I wondered what the job market would be like for my new colleagues, so I started looking at the openings for registered nurses on the west coast.

Three metropolitan areas: Seattle, Portland and San Francisco.

There are a lot of nurses needed!

Emergency, labor and delivery, peri-operative, med-surg, critical care, case management, hospice, home health…there is no shortage of available jobs!

There is, however, a definite shortage of of nursing leaders who are willing to step up and invest in the next generation of nursing.

I’m not talking about nurse educators or clinical nurses on the front lines who are willing to precept students, although granted, we need more of them.

I’m talking about nurse leaders in the field. Nursing managers. The ones who have the hiring power. The ones who can choose to hire newly licensed Registered Nurses.

Where are you?

And why aren’t you hiring newly graduated registered nurses?

When I heard new graduates talk about how hard it was to find a job, I thought it was because there were no open positions in acute care hospitals. That they were precious, and few and far between.

Hardly.

My searches would bring up 10 or more open positions in hospital after hospital, but here was the clincher: experience required. Experience preferred. One, two, three years.

And so the position sits open, when newly licensed RNs are praying for work.

Everyone can’t pass off the development of our next generation of colleagues to “someone else”. Everyone can’t just figure all these new nurses will go and get their experience “somewhere else”.

Nurse managers are supposed to be nurse leaders. Doesn’t it make sense to lead the future of the profession and invest in the future of your department by hiring and developing new graduate nurses?

What does it say about our profession that our newest colleagues are hurting for work while positions sit open because no one is willing to hire them?

It isn’t flattering.

And it can be rectified.

Sixteen semester units, a full-time job as an RN on a med-surg floor, three kids under ten, and planning to take another 16 units next semester.

It wasn’t unusual to see this description among my classmates in my online BSN course.

With so many obligations, I wondered why so many saddled themselves with so much classwork. It wasn’t required. There was no time frame in which we had to complete the program.

When I made inquires, the usual response was, “I just want to be done with it!”

And I thought how different my mindset was than that of many of my classmates. My children were grown, I worked part-time.

And truth be told, I was actually savoring the process.

Sure, I wanted the degree as badly as everyone else, but tuition and class schedules made it so that I had to take one or two classes at a time.  And truth be told, I’m somewhat of a nerd. I enjoyed studying.

Taking it at a slower pace allowed me to immerse myself in the material, to actually learn and incorporate what the professor and my fellow students had to offer, as opposed to quickly skimming material and cramming for exams so I could move onto the next assignment.

My classes became an enjoyable addition to my career instead of a cumbersome addition to my day, another obligation to be checked off a “to do” list.

How do you approach studying?

If I had to give one piece of advice to a prospective BSN or MSN student, it would be to take your time with your program.  The urge is strong to do as much as you can as fast as you can, but something is lost when you are pressured to produce.

If you have the ability to pace yourself through your program, be sure you give yourself time to actually enjoy the process.

You get so much more out of your education when you do.

It’s a huge factor in nursing care and the emergency department is no exception.

Standardized discharge instructions are usually enough for the most common diagnoses, but when a patient has a diagnosis that isn’t covered, or needs more information than what the standardized instructions furnish, what can you provide?

In these instances, I turn to two specific sites on the internet for information.

1. National Institutes of Health: Health Information

The National Institutes of Health (NIH): Health Information website offers a portal to a virtually limitless source of health information geared to the consumer/patient.

Search alphabetically, by health category or by typing in a specific topic.  This brings up a list of links from the different Institutes concerned with that topic. For example, “Anemia” has links listed under four different Institutes, covering the basics of “What is Anemia?” and “Anemia in Kidney Disease and Dialysis”, among other topics.

Each topic can be printed with a simple click.

It is so easy to use this resource, I am able to find what I need for patients in the middle of a busy emergency department.

2. Centers for Disease and Control: Diseases & Conditions

The Centers for Disease and Control: Diseases & Conditions website is similar to the NIH site in that it has a wealth of information geared to the consumer/patient.

Then it gets a little more complicated. Instead of a page of basic links, you will find a colorful page of sub-topic options. On some topics, such as diabetes, heading for the need-to-know information for patients is front-and-center, but takes a few more clicks to actually reach the information. Other topics require a scan of the page to find the link for basic patient centered information.

Once you find it – it’s well written, easily understood, and easy to print out.

I will say that for a patient doing their own research, the CDC site is a more colorful site, and possibly offers more in-depth information over all.

*******

Whether you need the information quickly, or have the time to look over the resources, both the NIH and the CDC are fantastic resources for patient education. In the ER I print out information, but I also pass along the web addresses, to ensure my patients have access to solid health information.

If you use either resource, let me know what you think!

You did it!

Classes, caffeine-riddled nights of cramming for exams, and clinical rotations are a thing of the past.

That BSN is firmly in your grasp.

As you stand on the threshold of your nursing career, the NCLEX before you, pondering the job situation for nursing graduates, the last thing on your mind is more education.

But right now is exactly when you should think about that very thing.

Long-term goals for a nursing career should include options for an advanced degree.

Thinking about it now, when you are just starting out, gives you a couple of advantages.

First, it gives you time to really check out different programs while you are gaining that most important asset: experience. When it’s time to come back into the classroom, that experience will be invaluable.

From here on, when you take a nursing class, the material will have meaning because you can decide whether or not to apply it to your own practice, and you will be contributing your own nursing perspective to the conversation – something no one else can provide. You’ll find yourself learning from, and contributing to, your fellow colleagues, with professors acting as facilitators of learning as opposed to “teachers.”

Second, by keeping the idea of an advanced degree as part of your career goal, you will naturally begin to work toward that goal. While it is never too late to obtain the degree, I would advise not waiting decades into your career.  An advanced degree gives you options and mobility. Healthcare is changing; it is moving away from the classic hospital bedside and nursing roles will be changing dramatically in the next few years. An advanced degree will keep you ready for whatever changes healthcare reform requires of our profession.

Graduation is really just the beginning of a career of continuous education. Stay ahead of the curve and make an advanced degree part of your career plan.

Welcome to the profession!

Audiologists and physical therapists will soon be joining advanced practice nurses, according to the recent U.S. News.com article, Doctoral Degrees Gain Steam in Healthcare Industry.

In the debate for the nursing doctorate, nurses are told other professions are requiring a doctoral education, often as the entry level of practice.

But is it as controversial for other professions as it is for nursing?

Yes, and for the same reasons it is controversial in nursing.

Looking at a page from TherapyJobs.com, Physical Therapist Share Their Thoughts on the DPT  we find:

• Physical therapists bemoan the lack of increased compensation for the advanced degree; nurses often find themselves earning little more than they did pre-doctorate unless they enter a high-earning specialty.

• Nurses debate that experience matters more than an advanced academic degree, physical therapists find that patients respect experience and outcome more than the therapist’s degree.

• Therapists are split on whether or not the term “Doctor” should be used. Nurses (and doctors!) have heated debates on this topic.

• Nurses often say there is no incentive to go back to school and it’s much too expensive to consider. Physical therapists have the same issues.

A quick Google search on “audiologist doctorate controversy” yields similar results.

I always had the impression that nursing needed to rush to advanced degrees to keep up with other professions. My take-away from the debate was that they were light-years ahead of us and that if nursing didn’t make haste to push ahead we’d be left in the dust, so-to-speak.

Well, the other professions, at least physical therapy and audiology, are exactly where we are, having the exact same debate.

A debate that didn’t begin yesterday for those professions, either.

You can see the nursing debate raging in the comment section of the U.S. News article linked above.

Personally, I see the reasons for an advanced degree. I want one. I am encouraging my daughter to get one.

It has nothing to do with money or outside respect; I’m want it because I want the knowledge that comes with it; I want it for my own professionalism.  It’s a personal decision, something deep inside me that is driving me to do it.

While I can understand wanting a doctoral degree to be the standard for advanced practice, I might have more confidence in that decision if we, as a profession, were able to at least come to a consensus on an entry-level degree.

That’s taken over 60 years.

I wonder if some blogger will be writing about this issue 60 years from now.

I just read a perfect example of what is wrong with my profession.

Nursing suffers from “not in my backyard syndrome”, or “NIMBYS.”

NIMBYS is manifested by the verbal agreement of the need for a single entry level into practice, namely a BSN,  while simultaneously blocking attempts to facilitate that transition when it affects your “backyard.”

Check this out.

In Michigan, there is a move to allow community colleges the ability to offer bachelor’s degrees in nursing. A bill has been passed by the House, hearings have been held in the senate, and it and is being considered by the Education Committee.

According to this article, Bill in works to let Michigan’s community colleges offer 4-year degrees in nursing, other fields,  it is difficult for students to obtain their BSN in Michigan.

Either the universities don’t have enough space for all the qualified applicants, or they have stopped accepting transfer students, or students do not have access to the universities because they live rurally.

Making it even more difficult, facilities are starting to accept only BSN students for clinicals.

And, of course, it’s cheaper to attend a community college than it is a state university, so that would be a huge benefit.

Allowing community colleges to run a four year nursing program and grant BSNs would go a long way toward helping alleviate those issues.

Guess who is fighting it?

Yep, the state’s 15 public universities, who are afraid letting the community colleges offer the 4 year degree will siphon off their resources. Oh, excuse me, that would be “draining dollars from the state.”

One university president “has concerns about the resources community colleges have to support nursing programs and to pass stringent accreditation standards.” Well, if they don’t have the resources, then they don’t pass those stringent accreditation standards and they don’t get accredited.

Right?

Am I missing something here?

And one of the quotes is from a senior nursing student who says that her university’s nursing program, “… is based on a sound foundation of liberal arts, which supports lifelong learning, as well as the importance of scholarly endeavors for extending the existing body of nursing knowledge…”

How can anyone say that a bachelor’s degree program at a community college won’t be based on that very foundation?

She then goes on to insinuate the community colleges are doing it for the money.

*****

You have those willing to try a plan that would help ease the nursing shortage, facilitate the earning of BSNs in the state and help students become RNs without going into massive debt.

Then you have those who are afraid it will take what they have and so before it even is fully approved they cast aspersions on the integrity of the program and the motivation of those who would dare to suggest it.

My friends, I give you: nursing in a nutshell.

Read the article. Is it just me? Am I reading too much into it?

Possibly.

But maybe, just maybe, this is why we are still discussing the BSN as the entry level after 60 years.

Oh, if you are extremely lucky, and the ER has a Fast Track, and they aren’t very busy, and your problem truly isn’t serious, you might be in-and-out quickly.  But the reality is, there is going to be some sort of waiting involved.

I recently wrote a blog post on how to de-stress your ER visit, including a tip on bringing something to do while you waited. This brought out a few comments, such as:

 “If you had a real emergency, you wouldn’t have to wait!” and

 “If you are waiting for a long time, you probably don’t need an ER!”

 While I can see the point behind my colleagues’ comments, they are a bit disingenuous.  You see, while a “real” emergency or urgent problem may get you into a room and seen by a physician on arrival, what happens after that isn’t always immediate.

 You need labs drawn?  Those are drawn quickly, but you wait for the results.  Depending on the test, and how busy the lab is, you can be waiting for a while.

 Need an x-ray?  Patients there before you are also getting x rays.  Unless you are critical and need it STAT, you are taken in order.  That means you wait.

Are you going to be seen by a specialist? You wait for that doctor to arrive.

Are you going to be discharged, but getting an IV antibiotic first? Some antibiotics take 90 minutes (or more) to infuse. You’ll be waiting while that happens.

Are you being admitted? You could be waiting for hours in the ER before going up to your room, with no access to a phone (unless you have your cell phone and are allowed to use it) or television to keep you occupied. 

Saying that “real” emergencies don’t wait in the ER is not true. Everybody is always waiting for something.

 So I stand by my “tip” for emergency department visits of all types, for both patients and their friends and family.  When you go to the emergency department, unless you are whisked off by ambulance in a true life-threatened state, take something with you to occupy your time while you wait.

You’ll need it.

We communicate continually with patients, nursing colleagues, other healthcare providers.

We communicate verbally, through body language, on paper, by computer, or through text messages and email.

Of all nursing communications, those with physicians can be the most important, and the most problematic, because physicians are often off-site, depending on our communication to tell them exactly what is happening.

Here are five tips to help ensure your nurse-to-physician communication is clear, concise, and  gets your point across so your patient gets what they need.

1. Know what you want to accomplish.

Make a list of what you want to talk about before you make the call to the physician. If there are multiple issues, prioritize them. The physician may be taking call and not know the patient, so know what you want to accomplish with the communication.  Are you reporting a change in a patient’s condition? Do you need an order? A change in medication?

2. Collect your data

Have everything at hand before you call. Get a recent set of vital signs, including intake/output. Have the chart, including lab results and the medication record in front of you. You will need to know a brief history of the patient, and you will need to anticipate questions, especially if speaking to an on-call physician. Be ready.

3. Be clear and concise

By now we’ve all know about the SBAR style of communication: Situation-Background-Assessment-Recommendation.  Let me tell you, this is a godsend for communicating in healthcare.

Basically, it’s (a) here’s what’s we have, (b) here’s how it started, (c) here’s what I believe is happening and (d) here’s what I’d like (or like you) to do about it.

Short. To the point. Direct. Let’s roll. You have no choice but to be direct and concise using this method.

4.  Stay focused.

Sometimes physicians are not receptive to receiving a call. They may be preoccupied. It may be the middle of the night and you waking them up from a sound sleep. You may have interrupted a sports broadcast, their dinner, or they just aren’t happy to be called about “work” right at that moment. They might get angry. They might yell, or bring out the sarcasm so thick it can be sliced.

Tough. Don’t get caught up in their tone or behavior, or respond to it. This is why you make a list of what you need to discuss, so you are not flustered. Do not apologize for calling or “interrupting” or act in any way subservient. You are not doing anything wrong. Speak clearly and state what you need using SBAR. Repeat any orders back to the physician. If they hang up on you before you can do that, document this on clearly on the chart.

(Lest anyone think I am being overly dramatic in my examples,  I have been personally yelled at for interrupting football games and dinner. I have been hung up on before I’ve been able to repeat verbal orders. After waiting until 7 am to call a surgeon, he screamed at me for waking him at 7 am. This is a reality for nurses.)

5. Document everything.

This step is obvious, and is for your protection and for the physician’s, also. Document the time, what was communicated, what was ordered and what was done. 

One last note – if something significant occurs on the night shift that does not require a call to the physician, but you feel should be communicated to the physician, consider calling them before you leave and speaking to them directly. Your insight and direct observations are things that can get lost in the translation in reports or in notes left on charts. By directly communicating, you can ensure the physician knows exactly what you saw, and the plan behind your nursing interventions.

In summation, communicating with doctors can be easier and more productive if you know what you want to say, are organized before you begin the conversation, communicate clearly and concisely, stay focused on the goal of the communication, and document clearly all aspects of the communication.

I will open a folder and double check that I have at least 30 continuing education hours. I will then write a check to the California Board of Registered Nursing, thereby renewing my license for two years.

And I won’t give another thought to the CA BRN.

Should I be thinking about them?

I’m embarrassed to admit it, but until recently, when I became aware of the Amanda Trujillo case in Arizona, I actually knew very little about what my state Board of Nursing actually did.  The one thing I did know? They didn’t exist for my benefit, they were there for the protection of the public.

I decided to find some information on the National Council of State Boards of Nursing website.

Boards of nursing: (a) approve nursing programs and enforce licensing and the nurse practice act, (b) develop standards of practice, policies, and administrative rules and regulations, and (c) take action against the license of any nurse demonstrating unsafe practice. (National Council of State Boards of Nursing [NCSBN], 2012)

Turns out my one piece of BON knowledge was correct. Boards of nursing (BONs) were created over a century ago to “ to protect the public from the unsafe, incompetent or unethical practice of nursing.” (NCSBN, 2011) They ensure those who carry a nursing license have met at least the minimum qualifications set for a beginning practitioner, and they specify who can legally use the term “registered nurse.” BONs  give “clear legal authorization for the scope of practice for the profession.” (NCSBN, 2011)

Where do the boards get their power? From the Nurse Practice Acts of the individual states. Nurse Practice Acts  define what a state’s BON will look like. Nurse Practice Acts can also be pretty vague. The BONs write rules and regulations “to clarify or make statutes more specific.” (NCSBN, 2011)

The BONs also disciplines nurses for actions that place the public in danger. Actions that fall under the general categories of unprofessional conduct, incompetent practice, unethical practice, and criminal convictions (NCSBN, 2011) can be met with anything from reprimand to revocation of the license.

So, while we may not consciously be thinking about our state boards of nursing, their existence informs everything we do as registered nurses.

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The National Council of State Boards of Nursing (2012). Boards of Nursing and you. Retrieved from https://www.ncsbn.org/2730.htm

National Council of State Boards of Nursing. (2011). What you need to know about nursing licensure and boards of nursing [Brochure].

Easy to do in the dead of winter, but not always so easy to do when interacting in the world of social media.

Like interactions in real life, social media interactions are spontaneous and off-the-cuff.  And, like in-person interactions, they can also be contentious.

Social media interactions differ, however,  in that they are on display, in writing, and permanent. Yes, blog posts can be altered, tweets removed and facebook posts limited to “Friends”; but screen shots can be taken, pages and texts can be saved.

Basically, if you say it online or send it in a text, you have to assume that you have (a) said it forever and (b) said it to the world.

In our private lives, this may not seem like such a big issue, but what about engaging in social media surrounding professional issues?

Nurses are a passionate group when it comes to discussing, defending and promoting the profession, and that doesn’t change when the venue is social media. Here are ways to keep your cool when topics are controversial, opinions are flying and the heat is intensifying:

1. Put Your Name On It

You are less likely to say anything you will regret later if your name is attached. For some, anonymity is a necessity, but putting your name on the line adds credibility.

2. The 5 Minute Rule

Incensed by what you’ve read and ready to let ‘em have it? Fine, pen that missive! Then walk away for five minutes. Come back. If you are comfortable after re-reading with fresh eyes, hit the send button.

3. Remember…

Do not forget that there is another person at the end of that tweet, post or comment. Tone of voice, nuances of facial expression and other modes of communication are not present in the written word, and things are easily taken out of context. Rule of thumb: if you wouldn’t say it in person, don’t say it in writing.

What if you are on the receiving end of a heated social media exchange?

1. Take a breath.

Although it can feel like you’ve been hit in the chest, take a step back. Don’t respond immediately. The advantage of a written exchange is you have the chance to focus on a response. A second or third read may reveal content missed on the first run through, and waiting ensures emotions don’t get in the way of a calm, reasoned response.

2. Look At the Other Side

Look at the issue from the view of the other person. Maybe it isn’t personal at all, but simply a passionate response to a sensitive issue. Or perhaps it is an inadvertently insensitive response that happens to make some good points along the way.  Those could be worth engaging in a dialog.

If it the communication is just plain nasty, with no goal but to insult you and your mother’s ancestors, your best bet is to ignore it.

3. Don’t Argue

Don’t argue with someone who is angry. Acknowledge the opinions of the opposition and make your own observations if you feel you need to, but don’t waste your energy in getting into an argument vs. a dialog.

Staying cool while navigating through social media waters can be done. Own what you say, don’t hit “send” in the heat of the moment, and never forget you are dealing with human beings at the other end of the wifi. Don’t respond to attacks impulsively, try and look at the other side and remember that it’s useless to argue with someone who is angry.

Even heated discussions via social media can be productive, with simple rules and mutual respect.