Think Hard, Think Twice..Get a Sense of Humor Part 3 of 3
Written: Nov 22 '01 (Updated Nov 22 '01)
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Product Rating:
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Pros: Not as many as I once believed; a chance to prove your humanity
Cons: Often we lose the very thing that was most important, our humanity
The Bottom Line: Management is not the best part of any nursing careers. If you are contemplating heading in that direction, definitely think twice, think hard, and get a sense of humor.
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| artbyjude's Full Review: Nursing Profession |
This will be the last of the series! Aren't you glad? I am!
This is the wrap-up of my advice to those of you considering entering the profession of Nursing as a Registered Nurse, or wondering if you should stay. There are two other parts lost somewhere in the data base, and they may be more entertaining . If you are picking up where the others left off, let me use this "review" to tell you of the final two phases of my Nursing Experience, working as a Labor and Delivery Nurse, and Nursing Management. And even though it might be tedious, you'll have to sit through some more stories.
After my first year of hospital nursing I was simultaneously being recruited to a hospital 40 miles away over the boarder in New Mexico, and getting fed up with my job as Med Surg drone. Within a week of leaving the Med Sug job, I was working again in a hospital, and, (you won't believe this!) In labor and delivery.
In nursing school, OB was my least favorite rotation and the one place in nursing I had determined never to work. I had delivered my daughter two years before I started nursing school, and it was one of the least humane experiences of my life.
I had never in my life felt such anger! The nurses ignored me, I delivered on a stretcher, with no one in attendance, and had to endure personal insults besides. I won't tell you the whole story but suffice it to say, that when I signed out of the hospital 8 hours after delivery in a fit of rage, my blessed mother brought candy to the nursing staff . I went to the counter and snatched it up, saying they didn't deserve it! And this was BEFORE I moved to New York.
In nursing school my clinical OB rotation came up when Yoko Ono was delivering. I willingly traded assignments so as not to have to deal with THAT mess! When I did get a patient, the nurses kept yelling at my patent (and me) to whom I was trying very hard to be supportive. I lost all credibility when the Father of he Baby passed out at delivery and I was too busy watching Mom to notice that he was toppling over. It was a big crash, and I felt bad when I dragged him to the corner to keep him from being trampled under foot. But not bad enough to want to do this stuff all the time.
So when I went to interview at my new hospital, after an interview with the director they hooked me up with a manager, about as wide as she was tall, with a look of a belligerent bull dog. She opened with..."I don't hire new graduates! Do you have any experience with Labor and Delivery?" No, but I wasn't a new graduate. And I proceeded to list all my faults, hoping she would pass me by(arrogance, bull-headedness, smart mouth, self-righteous assertiveness, all of them) and for some reason, she had to have me. I didn't know then that I was the only non-experienced labor and delivery nurse she had ever hired (before or since). She posed a challenge. I took up the gauntlet thinking, 'hey, my daughter in law is pregnant. Maybe this will come in handy'.
And a challenge it was. I was given 2 weeks to sink or swim. I was determined that I would succeed, in spite of all obstacles. I got the night shift, and learned more in two weeks than I had ever learned in such a short time..because I had to! When I surfaced again I realized for the first time that I really loved it The adrenalin rush was like nothing else, the skills and stamina required are special, and not everyone can do it. I was thrilled that I could.
On the downside, it took awhile to convince my peers that I could cut the mustard. I was no longer in charge, and we were extremely busy. No one had time to hold my hand, or see me through tough times. But teamwork developed because we WERE so busy, often delivering as many as nine in a twelve hour shift, with only two primary care nurses on shift. I often think we were lucky to be involved in that crazy atmosphere, because it offered an intensity of experience that might have taken years to accumulate in quieter times. I delivered an average of 2 babies a month, by myself, when I couldn't get an MD in time, and participated in hundreds of full neonatal resuscitations, out of necessity.
My immediate supervisor was the toughest and could be the meanest supervisor I have ever known. She was also the best nurse manager I have ever worked for, because she demanded more, tolerated no incompetence, and always put patients first. She instituted standards in a specialty that didn't follow her lead until 10 years later. She was a pioneer in the fight for professional practice issues. But she wasn't perfect, (like I am) and needed to acquire a sense of humor.
This nurse manager was Hispanic, and in a pinch, she reluctantly came up to translate. We also had a fair number of Mexican nationals, who would cross the border at the latter stages of pregnancy so their children could be born US citizens. Occasionally, like any OB unit, we would have rare lulls in our activities and have 3 patients instead of our usual 8. On one such night, an old school OB doctor, (and he was a humorless old toad, who got angry when he was called in to attend a patient) came in to see a patient, but then went looking for a place to crash until the next crisis. The call room was already occupied. So we let him sleep in one of the labor rooms, turned off the lights and shut the door. He asked us to wake him at 7 AM.
When our head nurse came in, I decided we could kill two birds with one stone. I told her the patient in the quiet labor room had high blood pressure, spoke no English and wouldn't let anyone near her to check her labor progress (by examination of cervical dilatation with a digital exam), and asked my boss to help. Never to be deterred from a challenge, she donned her glove, and the KY jelly. I opened he door for her, and stood quietly while she tiptoed to the bedside, pulled back the covers, and discovered the doctor who did indeed get his wake-up call at 7 AM that morning. I heard a yelp, but the rest of the shift, crowding in behind me, was laughing so loud I didn't hear the curses.
Five years after starting in this phase of my career, I was on my way to the OR with a patient, with a baby whose heart rate was in the 70's and dropping, to an emergency C/Section, when the wheel of the birthing bed got stuck n the space between the elevator and the connecting hallway. I was the only one there, and the baby would have died if I went for help. So I pulled the bed out of the gap, with the patient on it, and rushed to the OR. The baby did OK with some quick intervention. I however, had injured my back. Three years after that, I had back surgery. And then two more to correct the first back surgery. (But this is another story.)
So here are some helpful hints on learning to be an OB nurse:
1. Be prepared to see your patients at their worst. They will use words that you could not have imagined they would know. I have never chosen to be offended by this. But if you harbor some illusion that the birthing experience is a fun time for everyone, disabuse yourself of that notion. Be prepared to support, and divert the anger into something more productive, like breathing effectively through contractions.
2. Learn how to read a fetal monitor strip, know what the danger signs are, as well as the ones that indicate everything is OK. I can't emphasize this enough. Seek guidance and teaching from your peers. If you have any questions, have someone validate.
3. In charting, be descriptive of the events, instead of interpreting them. If you claim the patient is "bleeding" say how much. Describe what it looks like, and inform the doctors as well as your charge nurse of the changing events.
4. Maintain your relationship with your patient The predators in our profession will give you their own advice, which you should quietly listen to, without arguing. But the one-to one therapeutic relationship with your patient is what will count in the long run. Your style of interacting is acceptable, if it works for the patient, even if it is not what everyone else does.
5. Know how to prioritize. In this specialty, you have to move fast, follow the protocols, and do it well. After six months, you will probably think you know everything about delivering babies. You would be wrong. There will always be something new on the horizon, and a dozen different ways to do what you have been doing the last six months. You have to understand the risks, and still be flexible. And you have to know what is important to do, and what will wait until things settle down.
6. Check your patient as often as you check the monitors. Central monitoring is available in most facilities now, and often allows us to put patients on auto-pilot. Monitors only give you the information that you program them to deliver.
- Always Validate contractions by palpation.
- Always locate the PMI for fetal heart Tones,
- Always evaluate your patient's physical and mental status, and document changes
- Always report anything that concerns you.
- Always document pain medication, labor checks, and vital signs. Later you can "fill in the blanks"
7. Before you attend any delivery ALWAYS know how to recuscitate a neonate, if NRP ** is not available as a course, try to get into one as soon as possible, even if you have a NICU, and a full support team. You will eventually be the first responder, sometimes the only responder, and your skill will make a critical difference.
8. Be prepared for some unusual, often depressing events, such as fetal demise, or any adverse income. Be aware of the grieving process: if you don't know these things, find resources to help you and the patient cope with loss.
9. Avail yourself of any and all Inservices pertinent to your field. Knowledge and practice will evolve quickly, and you are responsible to maintain a current level of expertise.
10. Know your professional organization and find out the standards acceptable for your field. For OB, the source is AWHONN. *
11. Follow your best instincts in caring for any patient. Maintain your sense of humor. I have never yet been in a situation where this hurt, and sometimes it helps.
12. Learn cultural differences per your population. Allow your patients to teach you. In birthing babies, more than any other aspect of nursing, individual cultural practices and attitudes will come into play. It is not your job to convince them they are wrong, but rather to support them in their particular responses, while using your skill to assure the best quality of care. Keep your personal feelings out of it.
13. Remember that how you interact with your patient is what the patient will carry home with them. Imagine yourself in their place, and be sensitive to their needs for privacy, as well as comfort.
14. Be an active coach, but know the limits Pushing, contrary to all folklore, is something you will have to teach each and every new patient. You may have to shout a little. But don't get so caught up in the shouting, that you forget the needs of your patient. All the techs, all the other nurses, the doctors and midwives like to get involved in this entertaining sports event. Remember, if this is your primary patient, you are for the moment the HEAD COACH. Also, there is more than one way to do it. Try to discover them!
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After I recovered from my back surgeries,(and I may some day reveal that experience) I was recruited to work in a Navajo reservation Acute Care hospital. After a year or so , I was encouraged to apply for a job as manager of the department. I was convinced that I could make a difference. It is sometimes harder to move from staff to management in the unit where you are working, but you do have some advantages.
First you already know the strength and weaknesses of the major players. You already know the practices and routines of the department, as well as what needs changing. You can skip the initial orient to the facility phase and start to work on the major problems.
Coming up from the ranks can be a PROBLEM because your objectivity will be questioned. All your friends and enemies will assume you are either going to play favorites to your friends or punish your enemies. If this IS your goal in seeking a management position, then you are the wrong choice for the job. Unfortunately, this is the way it happens, fairly frequently.
Since I have spent about half my nursing career in management I am going to approach the subject from two sides. It is called the "THEM or US" phenomenon. This view, unfortunately, seems to prevail in most places where I have worked, and the perception of the dichotomy is perceived from both the management/corporation group, as well as the staff. It is how you define your role as manager that can make a difference.
I have a distinctly different view of the problem, so let me make one thing clear before I start, and you can decide for yourself whether to continue reading. I have no love for the health care system that prevails in the United States. It fails the people who need it most, and often sacrifices critical aspects of care for the almighty dollar. The fact that we as a nation tolerate it, when we have examples of health care systems that work in other parts of the world (Australia, and Canada, for example) makes it even more reprehensible. My decision to re-enter the management team was made based on the fact that I also believe that if you know there is a problem and allow it to continue, you are part of the problem.
As a disclaimer, the things I will talk about in irony as the worst and best aspects of becoming a nurse manager may not hold true for every institution and every situation. So if you feel your place of work is not motivated by profit, and truly cares about the welfare of the nursing staff as well as the patients, I would be delighted to hear about it, so please leave me a comment. For the record, nursing middle management is a thankless job. And no matter what your intentions may be, you can't make everyone happy, all the time.
As I have stated, my first OB manager was the ideal manager to me, and to this day serves as a role model in my mind. She had some personality problems, and many people disliked her intensely. But she was consistent in maintaining standards, putting the patients first, and I knew she would back me if I was right, and stand her ground.
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In the spirit of my attitude (which translates as a problem with authority) these are the qualities sought in the profit- motive corporate health care hospital for a nurse manager.
The THEM Perspective on Management
1. A minimum of 1-3 years in your specialty. Here we are talking about the least amount of experience, with no validation of your performance. Corporations will rarely check the records, so if your performance is poor, simply refer them to Human Resources, who can validate the dates of your employment, and be careful not to list anyone as a reference who might know the truth.
2. A masters degree in nursing This now seems to serve as a BSN did in the past. Actually, a masters degree may allow you to move to the ranks of management without ever having to work as a staff nurse. This has two advantages for the corporation. First, you will have no sympathy for the peons who serve under your direction, and second, you aren't likely to be as worried about the problems of hands-on care. You will have proved you can put on paper the data that will most likely serve the corporate interest, and won't be hampered by actually caring how it's done.
3. You must be willing and able to enforce corporate policy and spontaneous changes in policy at a moment's notice. This means you will post notices, write up new policies (or make someone else do it), cut staff hours, fire someone, or in general hop to when told. It works especially well if you haven't got a clue about the way things should be done. You will be able to cancel vacations, require impossible hours from your few remaining staff, and never ever question the decision. Practice "Yes Ma'am" or "Yes Sir" in the mirror 10-15 times a day.
4. You must be able to distance yourself from staff You make the others on your management team look bad when you come in and staff when your staff needs help, so never work an extra shift (unless you do it once to prove that you can, and everyone else is doing it) Remember, if they knew anything, THEY would be a manager!
5. You must make an appearance at every stupid meeting ever devised to waste your time. This means you will have to sit through the goals of the engineering department, learn of the follies of the security staff, hear about the groceries delivered to the cafeteria, listen to Human Resources talk about their recruiting problems, and listen to endless reports of statistics that will mean nothing to you. The ability to sleep with your eyes open is an asset. The ability to say yes, and sign your approval to every project is an absolute necessity.
6. You must maintain the corporate image at all times . Coming to work in scrub attire, thinking you might be able to help is frowned upon. You will be expected to maintain a wardrobe, wear uncomfortable clothes, and keep up with your peers in the established tradition.
7. You must NOT have a sense of humor and if you do, be careful not to use it on anyone above you in the pecking order. It will result in immediate dismissal.
8. You must show proper deference to all CEO's, visiting corporate management, doctors, and nurses who outrank you. Remember, the corporation doesn't have to tell you why they want you gone. In most places, NO EXCEPTION, middle management is the least stable job you can have. You have no one to go to if you feel you have been wronged, and even the law will rarely protect you, unless you CAN PROVE that you have been discriminated against, based on strict Federal guidelines.
Not a pretty picture is it? The truth lies somewhere between the two extremes. The following are the qualities we as staff like to have in our nurse managers. Keep in mind that this too, is an ironic look at the "other side".
The US Perspective on Management
1. You must walk the walk I will have no repect for you if you have never worked with patients, or worked the hours that I am working. You will have to prove yourself to me, frequently. And even if I know you, I won't believe you know as much as I do
2. You have to show that you put our needs first without regard for your own security. This means that you will take the hits for us as we sit back and watch the show, never having to risk anything.
3. You have to be willing to take no vacations, holidays or days off Especially if we are short staffed. I on the other hand, expect all my holidays
4. You must be available 24 hours a day, every day Because I might need you for something. I expect you to solve all my problems for me.
5. You will not be allowed to make any changes in staffing, policy, or the workplace without consulting me After all, we've always done things this way. Why would we want to change?
6. If there is any kind of a conflict between me and another nurse, upper management, I expect YOU to handle it I mean that's why they pay you, isn't it? And since we are friends, I expect special treatment, or at least that you will take care of my enemies with no questions asked.
7. Don't expect me to do anything extra, work on committees, or do anything to promote the hospital I work in Because you are getting paid for that, right? I have a life outside of this job. I am not going to put MYSELF out.
8. Don't mess with my schedule. Just because 8 of us are working Monday, and no one is working the weekend, that isn't my problem. You fix it. But I only like working with these guys. I'd rather not work at all if I have to work with those other nurses.
So have you guessed by now that the truth lies somewhere between? There are only five qualities you really need to do the job.
1. Endurance and Stamina For the first year or so you will be severely tested by both THEM and US. Know which issues are important enough to fight for. Be willing to do whatever needs to be done to "put out fires", whether it is to follow up on a complaint, or pitch in and help with patient care.
2. An ability to do the paperwork- this includes payroll, Quality assurance reports, budgets, projected budgets, competence reviews, nursing policies, monthly and quarterly reports, performance evaluations and a bunch of stuff I haven't mentioned.
3. A sense of Fairness. Above all you have to give all the staff the same breaks. This can be hard when you have one or two people that you just don't like. Always hear both sides to a story, and and follow the same disciplinary procedure if that is what you need to do.
4. A sense of humor Actually, this just becomes more and more important. Try not to laugh AT people though. They rarely understand it in the way that you feel it.
5. Integrity Know why you do things, and be careful that you don't do them for the wrong reasons. If you lose this quality, retire. Now.
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So my return to Nursing Management with my particular style led corporate management to think I was still too much of a "staff nurse " because I came when they called, and I trusted them to bring problems to me. We got a lot accomplished those first years, because my focus was on improving skills, teaching and allowing others to grow into leadership roles. I have no regrets.
But that first year was tough. Nurses can be predatory at any level, the abuse is not limited to new graduates.
I relied heavily on my psych background to try to understand and communicate. Staff meetings, at first, played out like Group Therapy, and sometimes went on for hours. I had to learn to compromise, and be flexible enough to change. But, every once in a while, my tried and true techniques didn't work.
Negativity expressed in a thousand different ways, is the hardest obstacle to overcome. I had to work hard to maintain a positive attitude, set short term and long term goals, and keep focused on the tasks at hand. Every day seemed to be dedicated to short term fixes, "putting out fires" . Every couple of months, I had to sit down alone and make a list of all the staff I had under my authority, and find at least one good thing about each of them. This was especially important when petty bickering threatened to tear the whole group into pieces.
And every once in a while, a person to person conflict between nurses would arise that required mediation. My response to conflict was immediate, and consistent. Both parties were to come into the office, and tell their side of the story, but do so in the presence of the conflicting party. If that resulted in a draw, I would pull out my last card. I would have the two parties face each other, and find, "one good thing about each other" to admire, and they would sit there until they did.
This backfired on me once, after 3 years as manager of our unit. An RN and and aide had been bickering all day. The nurse had been rude, and demanding, the aide would just stay as far away as possible. If the nurse came looking for her, she pretended she didn't hear. The situation had reached the point where patient care was compromised.
I brought them both in, and went through my routine. Nothing could make either of them listen to the other, so I asked them to sit face to face until they could come up with "one good thing" about the other party. When they had stared at each other for forty minutes, unspeaking, I threw in the towel. I gave them the rules of conduct and courtesy, made them sign it and they left. Now, fourteen years later, they have still not found "one good thing" to say about the other.
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This last installment is nearly over!
Let me end with some small and practical tips for nurses starting their first year of management in middle management positions. Maybe you can learn what took me many years to find out, the hard way.
1. Insist on orientation to administrative procedures, policies , and practices. Ignorance is no excuse, but you may have to work hard to gather the information. Know which meetings you have to attend, what reports are due and when they are due, and the routine for posting schedules, payroll authorization and other daily necessities. Nothing will annoy your staff more than to have a short paycheck. Nothing will annoy payroll more than having to cut a check before the next pay day.
2. Know who fixes things, what the paperwork is, and how to follow up on it . We live in a technical world. Eventually, you may be able to delegate this task, but know how to do ALL aspects of your job.
3. Treat all staff with courtesy and that means ALL staff, from nurses to techs, to dietary and housekeeping. Your new position of authority does not give you the right to abuse other people, even if you can get away with it.
4. Establish and maintain a strict CHAIN OF COMMAND PROTOCOL This is critical. Your staff need to be able to come to you, but can cause more trouble if they can bypass you and go to your boss. If your boss has integrity, they will send them back down the chain of command. If they don't support the Chain of Command Protocol, quit that job as soon as possible, because you will be the scapegoat for everything.
5. Be willing to staff if necessary My opinion, and you may not agree, is that if you are the manager of that department, you should be the recognized expert in at least one aspect of care. If you don't know how to care for the patients whose care you supervise, you are not qualified to lead.
6. Be available to your staff to talk to, and try to schedule a regular meeting with YOUR supervisor to keep him/her informed Communication is the key to leadership. You won't be able to mandate all solutions for every problem you face. You are going to need support. Without it, you won't survive. You have to be available to all shifts, not just the day shift.
7. Spend at least half your management time Assessing the needs of your department, Try to keep a journal of events, so you have some reference, but spend time assessing strengths and weaknesses. You have many resourceful and talented nurses working for you. Recognize their skills and allow them to contribute.
8. For every minute you spend disciplining, spend two minutes praising Fear does not motivate nearly as well as appreciation. There are lots of ways to approach the positive feedback aspect of your job...and I'll be glad to answer e-mails if you have questions. Recognize when someone does something out of the ordinary, or has dealt with a difficult situation well. Approach problems with solutions, not a list of ways to punish.
9. Know your limitations You can't be everywhere all the time. Sometimes you do have to say no. You need your time as much or more than anyone else. Believe it or not, this has always been the toughest part of the job for me.
Now, thank goodness, I am finished. I need to take two aspirin and not call anyone in the morning. I may post again on Professional Nursing, because hoo boy, do I have some stories to tell!
If you have actually read this whole article, you deserve an extra star. Or you need to have your head examined. Take two aspirin. Don't call me.
* For AWHONN, contact http://www.awhonn.org
** For NRP , contact http://www.aap.org
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Member: jude paxton
Location: In a state of confusion
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If I'd known TODAY was to be my TOMORROW I woulda done better YESTERDAY.
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