One decision made

I'm going to work for at least a year before entering grad school. Suddenly life seems a lot less complicated.

Clinicals

I started my adult health rotation last week. I'll spend 5 weeks on a cardiovascular surgery floor, then 5 weeks on a short stay medical floor. Here's a quick rundown on what my weeks are going to look like from now until Christmas:

Mon: Lecture noon-8pm

Tues: Lecture 8am-3pm, go to clinical unit and copy patient information, write up a report on patient including primary diagnosis with pathophysiology, up to 6 comorbid diagnoses, explain their pathophysiology and effect on primary diagnosis, past medical history, drug cards for medications (up to 12), and a priority nursing diagnosis.

Wed: Clinical 7am-4pm, write up a report that includes assessment of patient, and nursing care plan with daignoses, interventions, expected outcomes, and method of evaluation.

Thurs: Clinical 7am-4pm, implement the care plan, write up an evaluation of whether it worked.

Fri: Simulation or Community Health (alternating Fridays). For simulation days, write SBAR report, critique partner's SBAR, blog, and comment on blog.

That's the summary for this class alone. I guess that's what happens when you take a single class worth 8 credits.

Other than the crazy workload, I think I'll really enjoy this clinical rotation. My instructor is great, gets really involved while we're on the floor. And the patient population is mostly interesting. I say mostly because I'm interested in cardiac surgery patients, but not vascular surgery patients. Vascular surgery is a lot of, "Oh, you had uncontrolled diabetes for your entire life, we're going to cut your gangrenous leg off now." I'm hoping to be assigned a cardiac patient for this week.

Also, our nurse manager had breakfast there for us on the first day. How cool is that?

I'll write more about clinicals when I start to get interesting stories to tell.

Grad school hunting

There are basically four schools and two degrees that I'm interested in. A master's degree (aka nurse practitioner license) and a PhD (aka license to do lots of research and teach). So I narrowed down my list of schools by finding ones that would a)be in places I'm willing to live b)have some way for me to work on both degrees at the same time and c)help me pay for those degrees. The list ended up being University of Rochester, Boston College, University of Pennsylvania, and OHSU. OHSU is sort of an honorable mention for reasons I'll explain later. Let's go through the pros and cons of each:

1. University of Rochester
Pros: I'm already here. MS/PhD dual degree program. Fully paid tuition for said program. Associated with a really high quality teaching hospital.
Cons: Staying in Rochester for 5 more years.

2. Boston College
Pros: 4 year MS/PhD program. Boston looks cool.
Cons: Boston's expensive. Not sure about the funding for this one. Reputation of not liking people from outside the area. Jesuit school, which may or may not matter.

3. University of Pennsylvania
Pros: Ivy league. Associated with nationally recognized hospital. Fully funded for PhD portion of program, plus $20K stipend. Philadelphia looks cool.
Cons: Have to fund the Master's degree myself (only one year). Moving to a new city.

4. OHSU
Pros: Portland! Faculty with my exact research interests. Associated with really good hospital. But mostly, Portland!
Cons: No dual degree program. No Adult Nurse Practitioner program (only Family). Bureaucracy.

So, based on this list Penn and UR are looking pretty good. But then I have to take into account what I actually want to do, which changes frequently. Right now I'm kinda liking the idea of bedside nursing, which I give up if I get my NP. But, I could still do if I just got my PhD. In which case, OHSU jumps to the top of the list. So, I think my plan right now is to apply for all of these things and then decide based on what I want to do when the decision has to be made. Usually there's an option to defer admission for a year, or start out part-time, which I could do while working a full-time job as an RN. Although I'm open to any suggestions for alternatives or additions to this plan.

Job hunting

This isn't so much hunting for jobs as deciding which ones I'm interested in. I love my chosen career already.

My first step was to shadow at Strong Memorial Hospital here in Rochester. They require you to shadow on the unit you're interested in before you can apply for the job. So I scheduled two shadows for last Monday, first on general oncology from 7am-11am and then on the bone marrow transplant floor from 11:30 to 3:30pm. I walked over in the dark early morning with Sarah, since she was shadowing on labor and delivery, and we got shuttled off to our respective units by the nursing recruiters.

I was introduced to my nurse, and she whisked me off to meet her first patient for the day. She was assigned 4 patients, 3 of whom had blood cancers. As I followed her around throughout the morning I just got more and more amazed at how efficient she was. She never stopped moving the entire 4 hours that I was shadowing with her. She saw and assessed patients, administered medications, hung a platelet transfusion, prepared a patient for discharge, prepares a patient for a surgery, reassured family members, fed a man who couldn't use his hands, and still somehow found the time to help out anyone that asked her for anything. The most amazing thing was how she managed to go from looking completely frazzled to looking completely composed the moment she stepped into a patient's room. I want to be like her someday. At 11 I realized that I hadn't been able to ask her any questions about the unit, but there was nothign that could be done about it, so I ran off to get lunch.

After lunch I was taken up to the bone marrow transplant unit. I was met by the charge nurse and the nurse manager (aka the people that hire people) and they were both very welcoming and eager to talk to me. First the charge nurse sent me into a team treatment planning meeting. It was very interesting, especially since they discussed the 3 patients I had met that morning on the oncology unit. When I got out of the meeting I had a long list of questions for the charge nurse, and she answered them all. Then I got a quick tour and description of the unit. They have 12 beds, all in private rooms. They take all kinds of patients, including pediatric patients, with every imagine disease that might need a bone marrow transplant. They do both autologous and allogeneic transplants, and they even have 4 outpatient infusion chairs. After my tour, I followed a couple of the nurses around for most of the day, just doing standard nursing stuff. Then I got to watch and help with an autologous transplant, and that was really cool. I actualy like the vibe and atmosphere better on the this floor than the oncology floor, but I still can't identify exactly why. I just felt more at home, probably because it's so similar to 5C at OHSU.

I got to talk to the nurse manager about the hiring and orientation process a little bit. They usually take 1-2 new graduates each year, and spend 12 weeks doing orientation (most units do 6-8 weeks). Orientation means working 1 on 1 with another nurse and learning how to do the day-to-day job. After orientation they let you loose to work on the unit as a regular nurse for a while. At some point during the next year, they send new hires to the ICU for a while to get critical care training. They also slowly introduce new hires to working with the pediatric patients during their first year. What this means is that nurses from this floor are the best trained in the hospital, but they also want you to commit to a year of full time work at the time of hire.

The next step for me at Strong would be to submit an application and get an interview set up. I will do that soon, but want to get to know my current clinical instructor better first so she can write me a recommendation. Based on the feedback I got from both the recruiter and the nurses on the unit I'm pretty confident that I would be offered a job on at least one, if not both of those units if I apply.

Job hunting in Portland has also progressed a little. I contacted OHSU a while ago to ask about working on the BMT floor as a new graduate. They said that yes, they do hire new grads, but I should just apply online when I'm about 6 weeks away from taking my NCLEX. I don't like that answer for a couple of reasons. First, I'd like to shadow on the floor. Second, I hate the OHSU online application process and have never had any luck with it. It sucks. I got my last job there through the Willamette Career Center after submitting dozens of applications online. Third, I don't know when I'll be able to take my NCLEX because I can't do it until UR gets some paperwork to whoever administers the exam. It might be delayed by a month or more after graduation. At Strong, I can work as a graduate nurse until I get my RN, it doesn't sound like that's a possibility at OHSU.

Based on all of the above, my mom contacted Dr. Meyers, who knows me fairly well and has always been very supportive of my nursing career plans. She kindly offered to get me in touch with the appropriate people to help get me a job on the BMT floor at OHSU. I haven't heard back from her yet, but I only emailed her on Thursday, so I need to give her some time. I lov having inside connections.

I haven't looked at jobs elseewhere yet. I'm betting that I'll either be in Rochester or Portland for graduate school though, so there isn't a whole lot of motivation to look elsewhere. I might check out the hiring process at some hospitals in Philadelphia (more on that in the grad school post) but that's probably it for now. It is pretty exciting knowing that wherever I go I will be able to get work, but I'd like to know that I can get the kind of work that I want.

Don't even know where to start...

A lot has happened in the past couple of weeks. So, I'll follow Matthew and Leah's lead and give a list of things to catch up on:

1. Job hunting
2. Graduate school hunting
3. Clinicals
4. Classes
5. Everything else

I'm going to try to write about most of that over this weekend, since once the week starts I have zero free time. I'm beginning to understand the true meaning of "accelerated program" and I'm loving it.

Recruitment

We're being seriously recruited. It's time to start thinking about where I'm going to apply for jobs and what kind of jobs those are going to be. Of course, my first choice of job would be to work on the BMT floor at OHSU. Since that is unlikely to mesh with my graduate school plans, I need to expand my search a little. Like, to the BMT floor at Strong Memorial Hospital in Rochester. Which, by the way, offers full tuition reimbursement for any classes at UofR for anyone that has a) worked at SMH for a year or b) worked in a university setting for a year. I believe I fall into category b. Pretty sweet deal, huh?

Then again, if I get into the MSN/PhD program, tuition is covered anyway. But, this would be a good backup in case I don't get accepted and end up doing just the MSN or something. Speaking of MSN/PhD programs, I've requested more information about the program at University of Pennsylvania (Ivy League, on my!) in Philadelphia. I hear good things about Philly from my housemates (they've both lived there) and Sarah and Ronen might consider following me there if I go, since they have an exceptional nurse midwifery program as well. Haven't discussed the whole moving thing much with Paul yet, I need to have a talk with him soon though.

I've been missing Portland a lot this week. Maybe because the weather has been so quintessentially Portland-like. About 65 degrees and misting rain. I love it, but it makes me homesick. Rochester is an okay place, but I would never choose to stay here because of the city itself, it would take something like getting into a fully-funded dual degree program to keep me here. I don't know if I would like Philadelphia any better, but I could at least visit there before moving. One definite perk of Philadelphia would be more access to the things I love to do, like cycling and dancing. There is no such thing as a women's cycling team in Rochester, the city is just too small to support it. And dancing is extremely limited and doesn't seem worth the effort to get out on a weeknight. Then again, if none of my friends came with me to Philadelphia, I'd have to start all over again.

Basically, I'm back to the waiting game, not sure if I'm hoping for my decision to be made for me by admissions committees or if I'd rather have all my options open and have to choose myself. So far my decision to come out here has proven to be a good one, but right now I"m really unsure if I want to stay for 5 more years.

A little more about the psychiatric hospital

People have asked me why I hate my psych rotation so much. It's not because I'm not interested in psychiatry, or because I don't get to be involved in patient care, although those would be reasons enough. It's because I come home angry and depressed every single day. So, here's a quick summary of the things that I have seen that make me so angry. I honestly hope it makes you angry too, because unless a whole lot of people get very upset about it, nothing is going to change.

First, there is one nurse for every 30 patients. That is simply not enough. The nurse spends his/her day filling out paperwork, not even giving medications (an LPN does that). Zero patient contact, unless a patient becomes disruptive or dangerous.

Second, the unit feels like a prison. There are locks on all the doors, and I understand that is out of necessity and cannot be changed. What could be changed are the institutional rooms, fluorescent lights, warnings posted on the walls, and complete lack of individualization of patient rooms. Several patients have said that they feel much happier and more stable when they're at the regular hospital or doing outpatient treatment, just because that place makes them depressed. Honestly, I would probably become suicidal after being locked in that unit for a month.

Third, there is nothing for the patients to do. The nurse is too busy to interact with them. The mental health techs don't seem to give a damn. The LPN just does medications. Who's left? Other patients. And they do okay together, but any time you put a group of 30 people together with no available form of distraction besides the one television there will be problems. Then do it with 30 mentally ill people, many of whom have impulse control problems or histories of violence, and you've just got a ticking bomb.

Fourth, the patients get medication, not treatment. Medication is not the same as treatment. The doctors don't seem to realize this, and the nurse and social workers are either too busy or too jaded to do anything about it. Medications help. They calm symptoms, like command hallucinations and extreme depression or mania, and make it possible for various types of therapy to be successful. There are several kinds of therapies available, and many of them are effective. But, they need to be implemented with consistency and expertise. One group therapy session each week is not going to make a difference in these patients' lives. So, instead of getting treatment, they get medicated to the point where they are "safe" (read: unable to feel or think straight) and then medicated some more to deal with the side effects of the original meds.

Fifth, the patients believe that nobody cares about them, with the possible exception of the social workers. And who can blame them, I've seen very little evidence to prove the patients wrong. Almost all of the staff are unapproachable and impatient. I don't blame them either, they are overworked, underpaid, and buried in paperwork.

So, who's to blame? Everybody. Why? Because none of us care enough to fix these problems. What's the fix, you ask? Easy, money. Mental health funding has been cut significantly in the past 10 years. They are now so broke at this place that they don't even have snacks or drinks other than water available between meal times. They have a full kitchen and used to bake cookies with patients. Now they can't afford the ingredients, so the appliances have been disconnected and the kitchen is locked. They used to get $200/month for the entire hospital (less than $1 per patient) for recreational therapy. That is going to disappear by the end of this year. They won't even be allowed to buy a deck of cards or a soccer ball, unless it comes out of the pocket of a staff member. This isn't a unique situation, this is standard for psychiatric hospitals around the country.

Where does the small amount of money that they do get end up? Paying staff to do paperwork. The amount of paperwork they have to do is beyond belief. Double, if not triple, anything I've seen at a regular hospital. That's why the nurses can't spend time with their patients, and the therapists don't have time to do more than one session per week. The intense overregulation of mental health care is preventing any actual care from being given.

So that's why I hate psych, because it's a broken system and there is nothing I can do about it, except be angry and try to care.