These are all aspects of professionalism, and they are expected of us in the workplace.
What happens, though, if you are not on the clock?
Does professionalism stay at work, or do you carry it around with you at all times?
Think of the last day off you had—what did you wear when you ran your errands or filled up your car’s gas tank? How did you act when you went out with your friends to the newest club or bar? Did you tell anyone you are a nurse, and do you think if you did, that others would look at you differently if you weren’t dressed to the nine’s, or if you had more than one or two drinks?
Yes we know that licensure demands ‘good moral character’, but that is a broad and hard-to-define term. Are you less professional if you have a few drinks with your friends? Are you more professional if you dress up to run errands? And as licensed professionals, are we obligated to act the part of professional any time we are in public, or just when we are in scrubs and on the clock?
Is there a grey area somewhere…between living life as a person first, and nurse second. After all, while being a nurse is a huge aspect of who I am, it is not the complete definition of me. What about you?

One of the first patients I cared for during my first semester of nursing school was Mr B, a nursing home patient with multiple medical issues including ORSA in the secretions from his capped tracheostomy. Because of this, Mr. B was on special precautions, requiring any staff who entered to wear gown, gloves, and faceshield.

I was paired up with another nursing student to care for him, since the staff had noted he was very needy. My classmate and I sat down early in the morning to devise a plan of care. We decided we would ‘cluster’ our activities, not only so as not to tire Mr. B out but also to try to cut down on our visits in and out of the room, and thus decrease our exposure to the ORSA, and consequent risk of spreading it to other residents at the facility..

The first time we went into the room, we brought in towels and washcloths, ready to bathe Mr B and get his dressed. He had an appointment at physical therapy at 11, and given it was 0830, we thought we had plenty of time.

Yeah, right.

First we forgot the soap. Degown, deglove, damask, get the soap, regown, reglove, remask. Next we had to get some extra towels (we were still pretty green at bed baths.) Again, degown, deglove, demask, get the towels, regown, reglove, remask.

We were working on our physical assessment paper, so poor Mr. B patiently sat through a double assessment, as my classmate and I both painstakingly looked him over head to toe, wondering to each other if his capillary return was really <3 and if his skin should be considered pale or pink. Finally, we had him dressed and in a wheelchair, a mask on his face and over his trach, and ready to go to his appointment.

While he was gone, we tidied his room, changed his linens, and worked on our assignment together.

When Mr. B. came back, he didn’t want to eat his lunch. He seemed restless and irritable. And he was on the call light often. I tried answering from the door, but there was often something he needed that I just couldn’t get from the doorway. There were increasing rounds of gowning, gloving and masking for all sorts of things. He dropped his remote, he needed a tissue, needed the urinal, needed the pillow adjusted. Finally, I got my instructor and explained to her what was going on, and how I was beginning to think maybe there was something wrong with Mr. B.
My instructor and I went into Mr. B’s room together, and the image of her sitting on the side of the bed with him, her face near his so he could see, and holding his hand is an image that I want to carry forever, as her body language and words conveyed the compassion that all of us as nurses strive for. My instructor held his hand and asked him what was wrong.

“I’m scared.” Mr B said shakily. “I feel like its almost time to die.”
:”You are scared that you are dying, Mr. B?” My instructor reflected back.
He nodded. “Is there anything I can do to help you?” She asked.
“Just don’t leave me alone,” he said.

My instructor pulled me aside and said that for the rest of the day, I was excused from any duties but staying to care for Mr. B one on one. Together we checked his vital signs, which had been and continued to be stable, and we got him up out of bed and into his chair. I sat next to him and we watched television.I don’t think I’ll ever forget the show; it was a documentary on the History channel of the history of salt mines.
Mt. B seemed a little calmer. He began to tell me about his ‘lady friend’ who was expected later in the afternoon. He told me that they used to dance together “before I got too weak.” I remember how he lit up and smiled when he talked of her and how the two of them could cut a rug in the old days. Unfortunately, after only a half hour, Mr. B began to become agitated again. “I want to go back to bed now,” he finally told me. I went to the door and tried to get someone’s attention, but it seemed that all the nurses and aides managed to look away just as I tried to catch their eyes. I began to see how frustrating it must have been for Mr. B, alone in the room, having to rely on other people to come in all the time, and all the layers of protective clothing between him and simple human touch.

Finally, my classmate came by and helped me get Mr B back into bed. He seemed calmer, and after telling my classmate about the upcoming visit from his ‘lady friend’, he drifted off to sleep.

Soon my clinical day was over, and my classmate and I stayed a little late to work on our assessment paper together. Our instructor stayed with us, and we discussed Mr. B’s care, and the fears he verbalized. He had stayed clinically stable the entire day, with no obvious physical distress. His mental distress, we theorized, was from being alone so much of the time, and that our therapeutic presence had seemed to calm him. We stayed almost an hour late, leaving finally around 2pm.

Two days later, before school, I saw Mr. B’s obituary in the morning paper. His date of death was the same day that we had cared for him at the nursing home. 
Upset, I went to my instructor, who told me that Mr. B had died peacefully in his sleep within 15 minutes of us leaving that day. I remember feeling sad that he had passed, and then glad that perhaps I had made some bit of small difference during his last day on earth. I can only hope that that he and his lady friend are still up in the stars somewhere, dancing on moonbeams and cutting a fine rug.

I have a patient who went on hospice care a few days ago. She appears fine. She is not fine. And she knows it. She is just waiting in a small hospital room watching reruns of CSI and whatever junk they have on TV these days, making herself happy in small ways with the food she can tolerate, complaining about things that she can control when she feels overwhelmed by the things she can’t.

Oh my God, how humbling. What would I do in that position?
What would you do?

Imagine this. You are sick but trying so very hard to beat it. You go to the hospital for a stomach ache. You are told that you have an intestinal blockage and it’s a tumor recurrence. Furthermore, there is nothing more they can do.”I’m sorry, there is nothing more I can do. I can make you comfortable, and keep your pain to a minimum…but there is nothing medically I can do to stop the progression of your disease. You most likely have about 2 weeks left.”

Oh my god. What if that were you? What if you only had two freaking weeks left and you are too sick to go home, too sick to do much, but well enough to be aware and to understand. Well enough to realize “Damn. The writer’s strike doesn’t matter to me because I am not going to be around to see the new episodes of The Office. Christmas ads mean nothing to me because I won’t be home for Christmas this year. I won’t see my cat or dog again. Ever.” It just goes on. No more summer corn on the cob. No more Valentine’s day candy. No more fireworks. You don’t need to worry about taking next year’s summer clothes out of storage and trying them on to see if they still fit.You can cancel your dental checkup and your next haircut. Any appointments you have…you aren’t keeping them.All of life’s special things, and all of life’s mundane things will continue on, but they will continue on without you. You won’t be there.

How would you feel? How would you handle it? You can talk, eat, drink, and have minimal pain. You are tired but not exhausted. You are alert, you are in your right mind, but within 2 weeks - FOURTEEN DAYS - You will become progressively more and more ill. Then you will die.Nothing we can do about it…. Would you cry? Complain? Retreat inward? Would you change anything? Would you mend relationships? Would you rebuild bridges knowing that your particular bridge is going into the great beyond? Would you confess your love for someone whom you’ve never told? Would you confess your hate for someone whom you’ve never told?

Put yourself there. It’s a scary place.

You really can tell infection by smell.
You can also tell impending death by smell.
Little old ladies can poop more than your average quarterback.
Little old men can have ‘innies’
The average man is NOT 7″ long
If someone says that they think they are dying—BELIEVE THEM
If you don’t clamp off your IV catheter before you attach the clave, you will see an amazing arc of blood.
Urine comes in many fascinating colors.
So does poop.

Yesterday, the ED was on Red which means there were no beds available. My side wasn’t quite slammed yet but with the acute side of the ED full, it was only a matter of time until our side got full not only from our own designated patients, but also with patients who may better have been on the acute side, were there any room. Basically, a relatively normal day.

I got to work prepared for a busy 12 hour shift. I asked the charge nurse, who is one of our Nurse Leaders, what my room assignment was and she smiled. handing me the charge phone, she said “We’re training you today for charge.” Now, I have asked for this opportunity several times and I feel ready for it. But the minute that phone was in my hot little hands, I felt a surge of panic.

Me? In Charge of the whole Urgent Care section of the biggest ED in my city?? ME???

I swallowed hard, my mouth gone dry. “Cool!” I managed to say, telling myself that I want this.

The Nurse Leader took pity on me. “You’ll only have two beds to care for all day, and I’ll be here,” she said. “Until 4″. Which meant that from 4pm until I was scheduled to leave at 10pm, she wouldn’t be there.
I smiled weakly. This is something I can do, I thought. I hope.
The phone started ringing almost immediately. Calls were coming from Triage..can I take this or that patient, do we have a bed for one patient, can the attending come to triage and evaluate another patient….I just kept answering calls and doing my best. Using critical thinking and my nursing judgement, (which apparently I do have!), I fielded each call and cared for my two beds.
I did my best to assign beds fairly, alternating between the different zones so that no nurse was unfairly overloaded. I asked lots of questions, and helped the other nurses as much as possible.
Before I knew it, it was 4pm and the Nurse Leader was leaving. She told me not to worry and told me I could page her at home if I had to. “But really,” she said. “You are doing fine. You won’t have any trouble.”
So I kept on going and the night was going very smoothly.
Until we ran out of beds again.

Around 9pm, we start to taper the patients we take on the urgent side, since staffing goes down for the overnight shift. Concurrently, at 9pm not only did we get five more patients to be seen, the rest of the ED had gone red again and there were 10 acute patients who had been waiting for hours in the lobby. The charge nurse from the acute side called me, begging for me to take some of their patients into the urgent side.

I sat and thought.

I had five patients waiting who were appropriate for my side of the ED, and I had to take them first. The urgent patients become my priority. Not because they are sicker than the acute patients, but because after midnight, we would go down to one nurse and one provider and if I took patients with heavier needs, the nurse/provider team would become overwhelmed and the patient care could be compromised.
I reviewed some of the charts for the acute patients, and found a few that could conceivably come over to our side if necessary.
I helped the rest of our nurses with their discharges, opening beds and filling them just as quickly.

All the while, I kept the attending physician aware of the plans, as well as the other providers and nurses.

When I left, all of our waiting urgent patients were roomed, we had one room reserved for patients coming in via ambulance/EMS, and there was a working plan for dealing with the overflow of patients from the acute waiting room.

When I walked out, my legs were sore and my brain was tired. It had felt good to give report and hand that ever-ringing phone to the next nurse. But I felt invigorated as well.

I did it. I ran the show for 12 hours. Everyone survived, no one complained.

Me in charge? Oh, yeah. I showed myself I can do it, and I can’t wait to do it again!

“A Dios mio! Pain! Pain!” I heard the woman’s cries all the way down the hall as she was led by the ED tech to my last empty bed. I sighed and took the chart from the tech. 60 year old woman with a three day history of left flank pain. “OK” I thought, this should be easy.

I went in to see her, and introduced myself. She was tiny, barely 5 feet tall, her graying hair held back in a bun. She told me her name was Sonya and that her doctor had diagnosed her with kidney stones at one of the other local hospitals. She’d decided to come here because “they don’t give me any help.” I had her put on a gown, started an IV and drew labs, and instructed her to give me a urine sample. “Thank you thank you,” she said in breathless, broken English. “The pain is very much worse.” I smiled and pointed her to her bathroom. She patted my hand before heading that way. I am always a sucker for the older patients.

In the meantime I checked on my other patient in the same room. David was a 30 year old “frequent flyer” who came in via EMS writhing in lower abdominal pain; he was going to be worked up for possible appendicitis, even though he’d presented five times this month already with similar symptoms. His tests had come back negative each time, and the doctors were starting to suspect he might be a drug seeker. David was resting comfortably, having received a morphine and phenergan IV cocktail.

I could tell when Sonya was back to the room by the progressive moans and groaning she made as she ambled back from the bathroom. I helped her into her bed and assured her we would make her as comfortable as possible. I told the ED resident that Sonya was in a lot of pain, and that she was ready to be seen.

Next I saw David’s call light go on and when I went in to check, he told me that the pain was back again, and he asked for more morphine. The pain was rated a 10/10 and he curled up on the bed holding his abdomen. I remembered his last visits, which were the exact same presentation but nothing was ever found on CT. I looked at the clock; it had only been 45 minutes since he’d received the morphine. I tried repositioning David to find a more comfortable position but it was useless. He was in pain no matter what position he was in. I asked the resident for another order of morphine and she wrote it with a sigh, mentioning that it seems David had increased his visits lately and maybe it was time for a psych consult.

The resident saw Sonya while I prepped David’s morphine.

When I took the medication back in for David, Sonya saw me and started moaning again. “Is that medication for me?” she asked. I told her I was sorry, it wasn’t, but that I’d have some as soon as the doctor ordered it. She looked so small and alone in the bed. I brought her an extra blanket. I quickly obtained the order and administered Sonya some morphine. She lay back happily.

Shortly, both patients were transported to CT. I went about my shift caring for my other patients.

A half hour later, after both of the patients had returned, “Look at this” the Dr said, indicating her computer screen. Sonya’s CT was perfectly normal, no evidence of kidney stones.

“And this too,” the resident said, changing computer screens. Sonya’s history came up on the screen; she’d had 15 visits in the last 2 months, all with pain. Futhermore, her history indicated a continuous use of street drugs.

The resident sighed and was about to get up and go see Sonya when her pager went off. She returned the call and turned to me. “David’s got a hot appendix. He’ll be going to the OR within the next half hour.”

As I sat filling out the pre-op paperwork for David and listened to the resident as she attempted to explain to Sonya that there was no evidence of kidney stone and that she would not receive any more morphine, I sighed. In this business, it’s so easy to gain preconceived notions and ideas. This was a good night to remember that nothing is ever necessarily just what it seems.

As I write this today, we are marching through National Nurse’s Week. This week there have been lots of fun things at work-free food, free gifts, bowling, and other things to do. It’s a chance for we nurses to be recognized and remembered for what we do for others.

Nurse’s week started in the 1950’s but was originally begun as a one-day celebration of recognition. Later, the ANA adopted the week of May 6 - 12 as Nurse’s Week, and it is permanently celebrated on these dates.

Nurse’s week is more than just a time to get free food and gifts, though. I find it to be a good time of retrospection. It feels like an affirmation of sisterhood (or brotherhood!). To me, having time where we are recognizably appreciated by management and media helps shine a light on our profession, and hopefully shows others that as nurses we are hard-working professionals within our profession.

If you are a nurse or soon to be a nurse, take some time to reflect this week on your reasons for going into the field. Use this time as a chance to reconnect with your initial feelings about nursing and to remember why you chose to become a member of this challenging, busy, tiring, fulfilling and awesome profession. Take a few minutes to relax and reflect; you deserve it!

For a great gift for a special nurse or for yourself, click here.

I had graduated. Before I knew it, I was in my very first hospital orientation, and it was two more weeks of classroom learning. Learning hospital policies etc… the studying started again.

The NCLEX-RN began to loom like a shadow….a big scary nightmare-inducing shadow. Dreams of failing it scored my sleep.  My fellow graduate-nurse buddies and I obsessed over and speculated on it…how many med calculations did so and so get? How many questions did it take to pass? How the hell will I go through with this? The Nursing Boards are a HUGE DEAL. Your life depends on it. Everyone knows the story of the graduate nurse who got her new job at the hospital, and bought herself a fancy car as a reward for finishing school. Then she took her NCLEX. And failed. She lost her new job, her paycheck, her car, and her sense of self-esteem. Yes we’d all heard of her and by whispered fears and nightmare study sessions we tried to ensure that we do not become her.

July 24, 2006 at 0830 I entered the test center. At 0910 I re-emerged into the summer heat feeling like I’d been hit by a truck.  My ENTIRE nursing education…all the labs, objectives, skills, vocabulary, notes, math and meds….all had been boiled down to one test WHICH TOOK LESS THAN HALF AN HOUR. The test itself is all computerized, and the number of questions you get is based on the answers you provide. The minimum number of questions are 75, and the maximum is 265. You can pass with any amount of questions. And you can fail that way too. I got the minimum number of questions. The computer shuts off when its decided that you either passed or failed. Turning off at 75 means you did very well, or really bad. The questions in the test seem to get harder and harder. When after my 75th question the machine clicked to grey and I realized it was over, I put my head down on the desk for a minute. That was it???

All the studying and I had four medicine questions about the same med and NO MATH? And almost all the rest of the questions were priority…no disease specific stuff, no peds, no OB, just almost all priority.
I came out feeling, and dreading that I had failed. I was completely convinced of my failure. I tried not to cry as I stumbled out. My mouth was dry going in…no gum, no mints, and no water bottles allowed. As I stumbled out of the test center is was watery in panic-induced nausea.
Oh my god I wanted to cry. Or laugh. Or sleep. Instead I went out to breakfast with a friend of mine who is already a nurse, and she commiserated with me and told me of her experience, when the exams were several days of written answers. Somehow that sounded better than what I’d just gone through.

That’s it. No more tests. Pass or fail. Thoughts of the student loans that I would have to pay off while flipping burgers at McDonald’s because I have failed the licensure exam hovered in my thoughts.

I went home and started checking the web for my results. The BON in my state posts pass or fail within 48 hours. Sometimes earlier (unusually) but mostly right at 48 hours, or at 10am, whichever comes last.
The first day of waiting I immersed myself in work. The second day I tried not to be sick I checked the site every 15 minutes from 8am on. By 0930 it wasn’t up and I thought okay, I really did fail. I will never be a nurse (By the way, you can retake the test if you fail, you just have to wait for a period of time.)  At 10am I decided to use the phone-in system. It would cost $10 but maybe it would have a result. My poor husband, who was at work and fielding my 10minute phone calls all morning, suggested checking the internet one more time. I did. My results were there. With a license number next to my name.

I PASSED. I was a nurse.

A real, live Registered Nurse. A PROFESSIONAL.

I could wear white pants and a stethoscope and not feel like an imposter. I had been deemed legally competent to practice nursing.

The feeling of knowing you passed your boards is like a weight falling off your shoulders. Literally. You don’t have anything left to study. You have no need for the $150 of exam review books that you’d been reading for the last several months in preparation. You are a veteran, a survivor of the NCLEX-RN. You went in the door of that test center a graduate and came out a nurse.

 Some people celebrated it with parties and drinking and fun. I went to work and began to sign RN after my name with great joy. Then it hit me.

Oh. My. God. I. Am. A. Nurse.

I am a licensed healthcare professional. I have been trained to assess you, and I am responsible not only for providing you with basic nursing care to meet your needs, I also will be providing you with specialized care. I know how to insert a catheter into your bladder and an IV into your arm. I know how to run the IV fluids and I know the reason for using normal saline vs lactated ringers and I can tell you if you ask me. I know the side effects and uses of all of the 15 medications I am giving you and I will tell you if you ask. I can give you a shot if I have an order for it. I also assess your spiritual, mental, and emotional health. I can talk to the doctors about my concerns and the doctors take me seriously as a peer. (Well, most of them) The new doctors ask ME what they should do for you and I can give them ideas, all the while reminding them “Well, I’m not a doctor and can’t prescribe but I have seen drug XYZ used in this case before” or “Did you want me to do ABC for this patient?” I am responsible if the aide/tech doesn’t complete her work and I am responsible to see that you have a safe stay in the hospital and that no matter how bad a shape you were in when you got here, when you go home you will at least not be in any worse shape.

I hug you when your mother dies. I hold your hand when you are taking your last breaths. I bandage your feet. I teach you how to breastfeed. I let you cry when you need to and I hug you until you stop. I laugh with you. I cry with you. I make you do things you don’t want to do, knowing that later you will thank me, and you do. I sneak you a cookie when it’s late at night and you have the munchies and hospital jello just isn’t doing it for you. I wipe your bottom when you can’t reach it and I hold your hair while you puke. I pack your wound and I measure how deep it tunnels. I change your bandages, your dressings, your diapers and your peri-pads. I sit with you and hold your hand where there are no words to say.
I do what it takes to make you well and failing that, I make you comfortable.

I am your nurse.

As I sit here tonight, thinking about my new job and all the new things I will see and learn….I start looking back to the time before I was a nurse, before I’d had this training and this knowledge base. Going to nursing school, graduating with good grades, and doing it all while raising two kids and having a husband who’s health is sometimes a question mark.
I followed a home care nurse around the worst parts of the city and into roach-infested apartments. I stood for 8 hours in a freezing operating room, watching gallbladder after gallbladder come out.  I suctioned trachs, flushed IV lines, gave shots and pills, fluffed and turned. I changed elderly adults soiled briefs, cared for people with ORSA, MRSA, VRE, scabies, lice and C-diff.  I did psych where the patients scared the hell out of me. In maternity I saw babies born. This was all stuff that I never dreamed I would be doing.
And I learned. Like a sponge, you learn to soak it all up. Don’t miss anything and write it all down. You never know what will show up on the next test. And then the final exam of the final semester comes almost before you know it. Dread and trepidation keep you up at night, along with the thought that if you don’t know it by now you never will. That final time you close your textbook and put away your notebook…you sigh and leave home for the final exam.

They were still giving out the grades immediately when I took my final. That was the last time they did it. I was the first or second person done with the test. I looked around the room, not believing that I was actually done. I didn’t check my answers. You learn by the middle of the first semester to go with your gut, and take your first answer. It’s always the right one. It was a 100 question test. When I finished I took my test up. I passed! I was done. 
I. Finished. Nursing. School.

I hugged the instructors and danced out. Apparently someone after me did not pass, and either fainted or freaked out (depending on who is telling the story) and now no one gets their grades in the test room. Now they all have to wait 24 hours until the grades are posted.

Pinning came a week later, and the ceremony was great. There was a slide show, and awards. We were each pinned by a member of the faculty, and then we took a class picture. 77 of the original 99. Not too bad.
 
And then there was a huge moment of nothing….I had this sinking, lost feeling. School was over. I’d graduated.  And I had nothing to do for two weeks until my new job started.

I felt lost while. I don’t know why. I had a couple weeks of just being ahead of me. No studying, no getting up at the crack of dawn for clinical, no tests. It was odd. I slept a lot. Probably a minor depression. On one hand I was glad for the rest, on another, well, I wanted a party or something. 

So I bought new wall-to-wall carpeting.

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