When I went into nursing, my first instructor made a very all important statement. One I remember to this day. She said that nursing is all about flexibility. You never know where your career or life will take you. Medicine is certainly about flexibility because if you are inflexible or set in your ways, you will never survive in this very demanding field. Take my case for instance, you would think that with almost 20 years under my belt, that my career path would be secure and set. Well, you would be wrong. I am finding myself making some career-altering changes even now. If you stop and think about this for a moment, you will understand why. Your nursing career can span your entire adult life. What you were able to do when you started in the field you may find out that you no longer have the endurance to do any more. You may also find that you are getting burned out in one particular area. Many nurses as they progress in their careers go into management or even education. These are by no means your only choices. You can go into the field of litigation, where you are a technical consultant for a legal team. This choice is best for a nurse with critical care experience. You can work as a case manager, a home health nurse, a transport nurse, a dialysis nurse, a perfusionist or even work for an organ donor agency. Probably the most lucrative duty is as a private duty nurse for wealthy people. I almost fell into a job caring for the parents of one of the wealthiest casino owners in Las Vegas.
But I digress, this chapter is supposed to be about my early years, there is plenty of time to discuss my “golden years” of nursing in later chapters. As you already know, I started my nursing career in Florida. While I only worked there a short while, my time there was very eventful. Apparently my primary Charge Nurse thought fairly high of me. She made the statement to my wife who was the charge nurse on my off nights that I had not been challenged enough during my orientation time as not only a new hire but a new grad as well. Yes, I know you should not work on the same floor as your spouse. She, being one of my immediate supervisors was not able to work on the same nights as I did. So I always got to work with her opposite. Due to our schedule, we only got to have one night off together a week. Some people may say that this was a good thing. We were still a fairly new couple so it was not that great for us. But we managed to get through it and besides, this arrangement as it turned out only lasted four months.
It turns out that my nurse “Ratched” had the same name as my first wife, Tammy. While she was not a cruel person, she rode me like the witch in the Wizard of Oz rode her bike. I always got the hardest assignment and I was the first to get floated even though I was a new nurse. I guess, because I never let myself get stressed out. She thought this meant I wasn’t working hard enough. It wasn’t all bad because the unit I was working on was full of very experienced and friendly nurses who were always available with a helping hand. So, needless to say, I was very busy. Our charting was a combination of paper and computer charting. The only part that was on the computer were the medications, labs, test results and order entries . The actual charting for the doctors and nurses was all handwritten. You may think that this hybrid system was inefficient, and you would be right. Each nurse was responsible for checking the paper charting to make sure that all of the orders written by the doctor were entered in the computer correctly for their 12 hours. The charge nurse was responsible for checking that the orders were correct for the whole 24 hours of that day. You may ask who was actually doing the work of entering this critical information into the computer, well, that would be the least trained individual on the team, the ward secretary. Makes sense, right? That is why we had to spend so much time checking their work. Life is a lot easier now because in most hospitals, the doctors put their own orders in the computer. I say most, because nurses still have to enter telephone orders in as well as any verbal orders given by sneaky doctors who are either too lazy or too busy to do so themselves.
Just prior to my getting hired to this hospital, they had installed what is referred to as a medicine dispensing system. There are two options… the original one is the Meditech system which just so happened to be the one we used at this hospital and the the other major brand was the Pixus System. Neither one was better than the other. They both had their strengths and weaknesses. Prior to this, each floor had a narcotic box or cart that the nurses took narcotic medications out of for dispensing. At the end of each shift, a count was done by two nurses. If the count was wrong nobody left to go home until the error was corrected. Thank God I dodged that bullet, knowing my luck, there would always be a shortage when I worked.
The reason that I seemed to function well is that I am by nature a highly organized and systematic individual. I did my assessments, charted and passed meds all at the same time. The certified nursing assistants (CNA) provided for the patients personal needs like bathroom breaks and clean ups. We only had to help when the assistant became overwhelmed. The CNA is one reason why I worked in the medical/telemetry floors for so many years. You don’t have CNAs in critical care, so you have to provide all the care that the patient needs. Our charting was by exception with flow sheets, so it was extremely quick. We only had to provide a patient note for anything out of the ordinary. In the medical floors this usually only involved one organ system, so even that was pretty quick.
One thing that I noticed in Florida was that the doctors in this state were very organized. Many had standing orders that covered all of the patients’ needs, so you did not have to call them for very many additional orders. Some of the surgeon’s standing orders were several pages long. This was a great thing since I always work nights and it is quite onerous waking up doctors at night for things like Tylenol or a sleeping pill. However, there were that occasional doctor who liked to practice medicine through the phone. This would happen for new admits that came in after the doctor went home. So he would quiz the hell out of you and give you a bunch of orders that would cover their care until the morning. It was a pain in the keister, but I guess it was understandable and besides in the surgical units, the admitting doctor has 12 hours to see his newly admitted patient while in the ICU they only have four hours. Which is why nurse practitioners and physician assistants are in vogue now.
We had telemetry monitors right on the floor so we could frequently check the cardiac condition of our patients. However, it was the responsibility of specialty trained individuals in telemetry monitoring that kept a much closer eye on all the patient’s heart rhythms. As part of our tasks, we had to write three notes for telemetry discussing the patients cardiac condition. However, not all of our patients required such close cardiac monitoring. Medication passes are usually ordered every 4 hours or in some cases as needed, like for pain management and nausea. So, as you can see even at night we were kept quite busy. So, this is where I digress a little to discuss the unfair treatment nursing gets from the entertainment industry. First of all, we run the hospital and doctors would be totally lost without us being present to do all of the close monitoring that the patient requires. Doctors only spend a few minutes with each patient when they round each day. They only get a very brief snapshot of their condition. So they rely quite heavily on us. Besides who is going to provide the vast majority of the treatments that they prescribe for their patients? While it is true, the doctor has more specialized training, we are also highly trained and hard working individuals. We do not put mattresses and sleeping bags in the nursing station to take breaks during slow times. Most hospitals require a minimum of rounding every 2 hours and critical care requires rounding every hour at the bare minimum. We are also not busy in the closets playing grab ass with the doctors and surgeons.
Every hospital has different routines and schedules based on their clientele and the severity of the cases that they treat. In the four hospitals that I have worked in, there has been a marked variation in the systems used and even the software utilized for charting and ordering. This is one of the reasons that nurses have to be flexible. However, as the nurse ages this level of flexibility becomes less attainable. By nature, we become more set in our ways as we age. So ergo, many nurses chose some of the alternatives enumerated earlier in this chapter.
I am sure by now you realize that I don’t pull any punches, I say it is like it is. Insurance companies including Medicare and Medicaid have way too much say in the running of hospitals along with that tyrannical commission known as The Joint Commission on Accreditation of Healthcare Organizations, or JCAHO. It seems that Medicare and Medicaid take a great deal of enjoyment in finding reasons on not to pay the hospitals for the services they provide. It is bad enough that insurance companies can take an entire year to pay the doctors and hospitals. They also pay less than the rates charged by the hospital. Let us be honest, I think hospitals charge excessively so that they can write off the differences as a loss to reduce their taxes at the end of the year. I may be wrong but I think that this is the case. JCAHO also seems to take the greatest deal of delight in finding the most miniscule of infractions just to justify their existence. Unfortunately, we have to take them very seriously because without their accreditation, we receive no Federal assistance or compensation. I guess, they are trying to bankrupt the hospitals? I just don’t understand. I have noticed that the largest and therefore most essential hospitals get more lenient treatment than do smaller and therefore less essential facilities. This is an unfair practice but who am I to say that this is happening for sure. It just appears to be so to me.
Before I wrap up this chapter, I want to discuss a few more niceties about this hospital, things that I have not seen since. Unfortunately, our hospital had quite a few employee injuries related to moving and lifting patients, so they developed a zero lift policy, and as a result purchased quite a bit of equipment to assist the nurses. We also had two flex PCTs which assisted the nurses in transport of patients at night for emergency testing, code greys, CPR and any other activities that required some additional brawn. We also had, considering the small size of the hospital, a 24-hour snack shop that made sandwiches and grilled hamburgers and such at night. We had a wound care book with photos in it that the nurses used to write their own wound care orders for. All the doctors had signed off on this so, it made us feel like we were really doing something special. Now, nursing has been replaced by physical therapy for the vast majority of wound care and in many hospitals, the department is overseen by specially trained stoma and wound care nurse practitioners. All non critical care telemetry registered nurses were required to take a three-week telemetry course where we had advanced training in medication administration and care of patients. After we took the class and passed a test, we received a $2.50 raise. Our hospital also required all telemetry nurses to be ACLS certified. In most hospitals, it is only the charge nurses and critical care and Emergency Room nurses that are required to be ACLS certified. I have also never seen a hospital offer so much additional training and certifications. They offered additional pay for CNAs that had additional skills as well. I guess I took all this for granted, boy, was I shocked when I transferred to my next hospital.