had a lot of people I'd never met before come up to me and thank me for saying the things I said. It was a great experience, and I look forward to repeating it in Texas this year (in march).

This difference in debate style has a couple of instructive correlations. Puzzling over the difficulties that some of my obviously brilliant classmates have with our programs academics, it seems to be the same sort of issue. We're not being challenged to merely learn, we have to put what we've learned into context and adapt our understanding to changing circumstances. Another correlation that offers itself from my nearly two decades as a musician is the skill of sight-reading. Being able to play a piece of music the first time you see it is a radically different skill from taking it home, noodling with it for a few days and coming back ready to perform it. Being comfortable enough with your instrument to simply play without any music in front of you at all is another thing entirely. Both modes of operation have obvious uses, but being limited to one is a liability. I say this fully realizing my bias towards the extemporaneous, the impromptu and the empty-hand is it's own liability. "The fool who persists in his folly shall become wise", I suppose.

So, during this period of respite, I thought I would go over a few of the things I do for fun. Leisure activities, I suppose you might say. In truth, many of these things are activities I take more seriously and invest more of myself in than the "work" of life.

The main thing is Go. It's a board game. It's also called Igo in Japan, Baduk in Korea or Wei Qi in China. Wei Qi means "encircling game", the etymology of the other two names are not clear to me.

The rules are deceptively simple. On a 19x19 grid (you can also play on 9x9 or 13x13), black and white take turns placing stones on the intersections of the grid. The empty spaces next to the stones in the four cardinal directions are called "liberties". If a stone or group of stones has no liberties, they are removed from the board. When both players decline to take a turn, the score is calculated by adding together the number of liberties that are surrounded with the number of prisoners captured by each side.

That's it.

It sounds simple, and it is, but the strongest computer program ever written to play it can only play at the level of skill it takes the average person a year to reach with regular study. This is because the iterative way that a computer approaches tasks is well suited for a game like chess or checkers, which only has 10-30 possible moves for each play, but not well suited for Go, which has 360-n (where n is the number of stones on the board) possible moves. Since a board position can have three states (empty, black stone, white stone), the number of possible board positions (not counting the board positions that wouldn't occur in the course of normal play, like a board full of white or black stones) is 3^360. For context, most estimations I've read for the number of atoms in the observable universe place the figure somewhere around 17^77, a number that's orders of magnitude smaller. It's almost mathematically impossible for two games to play out exactly the same, each ending board position is unique, like a snowflake or a fingerprint.




Go goes by another name in China and Japan, a metaphorical one. "Shou Tan" in Chinese and "Shudan" in Japanese. It means "Hand-Talk", and it's an apt description. Go is a game over which strangers can instantly become friends, it's said. It's true, I've experienced this several times.



It's also a game over which the unsaid becomes apparent, a kind of metalinguistic reflecting pool. A collaborative rorschach test. Reaching a certain level of familiarity with the stones might have some implications in your relationships, if you're lucky (or unlucky) enough to have a partner who plays.

It's been theorized that one of the other uses for the game was as a divination tool. The board is sectioned into four quadrants of 90, the four seasons of the Chinese Calendar. The number of board positions is equal to the number of days. Further information on this isn't available, I wonder if it's been lost to the ages..



For the past year or so, Go has been a kind of shelter for me. An activity that has no beginning or end, a way of speaking that succeeds where language fails. Supposedly there is clinical research in China that suggests that playing Go is an effective form of stroke rehabilitation, as well as generally strengthening the brain functions that are referred to as "right-sided" (wherever they're actually localized).

In any event, I try to teach the game to as many people as possible. It's popularity has been in decline in Japan for a while, and according to the newsfeeds that trend has started in Korea as well. Professional Go players are becoming a dying breed, and it's not hard to see why. Potential Pros start their academic training for the game at an early age, it's not guaranteed that they'll become a Pro, and what they learn doesn't really translate very well into other academic skills (although I'd argue that it strengthens a lot of reasoning and judgment skills). The game persists, though. If you're interested, check out

The Interactive Way to Go - a wonderful interactive tutorial to get you started

The Sensei's Library - A voluminous Wiki, useful to beginners and Pros alike

GoProblems - An interactive, commentable database of Tsumego, or Practice problems.

http://www.gokgs.com - The KGS Go server. My favorite place to play, very friendly towards beginners with lots of teaching games offered (more useful than reading about the game)



I mentioned music already, so I suppose that's next. I've been playing one instrument or another since I was very young. Piano came first, and I'd definately start a child on that instrument, since it imparts lots of understanding of music theory, as well as being generally beneficial for cognitive and neuromuscular development. Violin came next, but I abandoned that after middle-school because I didn't really have the posture for it. Trombone started in elementary school (the year after violin), and I played both instruments for school at the same time. Trombone is what I spent the most time on. I got to be pretty damn good at it, if I may say so. I got a Jazz Improv award in High School, enjoyed the heck out of Marching Band, got to travel around to NCAA basketball games with the pep band in College (nothin' like a free hotel room), and even beat-out music education majors for solos in one of the marching band shows in college. I had some great times playing the trombone, but unfortunately once I left university I shelved it for a few years. I'm forever meaning to pick it up again, it's sitting in the corner of my room glaring at me. Long-tones, I just have to remind myself..just play the long-tones and you'll get your chops back. Anyway, I'm currently awash in a love-affair with turntables, drum machines and experimental noise music. I DJed at my local watering hole for 2 years or so until Nursing School forced me to give it up (spinning mostly acid-jazz and trip-hop). I did some great live sets on the radio with a couple of like-minded primates, and ended up recording about 6-10 CDs worth of stuff I'm more or less proud of. My instrument of choice is the Korg Kaoss Pad, a programmable X-Y controller that lends itself to improvisation and noisy creative weirdness. My former band-mates (we called ourselves "flashmod lovebomb" and "the billy corgan trio" at various times) have all gone our separate ways, which is a shame since we were really starting to pull something interesting together, but such is life and at least I have the recordings to refer to if I ever pull the motivation together to get back into it. So much easier with other people around, isn't it? Music has been taking a back-seat in my life lately, mostly due to ennui related to the events of my life for the past 6 months or so. I don't even listen to music in the car anymore, preferring either talk-radio or the spectral tones of a detuned radio set to AM.





Video games are another thing I have a great deal of fondness for. I take a lot of flak from some people for liking them, but I think they have made and will continue to make a contribution to society that is difficult to ignore. A lot of the same resistance to video games echoes the resistance to movies, television and radio in different times and places. Those objections aren't totally without merit, of course, the birth of radio and fascism were only separated by a week or so, I've heard. Still, for better or worse, the speed and resolution with which we can share and detail our narratives continues to rise exponentially from the days when the printed word reigned supreme. Rather than "Video Gaming" I've adopted the current industry moniker of "Interactive Storytelling", since that seems to fit better. I still say video game a lot of the time just so people know what I'm talking about. Note that an actual story doesn't have to be explicitly told by the game, even the most lo-fi or abstract game can tell a story in your mind.

Currently I'm fond of Roguelikes, a style of game that originated in the 80s with ancient *nix terminal systems. The genre continues into this modern age of 3d hardware acceleration and fancy graphics. I keep up with those games too, of course, but all too often good gameplay and good storytelling take a backseat to merely serving as a vehicle for forcing you to upgrade your graphics hardware or buy a better console.



I'm also big into Indygaming (like independent music or film, but for games) for many of the same reasons, you can check out my gaming feed Here, which aggregates a number of indygaming newsfeeds with one commercial gaming newsfeed.

There's a whole constellation of other things I'm interested in, of course, but these make up the bulk of my actual leisure activities. A lot of my reading is targeted towards philosophy, gender studies, maths, shamanism, futurism/eschatology, the occult, neuroscience, biomedical engineering, the psychology of religion, neuro-linguistic programming, conspiracy theory, stuff like that.

My leisure activity lately has mostly consisted of social bookmarking like digg.com, reddit.com, fark.com and the like. Browse, browse, browse, find what's weird, find what's new, hit refresh, wash, rinse, repeat. It's an activity of idle nervous agitation, when I don't know what else to do with myself. I suppose there's worse ways to spend your time than reading and absorbing information, but there are so many other things I could be doing!

1.05.2008

The story so far...

Hello, I'm PM. I'm a student nurse. I can't tell you where, exactly, for fear of retribution by overzealous administrative types. It's funny, how this reverse-pressure impacts blogging about health care. On the one hand, of course, we have to protect our clients identities. On the other, free exchange of information is vital to the advancement of learning. Even with the proper precautions taken, administrators are likely to object with the purpose of exerting tight control over PR. This sort of counter-current adds a delightful sense of prurience to the whole endeavor, in the same way cultural taboos concerning sexuality lead to increased "kinkiness". I decided to start blogging about my experiences in Nursing largely thanks to TS (other people's emergencies) , whose blog I found on one of the social bookmarking sites (maybe digg or reddit...metafilter? Yeah, that one). A friend of mine is almost through with Paramedic school, and a combination of that and reading TS's blog has me itching to get into an RN to EMT-P bridge program concurrently with graduate school.

I'm about 5 months away from taking the NCLEX and receiving an RN license, along with an associates degree from a community college. Our nursing program has less than 100 people in each of its two classes. I'd estimate our attrition rate to be about 10% per semester, for various reasons including grades, clinical performance, horizontal violence and personal issues. Our ADN program includes many more hours at the bedside than the 4-year university programs. While their students spend the state minimum required hours at the bedside, the students in our program get that many in their first semester, and more than that every semester following. After completing three semesters, I've spent over 350 hours at the bedside in settings that include a small private hospital, a large community hospital, a military ambulatory care center and an antepartal care center. The units I've seen include Medical/Surgical, Orthopedics, Neurology, Hemodialysis, Pediatrics, Telemetry, Coronary Care, Labor/Delivery/Postpartum/Recovery, Neonatal Intensive Care, Emergency, Operating Room, Post-Anesthesia Care and Respiratory. Some were full-on clinical experiences as a nurse (most in terms of hours), most were observation experiences where we're relegated to shadowing and assisting. Not bad for a 2-year program, eh?

Truthfully, I've taken 4 years to get this far. I started out as a Computer Science Engineering student, but that didn't work out so well (spent more time playing trombone in the marching/womens basketball pep band than I did coding software). After failing out of the program twice, I spent a few wasted years at Radioshack, hawking cellphones and satellite dishes at the behest of my corporate overlords. After that, a friend got me a job doing direct care at a group home for the developmentally disabled. That was a blast, and was largely responsible for the path I'm set on now. The clients were all interesting, with multiple diagnoses (out of four, all were autistic, all but one was mentally retarded, none of them that were mentally retarded were to the same degree, none of them were functionally verbal, one of them could sign, all had multiple target behaviors, two had to be restrained routinely), and the nurse who taught us how to administer medication told us that if we liked this line of work, and were good at math and science, we should get nursing licenses and make 5 times the money. Made sense to me! Still does. Unfortunately, that place of employment had some abusive people working for them, and as is the case much of the time when you rock the boat, you get pushed out.

That's when I went back to school and started tending bar. Another fun job, with many similarities to nursing (Administer dangerous substances, evaluate the response, titrate the dosage, provide therapeutic communication, etc). Slightly gunshy about returning to school, I took the general education requirements slowly. The first time I took the nursing entrance exam, I scored in the 99th percentile in all of the real subjects (math, reading, etc), but only in the 60-something'th percentile on the personality test. Since they only took the lowest score, it was back to the drawing board for a year. This actually worked to my advantage, since by the time I was accepted into the nursing program, I had completed all of my co-required courses, leaving me with just the core nursing program to complete. Unfortunately, there was no alternative but to take those courses one semester at a time (no summer sessions), so here I am, three-and-a-half semesters into getting an associates degree.

I've often said I'd like to make a video series in the cinema verite style (think Cops, reality TV, etc) chronicling the multi-faceted weirdness inherent in nursing school, at least in the time and place I've attended so far. Even the faux-documentary style of "The Office" or "Trailerpark Boys" would suffice (and would probably be easier to work out for privacy reasons). There were plenty of experiences on the unit, at the post-clinical conferences, and in the hallways and construction sites that would accommodate us between classes that would have been worthy of recording. Actually, I did record a snippet of one of our assessment labs at the beginning of last semester. It was held in the auditorium due to the mass chaos of construction and renovation.



I intended to record many more videos of this nature, but found my motivation lacking for a number of reasons. The Anatomy and Physiology class I took in the year preceding the nursing program was a life-changing experience. I recorded each lecture obsessively. The instructor had a marvelous non-linear way of describing all of the systems of the body in a way that made it obvious how seemingly unrelated systems are interdependent. We jumped from chapter to chapter of our textbook in a way that might have seemed random and arbitrary if it wasn't prescribed by a syllabus that related all the concepts to each other logically. The degree to which I've been successful in the nursing program so far is largely thanks to that class.

After that experience, the nursing program has been pretty anticlimactic. The clinical part has been amazing, and every faculty member I've seen in the clinical environment has been an amazing teacher. Lectures, unfortunately, are another story. Power-point slide-shows are not an effective way of imparting information. Period. There's evidence to back this up, I'm too lazy to link to it right now. The actual academics involved in this have been insultingly easy. There wasn't really anything that I -wanted- to record until the second year, and even then the times were few and far between (basically, any time the faculty started just talking without referring to powerpoint outlines or slides). The lectures only served as outlines for previously completed reading, but no one reads beforehand so I'm always stuck answering the questions that are asked in class (most of the time I didn't do the reading either, but since I was listening to them instead of taking notes I was able to remember what they said 30 seconds ago and put the information in context, while they were just recording it in the hopes it will make sense to them later). My classmates hate this. A lot.

I started off being well-liked by my classmates but loathed by my instructors, who saw me as detached and arrogant because I never took notes in their class. After explaining to a few of them that I never take notes, preferring to focus my attention on the lecturer instead, most of them warmed up to me, especially after taking over as President of the Student Nurses Association. Here's a protip for those of you just starting out. A good way to win over faculty is to get involved. Donate your time. Besides the pragmatic effects of currying favor, it's a good thing to do anyway. Get out there and network, meet people from the professional organizations and state councils. Even if you're not planning on sticking around in that area, it's a valuable experience. Just studying the material can only get you so far. If you really get involved in the profession, you'll increase your interest, which will make it easier to retain information. Trust me, it works. Spending a couple hours with your local state league for nursing or board of nursing educators is worth a dozen hours sitting in a room reading a book. Conversely, don't date one of your classmates if they're emotionally labile. Enough said.

The second half of nursing school saw a complete reversal of the social profile. I walked on water as far as the faculty were concerned, but my friends among my classmates were few and far between. Can't please everyone, I suppose. My classmates are an interesting bunch, probably a typical profile of nursing students at a community college. Only having been in one class I can't say for sure. They range in age from 18 to the 60s. Some have degrees in microbiology, psychology, sociology, there was even a fellow engineering refugee. Some had never had a full time job, some were on their 3rd or 4th career. Some have children. Some have grandchildren. The usual Nursing stereotypes were in effect, however. Only about 10% of us are male (maybe less now, but that's still double the average), probably that same percentage are non-white, and the average age is probably somewhere between 30 and 40.

As I started to find ways to incorporate skills I acquired in the past through bartending, engineering, selling, trombone, shamanism and dozens of other seemingly unrelated life experiences, I began to marvel at how nursing may be the one discipline that is the "universal recipient" of past experience (perhaps a "universal donor" as well?). One of my classmates who came to nursing from 20+ years in construction brought with her proficiency in organizing a team and delegating responsibility. Another classmate with a full careers worth of sales experience brought with her proficiency in customer service and expectation management. Students with BSs in Bio, Chem, Micro, even Psych come with a head-start on some of the concepts. The former LPNs and CNAs were able to take to clinicals like a duck to water, while the rest of us were trying to figure out how to change the sheets. Even a cashier with no post-secondary education can be a wiz at metrology (calculation of medication dosages). Sadly, many of these people were too hung up on taking on a new role to see that the role, to an extent, can meet them halfway.

My biggest sources of frustration in attempting to acclimate to this new culture are what seem to be severe deficits in information literacy and critical thinking skills in many of my peers and betters. I've taken for granted for many years now that the way most of us have been educated is a way of making sure we don't get TOO smart. See "Dumbing us Down - The Hidden Agenda of Compulsory Education"
for more information. We also have some tools at our disposal to make learning easier, but if even the faculty are deriding them as useless and not using them, how can we expect the students to? Even the limited degree to which it's been implemented represents a major hardship to most of the class (all that "reading" and "clicking"..gosh). I dislike the courseware we're given to use (criminally bad user interface design, buggy infrastructure, sloppy construction), but it's worse than useless if no one's using it. I find myself among a group of people to whom email, message forums and blogging are alien concepts. The limiting factors, I've found, are typing speed and reading speed. Hardly any of these people are readers, or if they do read they read things that aren't very challenging. Additionally, few of them can touch type, and hardly any of them are comfortable using computers.

This makes me slightly nervous for the future of the profession. Things are only going to continue to change more and more rapidly, and without information literacy, lots of people are going to be left in the dust, either as Nurse Technicians, or worse still, leaving the practice entirely. Without information literacy, home-brewed computer applications for keeping track of medication administration and charting can potentially cause more errors than they prevent. Worse of all, without information literacy, people tend to rely on "tribal knowledge" and word of mouth, since it's radically easier for them than keeping current with publications and journals.

This was a lesson that got drilled into me in clinicals..don't take anyone's word for anything. I asked my co-assigned nurse once what sucralfate was, since I had to administer it soon and the instructor was coming. I blindly accepted what she told me, and when I told my instructor that I was about to administer cough syrup instead of a GI-cytoprotective buffer...well, it was bad.

Some of my most memorable stories were stories of times when I made a mistake. Some are of things I've done exceptionally well, of course, but no one likes a braggart, so I tell the stories of mistakes I've made. Maybe that's why I remember them better. I think you learn more from a mistake than a success, anyway (that's held true for Go, at least). Another tip I'll confer to nursing newbies out there is this: wherever your clinical education is taking place, there's probably something similar to a "clinical occurrence", or being written up for getting something wrong you shouldn't have. Don't let this throw your game off. It's there to make you better. A good instructor will present it to you in the way it's meant to be intended, an opportunity to improve your skills with a targeted identification of something you need to brush up on. A poor instructor will use it as an opportunity to wreck your confidence and make you feel bad. My point is that you can't allow the quality of your instructor dictate your progress. No matter how it's presented to you, take a deep breath, remind yourself that you're still a student, and get it right next time.

So...one more semester. Those of us who've made it so far have given up a lot to be here. Some of us have lost spouses during our time here, one or two ended up in a psych facility, the stresses involved seem to have turned most of our lives upside down in one way or another. In the process I lost a fiance, my raison d'etre, the one thing I would have postponed all this for another year for the sake of. In the fallout from that I also lost all of my oldest and dearest friends (partially on purpose..sometimes something bad enough happens that anyone who thinks it's a good thing is no longer your friend, no matter how close). Pinning ceremony will be a bittersweet victory. Although I've reached one of my intermediate destinations, it will be in the absence of all of the people who've made the trip worthwhile this far.

From there, my course is unclear. I'm filling out applications to graduate schools (Accelerated RN to MSN programs), and where I go and what I do will largely depend on which school accepts me. A more arbitrary seed than planning to settle down and start a family, but not by much. I'd like to eventually do Travel Nursing, since I don't have any concrete obligations, I might as well. For now, I want to get into Emergency and ICU. Since I don't have any real prior healthcare experience to speak of, I'm trying to find tech jobs at the local hospitals before I graduate, hoping that the experience will translate into the critical care environment. I'd really be happy working anywhere, to tell you the truth. My goal of becoming a Family NP is mainly centered in the thinking that it will give me the broadest scope of options. You don't need to be a clinical nurse specialist to do research, you don't need to be a clinical educator to teach, and Family NPs can be found in critical care and sub-acute settings, treating the young and old alike. At the moment, at least, I want to do it all, and I won't accept a path that leaves me specialized or limited in some way.