The People Fade, but the Stories Do Not.

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In 1957 my grandmother received her nursing pin as a graduate of a diploma nursing program, in the era before the emergence of formal nursing education. Nine years ago my grandfather gave me that pin when I graduated with my BSN and now the pin sits in a pretty box in my room like a treasure, something full of lost memories. It’s grown tarnished over the past sixty years, fading to a dusky golden color that has lost it’s original sparkle, but every time I look at it, it grows in value. That pin has become a symbol to me of many truths- that my actions are bigger than me, that legacies really are something to strive for, even in our culture that seems to think that nothing lasts, and that this profession will never die. The pin has meaning to me now because I ended up with the same job title and because I know how hard she had to work for it. How much she had to sacrifice to be a nurse. How I benefitted from her perseverance.

Although I don’t know a whole lot about my grandmother’s story, I know that she worked on the weekends while my grandfather watched my mother and her sister. I know she wore white shoes and a white hat to accompany her white uniform. I know that she worked at a psychiatric facility, probably straight out of One Flew Over the Cuckoo’s Nest. I know that she was a kind, caring person who loved her family and I can only assume loved her patients in the same way. She passed away when I was in middle school and I wish so badly that I could hear her stories, that we could go out to dinner and that she could tell me the honest truth about what it was like back then. The good, the bad and the ugly. I think I’ve been in the trenches in the trauma ICU but I’m sure she could beat me by a long shot. Working in a psych facility in the 50’s automatically trumps any crazy stories I could tell.

What’s the point of this? Yes, my grandmother was an amazing woman and she should be honored as the first nurse in my family and a contributor to my own career path. But I’m getting at something else. We all have nurses who stand out in our mind, those who have worked extremely hard to love people day in and day out, those people who have impacted you in a significant way. Some of those people are memorable because they’re valiant soldiers who braved bedside dangers and trials, maybe even on your behalf. Others remain lodged in our memory because they were crooks and narcissistic thieves, people who spread shame like a contagious disease across the great name of nursing. Most of us have interactions with a plethora of people but there will always be those who left a mark. Here are a few of the memorable nurses in my life, for both good and bad reasons, and I’d love to hear your thoughts on the nurses who have impacted you.

  1. My very first preceptor as a new graduate in the ICU– I spent the better part of the five months wondering whether she actually hated me or not. She was a fireball, always looking over my shoulder to correct me, always pushing me farther than I thought I could go. I had more than one day where I disappeared into the supply room to cry. She made me take patients that I thought were out of my league, assigned us to double isolation to learn clustering my care, and gave out smiles like rare jewels, reserved only for special occasions. I couldn’t wait to graduate and be free from her. It wasn’t until I started precepting new nurses myself that I realized how great of a preceptor she had been, for stretching me while I was still young and under her care, for actually caring how I turned out as a nurse.
  2. Night shift nurse who scared the crap out of me as a new grad– On one of my first nights on my own after graduating from my ICU nurse residency program, I was assigned to a patient. My patient happened to be positioned next to the patient of a scary-looking night shift RN. She was unknown to me, with bags underneath her eyes and ratty, nasty hair. Her eye liner drooped haphazardly down her face. She told me weird stories about her daughter as I tried to escape her and do my work. And then she told me that nobody actually gives the insulin prescribed on the sliding scale protocol. What good does 2 units actually do anyone? she argued. I politely disagreed and spent the rest of the night avoiding her, terrified of what else was going to come out of her mouth. She got arrested and fired for being high at work only a few weeks later.
  3. My mother’s friend who let me shadow her in high school– As a junior in high school I was fairly certain that I wanted to work in the ED or ICU as a nurse so one of my mother’s friends let me shadow her for a night in the ED at a major hospital. I borrowed a pair of scrubs and fastened all the bravery I could muster as I walked in to the hospital with her that night, having no real idea what I was walking into. I pretty much failed at being helpful, even at taking a temperature, and I almost passed out when we received a trauma patient who had been thrown from a horse. But I walked out after that experience feeling like I had found my true calling, a job that was hard-core and exciting and would push the limits of what I thought I was capable of at that time. I followed that dream and have always been thankful that this nurse took the time to show a high school student what nursing could look like.
  4. The nurse that made me almost have a heart attack– one night when I was a new grad, another nurse told me that I was getting a level one trauma hit in my empty bed. I had never taken a level one on my own and I was literally speechless. He told me to get the rapid infuser and a few other pieces of equipment and I spent the next ten minutes racing around the unit, trying to keep from peeing in my pants. After those ten minutes he couldn’t stand it any longer; he told me it was a joke. I didn’t understand and at first I thought he hated me for playing such a cruel trick. But then I realized that it actually meant that people liked me on the unit, otherwise they wouldn’t have teased me like that.
  5. My many friends on the unit– Seeing death every day bonds people together, and I think this is seen acutely with nurses. I cannot tell you how many of my friends, three specifically, treated me more like a sister than a coworker. We helped each other when one of us was getting overwhelmed. We cried when we lost a patient.  We took snack breaks together. We vented about whoever was on our nerves that day. We switched shifts when someone needed it. We sacrificed ourselves for each other, not out of duty, but out of love. And those memories never disappear.

This is nothing to say of the many physicians, chaplains, managers, patient care assistants, and others who will live on forever in my mind. A few physicians that I would like to never see again (and a few that I loved!), a chaplain who I still miss seeing her shining face, a manager who truly always had my back. I remember the stories because of the people in them. I wonder if I am burned into anyone’s memory, if I live on in their story.

I have no idea whether anyone in my family after me will go into the medical profession. My two year old daughter has a Doc McStuffins bag and carries it around giving “check ups” so I’m hopeful for her. But regardless of whether I hand her my nursing pin one day or not, I hope that she will know that her mother loved her and loved other people and was brave and kind and smart and often made mistakes but always asked for forgiveness. I hope my coworkers remember me in the same ways but in the vein of honesty, maybe I’m even tattooed in someone’s brain for something negative, although I hope not. Nobody is perfect. Legacy is inherently built inside of a family, including a hospital one, and I believe there is value in pursuing a memory that leaves a mark.

A woman wearing white shoes passing out pills to psych patients probably never though she would end up being the subject of a blog post one day. I would venture to say the same thing about us. We simply cannot understand the ramifications of our actions and how they may alter the future. Life is ironic like that. We remember faces long after we forget the names.

We remember the stories, long after the people have faded.

 

 

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The What, Why, and How of RN to FNP

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When I talk to people outside the medical profession, I often get asked, “so why are you becoming a nurse practitioner? Isn’t that a lot of school to essentially do the same thing you’re doing now?” I smile. I explain. I do my best to educate. But I still wince at that question because many, many people do not understand the difference between a nurse and a nurse practitioner. The tide is slowly moving in the right direction as nurse practitioners become more prevalent but there is still a huge knowledge gap in the public.

With my friends within the healthcare world, the questions are quite different. “Why did you decide to do FNP?” or “How much time do you really need to commit to school?” or “How in the world are you doing that school along with everything else in your life?” All valid questions based on real concerns. Deciding to become a nurse practitioner is a big career move requiring time, support, money and a huge portion of your sanity. This is part of my story along that journey.

Ever since I graduated from nursing school in 2009 I knew that I wanted to eventually get my master’s and become a nurse practitioner, even before I really knew what that entailed.  To be honest, I didn’t have a whole lot of backing behind that desire other than I had always been a “school person” and wanted to say I had a master’s degree. At that time I was nearly as ignorant as most people on the street about the qualifications, the education, the job description. I think I even revealed my professional plans in my “welcome to the unit” profile at my first job (so naive, not the smartest move). I just though it sounded cool and made me look like I had ambitions.

The WHAT: After a few years in the ICU I started to get a handle on where I could go with my career. I could stay in my unit and pursue a management position. I could go to CRNA school and live in the OR. I could stay where I was at as a RN. I could become a nurse practitioner. And a few more options that I never seriously considered.

After ruling out all the other possibilities for one reason or another, I decided on nurse practitioner only to discover that, like nursing, the NP job description varies intensely from position to position and environment to environment. I could become an acute care NP and work nights in the ICU responsible for thirty very sick patients. I could move to a specified clinic like nephrology or neurology and work solely with those patients. I could transition to outpatient and pursue a career in something completely foreign like family practice. And that’s ironically what I chose.

The WHY: Why did I choose family nurse practitioner over the other varieties? The standard reasons are obvious: no holidays, more money, less time on my feet, more responsibility. I wanted a weekday schedule with no weekends and holidays. I have a young family and it’s difficult for me to spend twelve-hour shifts away from my baby plus I’m tired of fearing that I’ll have to work on Christmas. I was also weary working in a job that required so much physical exertion. Turning large male patients, standing on your feet for hours on end, and sometimes not being able to take a lunch break until 3pm are all taxing on your body. I know I just turned thirty, but I could see the future and it was full of back problems and tired feet. I didn’t want all that exertion for the rest of my professional career.

The most professionally motivating reason for my career change was that I wanted more responsibility for patient care. I had finally gotten to the point where I wanted to write the orders instead of take them and felt that I had enough experience to take that step. I had always been afraid of such great responsibility (and rightly so) but I had gained enough self-confidence to know that I could learn and practice and become a proficient, caring provider. And while it’s the least romantic of my motivations, a better salary was definitely on the list. Getting paid more money for less physical labor is always a good thing.

But the question of why I chose FNP over ACNP (acute care nurse practitioner) also puts me in a honest place because I’ll have to give you an honest answer. The most compelling reason, the one that comes from a deep place in my heart, is that I was tired of seeing the worse case scenario day after day. I was heartbroken from seeing family members weep and watching people kiss their loved ones goodbye. As much as I loved the intensity of the ICU setting- the adrenaline of codes and the significance of standing in the gap during those crucial moments- I wanted something different. I wanted to work normal hours and to treat happy kids sometimes and to forget that those terrible, horrible things happen everyday. To those of you who are in that setting as ACNP, I respect you more than you can know. You’re dealing with vast responsibilities and dying patients and desperate families. You’re in a different spot than me and it’s a good thing we’ve both found our individual callings.

The HOW: So I applied for a FNP program at a local university, got accepted, and signed up for my first class. However, it didn’t quite work out like I had planned and I will tell you a slightly embarrassing secret about my journey through NP school. I took one class and quit in 2013. I had thrown myself into my nursing graduate research class for that entire semester only to discover upon completion of the class that I did not have the stamina for the program. There were many reasons behind my decision to not resume school, mostly to do with my tenuous health at the time, but I felt embarrassed. I had touted this new career ambition to almost everyone and then found myself backtracking, having to admit that it was too much for me right now.

When I think about that decision now, I see clearly that it was the right call. I wasn’t ready to take on life as a FNP. Two years later in 2015 I started school again and now here I am only two classes away from graduation. During that interim time period I took a new position in the ICU and gained valuable experience that I wouldn’t have had otherwise. So for those of you who find yourself in the same boat, don’t give in to the voices of guilt or shame or insufficiency. Maybe it’s just not the right time for you and there’s nothing wrong with that. Maybe it’s not the right career move for you at all and that’s ok too.

I’m not going to discuss choosing the right NP program because that is a whole other blog post in and of itself. There are a plethora of programs and they each have varied requirements, advantages, and disadvantages. Since I have a daughter, I chose a program that had all the didactic course work online followed by three intense semesters of clinical. I will say that online school is not for the faint of heart- you have to be disciplined and self-motivating. You have to make time when you don’t want to study. You have to stay up late and get up early and make your school work a priority in the midst of everything else you do in life. It’s grueling but in my case, it was worth it to not have to travel to school and find someone to watch my daughter. Choosing a program is a unique decision and you should be prepared to do some investigation.

Finding clinical preceptors is also an arduous part of this journey. Wait, let me rephrase that, an exhausting part of this journey. For my school, I was left on my own to find preceptors, which meant pleading for friends and family to help me. I emailed NPs and never got a response back. I cold called offices and never heard a thing. I did end up finding three fantastic preceptors in my area but that was only because of nice friends who put me in contact with their provider friends. This is where the word networking comes into play. You can never underestimate the value of establishing good relationships with other people in the medical world. If you’re trustworthy, kind and smart, they’re likely to endorse you to other provider friends but if you bad-mouth other people, seem uncompassionate towards your patients, or don’t care about your job, you may have a harder time finding someone who will spend a chunk of time investing in you. In short, make friends and don’t burn bridges.

Remember, preceptors for a NP program (MDs, NPs, PAs) aren’t getting paid to teach you (unless you’re involved in a paid preceptor program). They are giving of their time and energy willingly with no guarantee of a return. Ideally, I would like to get a job at one of the sites that I worked at during clinical because I already have an understanding of how the clinics work, the types of patients they see, and the responsibilities that I would be asked to take on. In this instance, it pays off for everyone because the clinic doesn’t have to spend as much time training you, but this isn’t the norm.

Making the jump into graduate school isn’t for the faint of heart. You have to have a clear vision for your future and be motivated enough to stick with it. You need the support of your family and friends and your job. You will have to give up some things now for a better return later. And if you stumble along the way? Forgive yourself. Nothing in life ever goes the way that we think it will.

I hope this gives you a glimpse of what it takes to go from a RN to a FNP. I hope you can understand my reasoning and my desires. And I hope, if you’re sitting at home contemplating these same things, that this helps you along your journey.

Go get that MSN.

 

The Bottom of the Ladder

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Nobody likes standing at the bottom of the ladder, gazing up at everyone above and knowing there’s nothing but time, labor and learning that will get you any closer to the top.

It’s a well-established phenomenon that nurses have a hard time transitioning from expert nurse to novice nurse practitioner. This makes sense- you’ve gotten really good at your job, knowing what every medication does, what those labs mean, what the physician is going to order next- and now you’re back at the starting line, feeling more insecure than ever, hating the fact that you don’t have all the answers anymore. If you stayed in your area of nursing experience, I can imagine that this transition is less jarring since you’re already accustomed to your future role but I think regardless of where you came from, the rules are different as a NP. And this can make for some serious anxiety.

If you’re entering into a new clinical environment like me then this transition may leave you feeling breathless, alone and scrambling to catch up. I spent my first six years as a nurse in a surgical ICU learning how to titrate vasopressors and check for compartment syndrome and draw ABGs. I will be thankful every day of my nursing life for the experience of learning to handle such acute patients in a tenuous environment because it gave me an extensive knowledge base about both medicine and people. Over a period of a few years, I rose through the ranks, climbing up the rungs, and finally found myself near the top, confident that I could handle any trauma patient that rolled in the door. But  since I had always wanted to pursue a career as a NP, I felt it was the right time to move on and grow in my capabilities as a nurse.

So after years of hospital life now I’ve entered into the world of clinicals in a family practice outpatient clinic. On the first day I asked, “where’s the crash cart?” and everyone looked at me like I was crazy. Eventually I found the AED and that was it. They didn’t even have an IV start kit! Every bone in my body was rebelling, thinking what in the world would we do if someone codes? Call 9-1-1 and start CPR like everyone else, I suppose. The outpatient setting is vastly different and at first I wondered whether I would enjoy the slower pace or whether I would be sitting at my desk the first day of clinical thinking, oh my gosh, have I just wasted the past two years of my life? But thankfully, I have adjusted more easily than I even thought possible, finding the challenges of a clinic different but not less than, still experiencing the thrill of seeing patients except these patients can actually talk to me.

With two clinical semesters to go, I am still at the bottom of the ladder, dreaming about the breeze of graduation on my face and yearning for the freedom of practicing on my own in the high, clear air. After doing online classes for the past two years, I found that I had in fact learned a few things but I still came home everyday with more questions than answers. I spent my hours at home looking up articles, listening to podcasts, trying to be better. Fortunately, I had a preceptor who allowed me to ask dumb questions and look up answers and Google pictures of skin rashes. He made no ultimatums; he didn’t shame me in my ignorance and for that I will forever be grateful. Plus, I quickly realized that even after years of practice, you never stop learning. You never stop reading articles. You never stop changing your care plan based on the newest evidence. In short, I will be a learner for the rest of my career.

I had so many instances this semester where I felt out of my league. Patients who came in and hadn’t seen a health care provider in forty years. Patients with hemoglobin A1C levels so high the point of care machine couldn’t even calculate it. Patients with feet so disgusting that I literally didn’t know if I should send him to an emergency podiatrist (do they have those?) Patients who told me they had thought of committing suicide. Patients that were medical minefields with a list of diagnoses several pages long and too complicated for me to navigate without some help. Patients who asked me point blank what I should prescribe, in front of my preceptor, and I had to admit that I didn’t know. I was out of my league and that’s just part of adjusting to a new role, of being a student.

Even with my preceptor as a safety net, I still feel the weight of the job like a heaviness in my chest, the responsibility crushing at times. There is a holy reverence when you’re taking care of another human being because they’re putting their trust in you. They look you straight in the eye and believe what you tell them. They listen and consider and take the medication you prescribed. So even though I long for a day when I feel comfortable in my new position as a NP, I can’t too easily wish the anxiety away because it’s going to keep me from getting too comfortable and making a mistake. Hopefully, eventually, anxiety and reverence fuse, leaving me a great nurse practitioner with a holy level of fear.

Am I nervous every day that I show up to clinical? Of course. Will I carry that anxiety with me as I graduate, get a job, and start practicing? I’m sure of it. It’s like when I started in the ICU as a RN and someone told me it would be about a year before I was able to come to work and not be terrified that I was going to kill someone. And they were right; it took me a year to feel comfortable there. It’s like that. From what I’ve heard and read, there are some factors that help lessen this anxiety but nothing replaces years of experience.

So here I am, at the bottom and climbing my way back up. It’s a different ladder of course, one with no weekends and holidays and better pay and different responsibilities. It’s comforting to know that I’m not alone; that every nurse practitioner student in the world probably feels the exact same way- excited, nervous, and a little bit terrified at times. There is hardship in this transition but there is payoff too, mostly in the faces of the people I help or the exultation of knowing I made the right call. There will be falls along the way, missteps. Scraped knees and elbows as I try to hang onto the rungs.

But despite all the challenges, despite those days when I wonder if I can do this, I’m confident I’m headed the right direction. I can see the top from here, and it will be worth it.