Let’s try again: Heidi’s nursing journey journal

[K888]

^ You say you can't help, but you already are.

Can also guarantee you every single healthcare worker is fazed and bothered by all of this, people just hide it very well, because what else can they do? Everyone is exhausted but they soldier on. Anyone working in any aspect of healthcare atm is working under significant pressure and stress - you don't have to be working on a COVID ward to be affected, the pandemic is affecting every single healthcare worker.
Please don't feel like you don't count or that your contributions are insignificant, or that the things you are experiencing or feeling are in any way less valid.

[heids]

^ You say you can't help, but you already are.

Can also guarantee you every single healthcare worker is fazed and bothered by all of this, people just hide it very well, because what else can they do? Everyone is exhausted but they soldier on. Anyone working in any aspect of healthcare atm is working under significant pressure and stress - you don't have to be working on a COVID ward to be affected, the pandemic is affecting every single healthcare worker.
Please don't feel like you don't count or that your contributions are insignificant, or that the things you are experiencing or feeling are in any way less valid.

Thank you, K888. <3

Firstly, apologies for focusing far more on work than uni in this uni journal.  Even though I'm a full time student and a part time employee, my self-identity is as a worker, rather than a student.  Uni fades completely into the background of my mind, compared with work.  The constant switching between the identity roles, and the vastly different demographics of my co-workers vs my co-students, is surprisingly stressful... despite them being the same industry.  I'll be relieved to be off uni for a while over the summer.  A part of me questions the decision to draw out my studies an extra year, because I wonder if it just draws out the stress and the "I should be studying" that sits constantly and uneasily in the background.

So here's an actual uni update: 

Assignment marks:

I've got back two marks, both higher than anticipated, and both further eroding my trust in the validity and inter-rater (and intra-rater) reliability of assignment marking.

NUR1113 Group Assignment: 80

80?!? I definitely didn't feel this was HD standard, or better than my previous assignments in 1111 and 1113.

* Two sections both had the comment "good" and nothing else: one got 9/10, the other got 7/10. 
* 9/10 for group work - my last group assignment got 7/10, with the same level of coherence. 
* 17/20 for video presentation, though we were just reading directly and blandly off a script with no preparation.  I made the slides and finished our scripts in the couple of hours before we recorded our zoom presentation.  (It helped that we sped the video up post-recording to get it down to 10 minutes - the bland, stumbling script-reading became much less noticeable.)

NUR2447 Pain Assignment: 88.5

This is the assignment that I struggled to start and felt I wouldn't be able to finish.  And I got the same* mark as my wounds assignment, which I thought I did much better. *0.1% less

I was given 15/15 and 40/40 for two significant sections because I "covered everything I needed to".  In my experience so far, doing that achieves an 8/10 mark, not 10/10.  And then I got weird comments elsewhere.  Like "spelling" in my reference list (Encyclopedia of Behavioral Medicine - there's no "u" in "behavioral" in the published title, so I didn't include a "u").  7/10 for presentation (formatting, academic language, spelling/grammar etc), when I think it was equivalent to my last assignment, which got 10/10 for presentation.

Look, I get it.  Marking is difficult and subjective at the best of times, but uni markers are under significant time pressure or even on unpaid time.  Context also has a disproportionate impact: Is this the first or thirtieth assignment you've marked on this topic?  Is this your seventh paper in one sitting and the thousands of words of bullshitting students have turned into a meaningless blur?  Were the papers directly before this one incredible or terrible?

What I've learned:

a. I don't need to spend so much time being perfectionistic, overthinking, or fine-tuning my assignment (except to cut word count).  My assessor won't notice or care.

b. Marks mean very little.  Sure, I imagine they're accurate give or take 10% or so, but it's stupid to define myself by them, because different markers would give very different marks for the same piece.  Even the same marker would likely give different marks at different times.

Exams: Finished!!! (Monday, Tuesday, Wednesday, Thursday this week)

Written before exams

I don't feel like I'm very prepared, but it's interesting noticing my warped mindset.  If I get 90% on practice quizzes, that indicates that I know the content pretty well.  But I just see the ones I got wrong, and feel like I don't know anything because I didn't know the answer to 1 out of every 10 questions.

This semester, we had less content and 5 weeks between end of classes and exams (to fit in placements).  Other students have clearly used the time to study; they're asking all these super obscure questions about things I've never heard of.  This semester should be my best semester, because it's 50% exams and I thrive on exams, but I just haven't spent the time I normally would to fine-tune my knowledge.

There are definitely diminishing returns of effort the higher you aim, though.  If my goal were really to just pass, I could put in surprisingly little work, because a passing familiarity with the content would get me half the questions right.  But if your goal is very high, you have to learn every possible border case and remember every single piece of information just so you can answer the one or two left-of-field questions in the exam.  Same with assignments - just quickly outlining answers to questions and putting in some marginally relevant references would get me a pass with little time commitment.  But getting 85% for assignments is a real tough slog, and 95% is probably completely impossible.

I'm fairly prepared for NUR1114 and NUR2447, but we have no practice questions for NUR1113, and I really haven't even read all the basic content once.  I attended workshops with no pre-reading and just talked my way through scenarios.  I'm really relying on my ability to cram and bullshit - both decent strengths of mine, and much more possible with NUR1113 than my other subjects.

Written after exams

Well, they all went okay.  I expect I got 90+ on each exam.  I feel pretty awful as a result of four days of stress chemicals, and it got harder and harder to study for the next day after each exam.  But I'm just so relieved it's over.

1. NUR1114 Exam (anatomy/physiology/related nursing content): I felt underprepared, but realistically I knew most things.  As usual, the things I wasn't sure about were mostly areas that studying more wouldn't have helped much with, such as application MCQs, where two answers could be right in different circumstances but I can't explain why because it's MCQ.

2. NUR1114 Musculoskeletal Anatomy: Bone identification/landmarks, muscle origins/insertions/actions, basic joint information, etc.  All MCQs.  Very easy because it's so black and white without ambiguity, and I learnt this content thoroughly with Anki (and using active recall, which is harder than MCQs where the choices are there so you don't have to draw answers out of thin air).  If I don't get 100%, I've made a silly mistake somehow.

3. NUR1113 Exam (law/ethics): I only started studying this after the MSK test the day before.  I hadn't touched the content for six weeks, and didn't cover it thoroughly even when I did touch it.  I crammed pretty intensely, reading content I'd never seen before, and was panicking that I wasn't prepared, even though the content was simple and limited.  But when it came to it, it was fairly easy without trick questions, and what I'd learnt was very applicable.  The MCQs were mostly MUCH better written than last semester's equivalent unit NUR1111, with only a couple of ambiguities.

4. NUR2447 Exam: I felt very prepared for this, because I was interested in the content and learnt it thoroughly throughout the semester.  Our prac exam had lots of very specific questions on wound products, so I spent ages learning that in a lot of detail this morning, but only 3 marks were related to that in the entire exam   It was slightly harder than I anticipated, with several MCQs I wasn't sure about, but I feel I probably did about the same as in 1114 and 1113.

Summary: although I was anxious and felt under-prepared, I probably would have gained only a percent or two here or there if I had spent hours and hours more studying.  Before an exam, you don't know if they're going to go into a lot of detail in unexpected areas, so I always think I don't know enough if I don't know all of those possible areas.  And then in practice, they often don't ask anything too complex.

I'm honestly amazed that I've somehow managed to do so well at uni this semester alongside working so much.  Everything came together somehow.  It's partly because of lockdown taking away my other commitments, but I'm not really sure how on earth I did it.  The only beneficial habit underpinning this was consistent sleep - I consistently maintain 9 hours a night.  Otherwise... I don't feel like I organise and manage things very well.  There was lots of crying and hating the world at intervals, and I continue to be scared that I won't be able to handle the future. 

Once I've done placement (2.5 weeks from now), I'm finished!

Estimates for total unit marks:
NUR1114: 90 [double CP - very uncertain as I've only got back 15% of marks]
NUR1113: 84 [79.5 pre-exam]
NUR2447: 91 [88.5 pre-exam]

[heids]

Well, I've finished 1st year, finishing my placement Saturday evening.  It's been a challenging end to a challenging year.  I am so relieved it's over, and not all that keen to repeat it for the next three years - though I'm sure that at the end it'll probably feel like time has passed unbelievably quickly and no one should possibly let me be a real nurse yet!

Today I have my first day off in 19 days, but I'm back at work tomorrow.

I got marks back for two of my subjects:
NUR1113   Law, ethics and leadership in nursing and midwifery   85   HD
NUR2447   Clinical concepts   93   HD

My double CP unit will come back once they've processed my placement marks.  I'm estimating 95, because I think I got 100 for my placement rather than 70-80 like I guessed before it.  That would keep my WAM at 93. 

My 2-week placement was in a subacute rehab ward - patients not acutely ill and often* elderly.  Primarily neuro (strokes) and ortho (fractures, joint surgery, amputations), usually a halfway step between an acute hospital and home/permanent resi care.

[*Not always.  The sad cases are younger adults with young families who have had a devastating stroke, injury or prognosis.]

The spoilers below give much more detail about nursing and being a student on this ward.

The daily role of a nurse in this particular ward

Shift times are as follows:
- AM: 0700-1530
- PM: 1300-2130
- ND: 2100-0730

The roster is rotating, with staff being allocated rather than having fixed permanent shifts or getting choice.  Everyone rotates through night duty every couple of months.  PM shifts followed by AM shift the next day are common.

A nurse is assigned certain beds (4-5 beds AM, 5-6 beds PM, 10-11 beds ND).  For these patients, nurses will:

- Receive handover at start of shift, and handover to other nurses at end of shift
- Take vital signs/neuro observations/blood sugars according to plan
- Administer medications - mostly oral, some topical or injections etc
- Assist with ADLs: toileting (continence aid changes, transferring to toilet, wiping, adjusting clothes etc), washing, showering, dressing/undressing, eating, etc.
- Transfer the patient (assisting with standing/walking or using a machine, such as a wheeled standing machine or a sling hoist - to the toilet, to chair/bed, into wheelchair, etc.)
- More complex tasks as required, e.g. wound dressings, feeding through tubes, IV fluids, catheterisation, etc
- Admission of new patients - physical assessment, ECG, urinalysis, weight, settling the patient, filling out forms, etc.
- Educate patients on their condition, medications, self-management, advanced care planning, etc.
- Assess further if anything feels off or is outside normal ranges, escalate concerns to doctors, initiate emergency calls if required, etc.
- Respond to patients' call lights and requests
- Fill out paperwork and write progress notes

Additionally, nurses help out other nurses as needed, such as covering their patients while they are on breaks, helping with 2-person transfers or tasks, medications that need 2 nurses, etc.

Being a student on the ward

I was given my roster a week before placement started.  It involved AM/PM shifts across weekdays and weekends - I think we only do nights in 3rd year.

We were paired with a buddy nurse/preceptor each shift.  They tried to keep us with 1-2 main nurses on as many days as possible, but given shift swaps and sick leave etc this was often variable.  We stuck with that nurse and their set of patients, occasionally going to help other nurses or watch rarer complex skills being performed.

On day 1, we just shadowed a nurse.  They did basically all the tasks while we just watched, and participated slightly in basic tasks.  On day 2, we were required to pick a "focus patient" out of the nurse's patients.  We would do "everything" for that patient, initially with significant supervision and assistance.  We would plan the tasks for the shift, administer medication, help with ADLs, do their documentation, handover to the next nurse, etc.  After 4 shifts I started taking 2 patients, and eventually 3.  It was fluid, though - I usually filled out a planner for all our patients, participated in tasks for all of them, and my preceptor often did several tasks for my focus patients rather than waiting for me to do it all.

I was very scared of the idea of taking a focus patient at first, but then realised it's not all that complex, and the nurse expects that we need a lot of prompting and explanation at first, and will make sure we miss nothing.

My experience of placement

On day 1, I felt overwhelmed and lost and hated everything.  I was shaking while doing very basic tasks.  But immediately on day 2 I realised that I do know what I'm doing.  Because our patients weren't acutely unwell, it's a lot like my job with some new tasks added in, particularly oral medication administration.  I also knew more than I thought from classes - I could quickly understand abbreviations, conditions, medications, processes, and critical thinking.

I'll give an example of day 2 of placement, where I felt I understood the process:

Okay, we have a BP-lowering medication to give my pt at 2000, so I need to take vitals at 1900 rather than at the start of the shift.  Oh, the BP is very low.  I encourage them to drink, ask if they're feeling dizzy or lightheaded, sit them up a bit, retake their BP manually, withhold the BP medication for now, report to doctor, and later take another BP.  Doctor says to recheck in a couple of hours and withhold medication if systolic is <100.  Systolic rises to 110, so I go to give the medication, and my buddy nurse says "no, the doctor said to withhold".  Turns out I was right remembering the parameters.

It's not huge, but I felt confident in myself after that.   

I have a big head-start from working in aged care - I know how to interact, communicate, and carry out basic tasks (dressing people is not that difficult, but it definitely has a knack that takes time to learn).  Multiple staff asked if I worked in aged care, saying "it really shows".  Combined with pretty solid "book" knowledge from uni and a real desire to learn and help, I know I did well.  All the feedback I got from patients and staff was really positive.

Okay, except one: I was watching someone do a PEG feed for the first time - just pouring a supplement through a tube straight into someone's stomach.  The nurse asked me to open the juice-box and I fumbled for a bit trying to find how to open it - you just have to peel off a bit of foil.  She grabbed it off me and was like "that's not even a nursing task, that's incredibly basic, you should be able to do that!"  Once I'd seen it done once, of course I could immediately do it without half a second's thought.

That's what it must be like for other students with literally every single basic task - you have to be shown once before you know how to do it.  But to experienced workers it seems like obvious common sense and it's ridiculous that you can't do it immediately.  You can "catch up" very quickly, but you look like a fool for the first little while.  With harder tasks I haven't done at work, it can take me 5+ times of being shown before I get it.

Heidi has exceeded her ability as a year one student. I think Heidi will be a very good nurse in the future.

I really think that I could start working in this job now.  Not in acute settings, but in this subacute setting, I could fairly quickly learn on the job.  I'd be terrible at first, but I'll be terrible at first any new job - that's expected.  [/size]

Holidays:
I have no plans for anything beyond working full time.  I need to take a break at some point, but I still feel like I'm on a treadmill I can't get off.  And my brain still keeps nagging that I should get a second job to supplement this one and learn different skills.  It's like a constant fight between the sad, scared, exhausted part of me that cries about how much I'm working and begs to be let off and left alone, and the part of me that delights to book in more and more hours, and feels proud of me for how much I work.

But even if I dread work beforehand, I do like it while I'm doing it.  Not all of it, but mostly I feel like I'm finally bringing value to people's lives, and I feel like they value that. 

Still, after long days of being a problem-solver and a supporter and doing everything for other people's lives, I feel like I can't manage some of the basic elements of my own life.  I can shave them and get them food and tidy their belongings and wrap their Christmas presents and help them call their families, but I often can't do those things for myself once I get home.

I also keep feeling like the only way that I'm still afloat and externally succeeding is sheer luck, and the moment circumstances are different or the luck doesn't go my way, I'm going to sink and show up that I really can't do anything.

¯\_(ツ)_/¯

[K888]

@ that nurse judging you for not being able to open the juice box, that's unnecessarily judgmental, I always regret offering to help open patients drinks because it's never easy and almost always ends with me spilling something

Congratulations on finishing first year! Now you've passed that big hurdle I think you'll enjoy your degree more and more as you go along and develop more skills. Proud of you for absolutely smashing it this year <3

[Tapioca]

Hi heids, please check your PM 

[heids]

I get further off topic the further I get through this post, so good luck

Uni.

1. Final score of 2021: My double CP unit score was better than I dreamed: 98.  That brings my WAM to 93.75.   Reminder to self: I often get obsessed with all the tiny, left-of-field pieces of information I might not quite know before exams, and feel like there's a ton I don't know.  But usually, I do end up knowing the vast majority of what they ask me.  It's so easy for the stupid, negative, perfectionistic brain to latch onto everything negative and ignore the rest. 

I worked a lot of hours soon before exams this semester, and felt like I didn't get the time I needed to study, but spending extra hours really wouldn't have got me better marks.

2. Return to uni: It's coming up pretty soon now! 

A big part of me is really dreading it:
- juggling everything and switching between different parts of my life is tricky
- the need to study hangs over my head at all times
- I work in aged care for a reason... apparently I can only interact appropriately with people 50+ years older than me
- and (most of all) assignments are hell

But lately I've been learning about patho and medications during quiet times at work, and last week I did peer mentoring training.  Somehow my learning spark has been lit up again.  I really, really do love learning and understanding new medical information, putting new pieces of the puzzle together.  If uni were all exams rather than assignments, I'd be way more keen.  I'm definitely going to enjoy the content-learning aspect starting back at uni.

It will also be a good physical break, a change of pace, and maybe bring a bit more balance back.  (These are words I'll absolutely regret saying when I'm desperately waiting for holidays by week 2!)  But work has been very all-consuming, as well as pretty hard on my body.  It'll be good to give my physical body a rest, while stimulating my brain in different ways, and giving me a chance to step back from thinking and breathing exclusively work.

On which topic...

Work.

Work has been intense.

I'm not working with covid+ patients or doing testing, so I'm very much on the sidelines, but the aged care sector has REALLY felt the hit since Christmas, with the combination of staff taking holidays and covid reasons, such as testing positive, being a close contact, having symptoms, or burnout.  Agency staff are virtually non-existent, being swallowed up the moment they're available.  Double shifts and short staffing are an everyday expectation.

I've learnt that I can push myself further than I expected.  I have done 7am-10:30pm shifts.  (That's longer than I'm normally awake in a day).  I've done 7-9:30 and then gone back for 7-3 the next morning.  (The next morning is the killer... by 3pm I feel like I can hardly walk).  I've done 3 double shifts in a week, while working 6 days in that week.  I've worked many days in a row.

My brain argues daily over whether this "increases my stamina" or exhausts me to the extent that it will inevitably lead to burnout.  I prefer to believe the former.
 
You definitely do develop a stamina for longer hours, though.  I remember thinking that the US system of 3x 12 hour shifts per week was absolutely crazy.  And now I can see how you could do it.  I can see that for some people, it would be the better option - less travel/prep time, more clear free days off.  Once you're there, you can usually push through.  I personally feel like my ideal full time balance would be 4x9.5 per week.  But I think the real ideal would be a mixture of options to provide flexibility and choice - some people can do 12s if it suits, some people can do 8s (or even 6es) if it suits their lifestyle.

But I really think with rostering that freedom of choice - the ability to pick the things that work for you, rather than the false form of "equality" that is "a few people want to do nights and most don't, let's make it equal by forcing EVERYONE to do a mixture so we screw over everyone's biological clock equally!"

Sorry, I went riding right off topic on another hobby horse.  I just don't think that people should be forced to do rotating rosters in the name of equality - instead, night or other hard-to-fill shifts should be incentivised enough that enough people pick them up by choice.  After doing a string of only mornings, my sleep pattern is so much healthier, and getting to sleep and waking up are much easier.  Surely we should protect HCWs' health and sense of agency.

Side note on an important internal realisation I had a few weeks ago

I have finally truly realised I could do medicine and become a doctor if I wanted.

I've always put med on a pedestal, beyond my abilities.  I've always felt like I can't imagine how people can balance and learn it all.  And yet this year has shown me that I can do more than I believed.  That if I really wanted to, I could throw my energies into it, and manage both the scores and the hours of overtime.

But... I don't want to.

Yes, I'd love to learn all the information, and I'd love(/hate) to be pushed and challenged more academically.  But no, I don't want to be a doctor.  I want to be the person who is there with the patient for longer - to support, to educate, to care - in other words, I want to be the nurse.  Now, both roles are valuable and deeply essential, but one of them fits what matters to me more than the other.

Why my self-estimation has changed:

1. Academic scores for the year: Although my WAM really, really doesn't matter in becoming a nurse, getting 93.75 was still comforting, especially given how many hours I worked throughout and how frequently I panicked.

2. Amount I've been working: in the last few months, I've worked pretty significant overtime, on my feet and short staffed.  This really confirmed that I can do more than I expected and still survive, and comes on the background of essentially working more than full time for quite a long time.  I'm not the fragile useless blossom I often feel.

Now as with everything, there are always people who work more or score higher or succeed through a million disadvantages when I have none.  And I feel like I'm bragging.  But these realisations were surprisingly freeing.

I'm also a little disappointed that I, as a nurse-to-be, still hold all the prejudices and stereotypes of nurses vs. doctors.

I have also applied for another job: a RUSON role with Eastern Health (registered undergraduate student of nursing).  I haven't heard back, but am assuming I would get the role fairly easily if I want, because of relevant work experience + decent scores + good references.  I've decided I'll only take it if they offer me a role at my local hospital, and don't expect more than 1 shift per week during semester.

In the process of resume-editing, I realised something: on a resume, you simply record the number of months/years you spend in a role.  On that document, working 1 shift per fortnight looks basically exactly the same as working 50 hour weeks - but with 1 shift a fortnight, you can also be involved in other, different opportunities where you show different skills and build different connections.  Maybe I need to decrease hours and diversify.

On the other hand, when you don't split your focus, you do a damn good job at your one role.  For instance, because I'm there every day, I know everyone pretty intimately and make sure they're properly cared for.  People know they can trust me and rely on me to be there for them.

And yet, I get tunnel vision doing one role all the time.  It's hard to see a bigger picture - you get so deeply absorbed in the job and the type of people you interact with.  It's good to shake things up and realise that the world is a bigger, more diverse place.  But also... I find switching my focus and people mind-bogglingly difficult.  It's like getting whiplash over and over, and I don't feel fully present or like I properly belong anywhere.

So I don't know.  As with everything, it's about balance.  That necessary balance between being a specialist and a generalist, the balance of depth and breadth, the balance of focus and the bigger picture.  Only attained through trial and error - probably mostly error lol.

Anyway, if I don't stop rambling now, I'm never going to post anything.

Also, I really need to see a psychologist.  My brain is a mess (: