Shadowing an RN

Hello and welcome to Asclepius. Today I’m going to talk about my experience shadowing a Registered Nurse on the medical surgical unit. I asked the Nurse a few questions, and made some eye-opening observations that I feel are worth talking about for a major reason: Even as a student nurse I sometimes get discouraged by what I’ve seen in clinical rotations. Often, when I’m at clinical, the most I really get to do is morning patient care which includes feeding and bed-making. If the hospital allows us to, my classmates and I sort of “practice” under our instructor’s license, which allows us to administer medications with an  RN who works there or with the teacher. In the scope of 8-12 hours, these tasks can become tedious and honestly aren’t very enjoyable. These limited responsibilities are also few and far between. It’s more of a day seasoned with Nursing experiences than a full and educating day.

I’d love to say that a full day in the hospital spent helping others to heal is always impacting and satisfying, but honestly it can be stressful, and I’ve personally begun to find it more boring than anything. This may be happening to me for three big reasons.

  1. My personality. I love to be hands-on, in the action, and learning. I love challenges. I live for fast-paced activity. I very easily feel bored otherwise. Personally, I’d love to go into intensive care, critical care, or emergency medicine. Not Med-Surg. But my true love is surgery. That’s just me. The busyness of the medical surgical floor isn’t my flavor of busyness.
  2. My limited experiences. I’ve only done rotations in med/surg, pediatrics, labor and delivery, and a nursing home (mostly med/surg). And as I said earlier, my experiences in each rotation have been very limited. I’m not allowed to do everything and often I don’t get to do anything. I can probably count more clinical experiences where I was studying in the break room opposed to the time I spent actually on the floor.
  3. Not every nurse wants to be shadowed! If you don’t have a nurse to learn to be a nurse from, you don’t get to practice nursing. Simple as that. And trust me! I’ve definitely done my time running after anyone who would teach me. But after being pushed aside so much, it’s much more conducive for me to spend my time studying than pretending to be learning something from the few things I’ve done so many times already.

This experience was different thought. I spent about 9 hours with an RN, and I made it my duty to follow his every move. Luckily, I had a very gracious RN to work with, and he welcomed my nosiness unlike the other RNs I’ve tried to shadow. SO here is my experience, start to finish:

Hand-Off/Huddle

Every change of shift starts with the day and night nurses huddled together so they can “hand-off” their charges to the next nurse. They talk about the Patient and pass along all necessary information so the new nurse can form her plan of care for the day. They also talk about other things, like any events that happened on the floor during the last shift or supply shortages.

From the huddle, I followed my RN to find a computer. Then to the pyxis room for medications. Some hospitals have all the meds delivered to the floor by hospital pharmacy. In some hospitals I’ve seen the nurses go to the pharmacy themselves and receive the meds for their patients. But this time, in this particular hospital, I got to see a Pyxis Room. It’s like a storage room for all the equipment and meds. It’s really cool. The nurse explained how everything in this system is computerized. So after you find your patient in the system, the computer shows you which drugs are ordered by time of administration, and opens the right door to the compartment holding the needed meds so you can’t even take the wrong one. There’s little to no mathematical calculation with this system since it’s all computerized, so overall, there’s less room for error (which is the whole point). It’s like a safety net.

Study the Patient

This method of planning is specific to the Nurse I shadowed, since it’s a method he developed himself. He learned this organizational skill from his time in trauma nursing, and even had a custom “brain sheet.” It had six rectangular boxes on the page, one box per patient. Each box housed the vital information: Patient’s chief complaint and diagnosis, Lines, drains, devices, MD on call and treatment team, active orders including meds and fluids, labs and tests to monitor or that are yet to be done, Vein thrombus prophylaxis, Vital Signs, last note entered in the patient’s doc, diet (soft or regular for example), Medical and Surgical history of note, allergies, and advanced directive. Essentially, it’s like carrying a summary of the patient’s chart around all day, very simple and practical. All nurses have their own or standard version of this method. Seems like a ton of information, but it’s really basic when you’re on the floor. It proved helpful and for me was very easy to remember everything. I ended up not even needing to refer to it very often.

Meet the Patient

Next we went around to every room of assigned patients. This part is the fun part of the morning. You introduce yourself to the patient, explain what you’re going to do for them or what the goal is for the day, tell them how long you’ll be with them, and you assess them. The RN did a thorough but brief head to toe assessment of every patient: checked IV sites for redness, swelling, pain or tenderness (could be a sign of phlebitis or infiltration… not a good thing) as well as the tubing for expiration dates. He listened to lung, heart, and bowel sounds, asked the patient about their appetite and GI movements. He assessed their pain using a pain scale and their vital signs. As a student, even though this assessment should be brief it would have taken me a while. With experience comes speed, so he did it very efficiently and it was awesome to see in action.

Then we administered medications by mouth, injections, and IV. After we did these vital things for all six patients, he took me back to the computer and showed me how to document. In summary,  the computer system for documentation is very straightforward and I’m not really going to describe it any more detailed. This whole process of getting the day going took a couple hours.

Usually, this is where my day at clinical tends to die down. But not this time.

“So what do nurses actually do all day? I’ve seen this part so many times but after it’s over the Nurse tends to disappear and I have no idea what comes next in the 12 hour shift.”

“That’s interesting. Well, follow me. Right now we’re going to straight-cath someone.”

And the rest of the day stayed upbeat doing all sorts of things. Checking feeding tubes and starting feedings. Making nursing judgements and implementing actions. Communicating with the doctors and cooperating with the PCTs (We even went around to our patients with the PCTs and helped them clean and care for our patients).  Being present and aware at all times, always advocating for the patient, and getting something done whether it be a nursing action or even just documenting. The day was FULL. There was always something to do. And in the moments of downtime, the RN answered questions for me.

As I recall, there was never really a moment when the RN sat down. He barely even took a lunch break. He was always doing something for his patients. This was the most significant observation I made all day. He was IN the patients’ rooms. In and out, all day. When they say nurses are the doctor’s eyes and ears on the floor, they’re right. I think I saw my patients’ doctors maybe once… or twice. The RN was there the whole time. Obviously, not to a point where he invaded the patient’s life lol. But he was really actively caring for the patient. Whether it was intervening at the bed-side, assessing, or arguing with dietary to get the patient their food. Maybe that was the nature of  this RN, but I swear, if every nurse worked the way he did the world would be a better place.

RN’s Responses

What do you think is better, working a private hospital or a city hospital?

City. In private hospitals, it’s easier to lose your job because in private hospitals, client complaints are taken incredibly seriously. There’s little to no protection for an RN aside from malpractice insurance.

He told me a crazy story too:

I once worked in a private hospital. I had a patient who called me into the room one day and asked me if he could barbecue in his room. Barbecue. In the hospital room. Of course, I said “No, sir. You cannot barbecue in the hospital. That violates so many safety precautions.” Not long after the patient’s discharge I was called to HR. I thought I’d killed someone, I thought I was losing my job, or worse, my license. But it was nothing so serious: a client had complained about me. A particular client wanted to barbecue in their room and I’d told the patient no. It was time to answer for my actions. And as ridiculous as the complaint was, as justified as I was, I was without defense and my file grew a little bit thicker after I got written up for the “incident.”

Working for the city, you have more protection. The hospital inherently treats you more like an asset than a liability because they care about their workers as vital role players, not as pawns for their business. If someone makes a stupid complaint against you, they’re more likely to side with you because YOU are their business.

Medical work this far and goals for the future:

He was an EMT, a trauma RN, and now a med-surg RN. A total of nine years in the field. His future goal was to potentially quit nursing altogether. He expressed his dislike of the job due to its unrewarded stresses. “Don’t get me wrong, the money is good, but there’s so much that a nurse does that goes unrewarded.” He said maybe he’d teach instead… or drive for uber. lol

Travel nursing:

He explained the way travel nursing worked in his experience: you get a contract with a hospital for a set amount of time. Could be months, could be longer. In his experience, he traveled out of state to work in a hospital for 6 months and honestly felt like he was dealt the jobs no one else wanted to do. “They looked at me as a temp, and gave me all tasks they didn’t want to do themselves. I did about 2 things all day every day for six months, case after case.

Best Advice to New RNs:

“Statistically, 50% of new nurses quit within the first half to full year of work because of the STRESS of this job. This feeds the problem of a nursing shortage, which in turn, feeds the issue of work stress. Less people around to do the job, the more stressful it is on the few who stay to work. The more stressful it is, the more people don’t want to work. It’s a vicious and unfortunate cycle.

The other issue contributing to the shortage of nurses is the MONEY. It costs a hospital about $100,000 just to TRAIN a new nurse. So they can’t be hiring nurses left and right. This is also what makes it a competitive field, which doesn’t make sense otherwise in regard to the shortage. The other money issue is as I said earlier: a lot of what an RN does go unrewarded. Right now, we’re going to make a case for a patient to receive a very expensive kind of mattress to lessen the chance of her pressure ulcers worsening. Is anyone going to compensate me for the time I spend advocating and dealing with the “business” of it all? No. Is anyone going to compensate me for performing her wound care? No. If I got paid per nursing action by the value of that action, I’d be making significantly more. But I get one over-arching salary that honestly doesn’t measure up to the toll of the job.

All that to say though, Don’t be discouraged if you’re a new nurse. Just tough it out. And honestly, it’s best to figure out while you’re in school whether you CAN tough it out. For example, if you can’t handle the pressure and stresses of nursing SCHOOL, can you really handle the challenges of a nursing CAREER? Most likely, you’ll be a statistic.”

I asked him to clarify whether the stresses he spoke of were unique to his own personal experiences. Trauma and Med-surg nursing are known to be very stressful. What about in another specialty?

“I think every specialty has its own unique stresses, and the sentiment remains true: If you can’t handle stress, you probably can’t handle this career.”

MD and RN relationship:

“The relationship between doctors and nurses is mostly good, to be honest. I’ve worked in the south and in the north-east, and it’s a little different in either place but mostly it’s good. How is it different in NY than elsewhere? Well, in more rural areas, where it’s harder for a hospital to get doctors, it’s more strained because the doctors are more needed there than the nurses. The doctors tend to let this “importance” go to their heads and they act like they’re the gods of the hospital. And to a degree, it’s true. RNs are more disposable because the doctor can do more.… obviously.”

That’s all we really had time to talk about in passing moments, but I found it very interesting. Hope you did too!

The end of the day

Of course, the end of my clinical day was not the end of the RN’s day. It was fitting though that my last duty was to discharge a patient with the RN. This involved educating the patient, removing all lines and devices, legal stuff, and documentation. It was helpful to me to learn how to navigate the computer systems, and learn the routine of a discharge.

In the end,  I did so much that day I barely had time to write it all down in my little field journal, so I don’t even remember everything! Tried to hit the highlights though. Hope it provides you some insight into a day in the life of an RN.

 

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