Health assessment textbooks: a brief review

Health assessment is the process by which health care professionals (HCPs) perform a physical exam, take a health history, and determine whether and in what way a patient is in ill health. Most people think of this simply as the physical exam. As a patient, undressing and getting poked and prodded by a doctor or nurse is the most distinctive part of a doctor's appointment or trip to the hospital. For a good HCP, the whole procedure is much more involved than poking and prodding. In order for the physical exam to be meaningful, it has to be joined by an adequate knowledge of the patient's background, lifestyle, and complaints. Thus, a textbook for teaching health assessment has to cover physical exam techniques for all the bodies' organs and physiological systems as well as common pathology (what does a cancerous mole look like compared to a non-cancerous one?) and advice on interviewing and interacting with the patient.

In school I was disappointed in my health assessment class, and although I thought our textbook was adequate, I was interested to know how else the course might have been taught and what other decisions might have been made about the content. So after school I ordered some alternate health assessment textbooks to compare with the one we had been assigned, Jarvis' Physical Examination and Health Assessment. I found Bates' Guide to Physical Examination and History Taking and Mosby's Guide to Physical Examination. Was Jarvis the best our program could have done, and did I learn anything abstractly about health assessment from comparing these books?



As a matter of fact, I think Jarvis' book was the best our program could have done. The three books--which I'll call Jarvis, Bates, and Mosby--from editions published in 2003-04--all essentially purport to serve the same purpose. The introductions say they are for beginning or first-year health students. I'm not sure who else bothers with physical examination than nurses and doctors/PAs. And I'm not really sure that medical education is framed with a single "health assessment" academic course the way a nursing program might be, although it seems to be implied by the introductions of these books. My guess is that medical schools vary in the way teaching of physical examination techniques are integrated into the curriculum. Since each of these books contains an overview of relevant anatomy for each system (cardiovascular, skin, etc), I find it hard to believe that a medical school would bother assigning any of these books after a gross anatomy course, but perhaps.

Moving on: the books are organized essentially the same way (an introduction to taking a health history with interpersonal and cultural considerations, etc, followed by sections devoted to the physical assessment of individual bodily systems), but with some characteristics that mark them distinctively. First is authorship. Bates is authored by medical doctors, while Jarvis is authored by a nurse practitioner, and Mosby authored by a mix of health professionals including doctors and nurses. The fact that Jarvis does not have a medical doctor as author clues us that its intended audience is nursing students, while the opposite is true of Bates. And these clues are supported by the second distinctive characteristics, which are the supporting or "extra" material. I refer here to the fact that Jarvis makes a point of including sections on NANDA-approved nursing diagnoses, while Bates includes information specifically related to the construction of a History & Physical document. Mosby, again, is sitting on the fence, but its inclusion of appendices giving definitions of abbreviations and word parts suggests that the intended audience has less education than a typical medical student.

One of the things I was interested in was the content of the books, and besides browsing the books, I took a closer look at the sections on cardiac and skin assessments. In general, the illustrations in Jarvis and Mosby were very similar (both are from Elsevier imprints) or the same, and superior to Bates, which used some unclear photos that looked like they might be left over from standard references of the 1960s. (Bates is now in a new edition, however, with new graphics.) In the cardiac section, I noted that while both Bates and Jarvis cover the same exam and assessment material, Bates is arranged and designed in a way that draws attention to defining distinctions in assessment (how do you rate heart murmurs?) while Jarvis' design highlights the connection between assessment findings and their meaning (a heart murmur may indicate a faulty valve). Again, the skin sections contain mostly the same material with a superiority in graphics and design in the Jarvis book.

The books were so close in content and design that I decided I needed only one. Which did I choose? I considered keeping Jarvis because it was the one I used for school. I considered keeping Bates because it was most different from Jarvis, which I had already read. In the end, I kept none of these three because I discovered that my critical care textbook contains sections on patient assessment that mostly duplicate the material in the health assessment texts.

Critical Care: A Holistic Approach by Morton and Fontaine has pretty much all I need to know about physical assessment to operate in an ICU. In fact, I think it would have been an adequate textbook for almost my entire course of study, useful in the Care of the Adult courses as well as in the health assessment course, all of which required their own textbooks at great expense to the student, who was paying down debts and paying for school out of pocket at the time.

NCLEX exam this Monday

Gentle readers,

I have not forgotten you, nor have I failed the NCLEX exam. Yet. The orientation process at work has been so stressful and so literally tiring that I simply gave up blogging and reading my GoogleReader for the time being. At work, they tell me I'm doing well, but it doesn't feel that way. I have yet to go through a day and finish everything satisfactorily.

Also, I have made some mistakes. My worst has been with a patient who was playing games with us on a day when I didn't have time for it, and starting spitting out oral meds, then refusing everything. I eventually got the patient to agree to take crushed the very needed pills at the end of my shift and crushed some extended release pills without thinking about it. Luckily, no advserse results, but you know that was one of the days when I did not feel good after work.

Actually, for a period of about 3 weeks, I started drinking every day and probably drank more in that period than the entire year previous. Not good.

I'm sure most new nurses have the same feelings of inadequacy I do, but it has been very rough.

Anyhow, I am scheduled to take the NCLEX this Monday at the Pearson VUE office. I'm planning on holing up for a while--maybe calling in tomorrow and Friday (Do I dare?) and spending those days and the weekend in a motel or bed and breakfast. So far, I have studied about a total of 4 hours. I do not have high hopes. I find it almost impossible to combine the stressful floor orientation and the book studying, so heinous is the book studying to me. I don't know about other people, but I measure out my time in spoonfuls of anxiety, not spoonfuls of chronology. I have had very little time to study in other words. I have spent some time staring out the window, doing laundry, cleaning the house...

And when I am formulated, sprawling on a pin,
When I am pinned and wriggling on the wall,
Then how should I begin
To spit out all the butt-ends of my days and ways?
And how should I presume?

Anyhow, if I don't pass, I'll have to stop orientation and then I'll be back in the situation I wanted originally, which was to pass the exam before taking a job. I mentioned this to the HR department at work when I went in, but they wouldn't give me a position unless I started orientation right away. Well, they got their way, and now we'll see how things go.

Wish me luck.

Nursing textbooks: cleaning out after graduation

Is everyone stuck with a bunch of textbooks after graduation? I keep wondering if the folding legs on my table/desk are going to collapse. I've been looking forward to getting rid of a bunch of these and the day has finally come. So, here are my nursing texts divvied up by post-schooling usefulness...

Books I'm getting rid of immediately



Mosby's 2005 Drug Consult: I bought an old copy of a drug consult to save money. This one was a stinker. Very little info and difficult to read and look things up. The hospital where we did clinicals uses a different publisher's drug consult, and it was much better. Avoid Mosby's Drug Consult. Besides, in today's clinical environment, who needs one at all (Hint: go PDA)? Unless the computers go down, or you want to look something up at home... It's a good thing to have, I think.
Lab and Diagnostic Test Guide: I bought an old copy of this to get one that was co-authored by one of my professors. Not a bad choice, but in general the lab and diagnostic guide was not needed. Does anyone actually use this in school? All the information is available on the web, now, anyhow. Assigning it was not a good use of resources.
Nine Hills to Nambonkaha: ugh. Read my Amazon review.
Masting Project Management: double ugh. When I read books like this, I imagine people in lower and middle management jobs desperately looking for something, anything to escape. It depresses me. If you can't project manage intuitively, you're not going to be promoted much unless you kiss butt, period.
From Silence to Voice: I wanted to like this book, but in the end I thought it was mostly just a guide to common sense political wrangling and English composition. Better to get Strunk & White's and be done with it.
Nursing Diagnosis Handbook: I wrote a poor review for Amazon, although after I was forced to use this book more, I found it handy for school. However, I am still very skeptical about the entire nursing diagnosis project. Creating this entire system that's taught in school and then discarded in clinical practice just for the purpose of demonstrating "professional knowledge" seems like a waste. Plus, I'm not sure it does a good job of what it's supposed to do, which is describe nursing practice. In cardiac and critical care, there are plenty of assessments and interventions that nurses make that are essentially medical in nature.
Essential Drug Dosage Calculations: The math that nurses need to know is very elementary, however important it might be. Even more so now that so many products come pre-measured and pre-drawn. Buying this book was not useful for me, although, inexplicably, many of my classmates had difficulty with the simple math needed for nursing. In fact, there were even errors in the answer keys for some of our quizzes. I don't think this book was necessary, though, unless problem sets were going to be assigned from it.
Clinical Nursing Skills & Techniques: A fine textbook from which we did not have enough reading or test assessments. I am getting rid of it because it is out of date, but I may get another. The only thing is, all this information should be online for free!
Nutrition From Science to Life: The hokey title says it all. It was out of date when I bought it and would have been a waste of money anyhow. The science of nutrition is a lot more undecided and unknown than nutritionists would like to think, although there seem to have been great strides in the last 5-10 years. If I had to teach a nutrition course, I think I would make students more aware of the controversies rather than teaching "best diet" and "best weight."
Sociology in Our Times: Okay book, but I am outraged that this discipline is still teaching discredited crap like The Authoritarian Personality. This textbook has citations from the '50s and '60s. What a joke!
Understanding Psychology: Whatever. Didn't really need it for the Intro Psych class.
A Topical Approach to Life-Span Development: It aims low, but is a well-constructed text from which I was able to learn a lot. As with sociology, psychology has some sacred cows, like Piaget, that seem to me to be almost certainly wrong, although they are still taught without addressing issues like Piaget's out-of-date research techniques and lack of grounding in biopsych. All the background psychology a nurse needs is available online now.
Professional Nursing Practice: Read my Amazon review--this was a real, true waste of money.
Public Health Nursing: I think there was one reading assigned from this book in my community health course. Could have easily taught the course without this book. I think I may change my mind and keep it, though, as a reference. Public health nursing seems labyrinthine to me.
Wong's Nursing Care of Infants and Children: I hated this book. I hated everything about it. The prose, the design, the illustrations--it was all awful. It was almost unreadable, and I stopped trying when I discovered that it was still teaching Freud's developmental levels. These should be relegated to courses on history of psychology rather than being included in practical textbooks. The actual useful material in this book could have been condensed to a text maybe a quarter to a third the size.


Books I'm getting rid of soon



NCLEX review books: I'm tempted to keep Saunders' Comprehensive Review since it has a nice outline, but realistically, I'll never look at it again after the boards. These can all go to next year's students. Gone after the NCLEX.
Medical-Surgical Nursing: an okay text. It needs better design/layout. I couldn't really figure out how to use it efficiently until the course was almost through. Gone after the NCLEX.
Fundamentals of Nursing: why this text and the Med-Surg one? Too much duplication. If I ever want to refer to theory, I can find this in a library. Gone after the NCLEX.
Procedures and Techniques in Intensive Care Medicine: Well, this one wasn't assigned, but I'm getting rid of it after I read about a few of the procedures, like echocardiography. It's out of date, now, I think.
Psychiatric Nursing: Way too based in Freudianism and psychotherapy, but my impression is that without hanging on to these, psychiatric nurses wouldn't have anything to do except pass meds. The "decade of the brain" material seems like an add-on. Good layout, though, and easy to read. I came to enjoy this book.
Ethical Decisionmaking in Nursing and Healthcare: Arrrrrrrggghhhhhhhh!!! As soon as I find a way to make a formal and comprehensive critique of this book, it's going in the trash. What a boondoggle! Instructors can use it to justify any ethical/political opinion, and the book is so circular that they can get away with it.
The Complexities of Care: I read one of the chapters in the library and liked it a lot, so I purchased the book. Then after looking at a couple more, I am less enthusiastic, but I will read it before giving it to somebody else.


Books I'm keeping



Diagnostix: I got my blood pressure cuff out of the box once, when I first got it, to put it together and test it out. Why was this required for school? I will keep it for an emergency kit for the car, however.
Taber's: Whatever. All the terms are available on the web now, but I'll keep it. It was a waste of money to make it a required text, though. Books should be assigned thus: "Here are the web resources, but if Internet access goes down, you might need these."
Essentials of Nursing Research: Not much in here that couldn't be found in a library or online, but if you intend to pursue any research, it might be useful to keep in mind the standards that reviewers and editors will be looking to.
General, Organic and Biochemistry: I never learned this well enough before so will start reviewing after the NCLEX.
Critical Care Nursing A Holistic Approach: I thought this was a good book. I intend to read it cover to cover after the NCLEX. And if I'm going to start studying for the CCRN exam, it may come in handy.
Introduction to Microbiology: From our micro class, apparently a good intro textbook, although I have nothing to compare it to. I wish the micro class was aimed more at nursing and medicine, though if I were to pursue infection control, this will be a good review/reference work.
Pharmacology for Nursing Care: What can I say? I liked it. Others didn't. I want to keep it and compare it with other pharmacology textbooks in the future. I also want to review the material from time to time.
Physical Examination & Health Assessment: As with the pharmacology book, useful review material and I'd like to compare it to other assessment texts in the future.


Books for elective courses



Biopsychology: It was an okay course, but I was hoping for something sexier. I thought the Pinel textbook was weak and hard to read. Useful information is all on the web and changing very quickly anyhow. Getting rid of it.
Essentials of Strength Training and Conditioning: I think this book is outdated. Advice on workout design, nutrition, etc. seems old-fashioned. Getting rid of it.
Fundamentals of Molecular Virology: At first I liked this book, which is organized by viral family, but after getting into the course more, I wished I had a textbook that was organized differently--say, a chapter on known/common methods of cell entry, etc. This would have been better for long-term retention, I think. Keeping it.
Medical Microbiology: This was also the name of the course this textbook was for. It was a good course, and I squandered time and energy that semester being stressed out about Nursing Fundamentals, which turned out to be not much a challenge. Although much of the information in this text can be found online, it is not easy to access as it's in image databases, etc. This would be a good text to have on hand if you were working in a tropical area or even the south. Keeping it.
Emergency Care: I just discovered last week that my EMT license is still good. I thought it had expired, but apparently it's good for three years rather than two. The text is useful since it presents information in the way the EMS system utilizes it, which is different from nursing. Hopefully, I'll be accepted at a volunteer service after I get established in a nursing job. Keeping it.
Biochemistry: This text was for a course that I didn't actually get to take. When I was taking Biopsychology, I tried to get the professor for Biochemistry to let me into the course without the prerequisites. He said no, but I bought the book and started attending the classes anyhow, hoping he would let me in. He didn't. However, even without doing the reading, I was able to follow what was going on well enough, and I got to see a guest speaker who was a VP at a pharmaceutical company give a talk on the drug approval process. Very informative. Keeping it.


Books I bought for my own edification



Physiology: At the beginning of nursing school, I assumed that medical schools must use one, or a couple, standard physiology texts. I couldn't really determine whether this is true from looking on Amazon. However, Berne and Levy seem to be well-regarded authors. So, I got this text thinking that we would be studying physiology in more depth than we had in A&P (buahahaha) and that I would simply read from the Berne and Levy rather than from the nursing textbook. You can imagine how this worked out. Keeping it, though, and may start reading.
Renal Pathophysiology, Primer on Kidney Diseases, Clinical Physiology of Acid-Base and Electrolyte Disorders, Mosby's Fluid, Electrolyte, and Acid-Base Balance, Acid-Base, Fluids, and Electrolytes Made Ridiculously Simple: Somehow, I had the idea that these books were going to help me get way ahead on renal and acid-base info. Somehow, I had the idea we had to know a lot more about these topics than we actually did. Getting rid of them.
PDR Nurses Drug Handbook Cardiovascular Edition: This was a give-away from Bristol-Myers Squibb. Not much better than a standard drug guide. Getting rid of it.
Cardiovascular Physiology: This is the Berne and Levy, cardiovascular chapter only. A great little book that every cardiac, ICU and PCU nurse should read. Keeping it.
Principles of Physiology: A slightly less technical (dumbed down) version of Berne and Levy. Since I didn't have an A&P book, only an A book, this serves very well as a reference for physiology. Keeping it.
Core Curriculum for Critical Care Nursing: As soon as I get my "sea legs" in my first job, will start reviewing this to prepare for the CCRN exam, which I think can be taken after the equivalent bedside hours to about one year of full-time work. Keeping it.
Basic Arrhythmias: For when I thought I would get cross-trained as a telemetry technician a few years ago. Oh well. Keeping it, though.
Color Atlas of Anatomy: This is an amazing book that is actually photos of cadavers. This is about as close as I'll probably come to a gross anatomy clinic. Keeping it.
Atlas of Human Anatomy: Since I borrowed someone else's book for A&P, I don't have an A&P text. At first, when I still remembered all the anatomy from A&P, I didn't think that mattered. But I've forgotten a lot over time, so I needed a reference. I think this one is okay, although its low price and high volume at Border's made me wonder whether or not it might have some mistakes. I'm taking my chances.
Clinically Oriented Anatomy: I bought this after A&P thinking I would get a different perspective. This is a good text, but it's not an armchair book. It really needs to be used in a classroom setting. Still, keeping it.

Well, that's it. Really, there should be a single reference text that nurses could buy to support their practice. Classroom textbooks don't cut it as they present all information with equal emphasis, whereas some things will no doubt be easy to remember after starting practice, while others will not. Something to think about...

Post revised July 2009...

PSU 2009 commencement

In theory, I've now graduated from nursing school with a BSN. In fact, I've completed only the commencement ceremony today, and the actual graduation won't be finalized until after this semester's grades are turned in and all the i's are dotted and t's crossed. My name wasn't in the program for the commencement, but I assume this is because I turned in my graduation application to the registrar too late. Am I concerned? A little. The professor for the Community Health course is not trustworthy in my opinion, and we don't have tests in that course. Instead the final grade is based on her assessment of an overall portfolio of your work that is turned in at the end of the semester. The syllabus was a mess, and I'm not sure I turned in all the work for the course. Even so, I should be okay as long as she decides I'm sufficiently socialist for her liking. Anyhow...

Saturday started sunny but steadily descended into a drizzle with heavy rain later in the day. The commencement ceremony at PSU is split into a morning session--for the schools of education, health, and business--and an afternoon session--for the schools of art and sciences. We started gathering in the ice hockey arena at an overcast 9:30 for a 10:00am ceremony.



Commencement takes place in the gym of the college's field house--the only indoor venue large enough. It's pretty standard decorating fair, although they do well for a gym. A few years ago, a bagpipe band started leading the processional and recessional, which is a nice touch.



The student commencement address was given by a nursing student this year. The practice of choosing a commencement speaker based on grades is fairly dubious. My fellow nursing grad was smart enough but mostly just studied a lot, and her speech reflected that. It was schlock about going beyond your career path to become the type of person you want to be. Spoken like someone who has spent her entire life locked in an academic prison. Most of the grads there were, instead, in the position of having to face a career after spending the last four years exploring what type of person they were! We also had a speaker who's a star on some TV show and came back to college to finish his degree, but I don't watch enough to have any sense of his importance.

Then it was on to filing across the dais to shake the president's hand...



A family friend who is a professor was sitting in the front row as I came across the dais and gave me an embrace, which was really both unexpected and affecting as the rest of the ceremony was both anti-climactic and overshadowed by the aforementioned Community Health question as well as the upcoming NCLEX exam. For myself--and I sense this is the case for most nursing grads--passing the NCLEX is going to mean a lot more to me than graduating from nursing school.

Actually, if I'm honest, I'd have to say that nursing school, despite being in a BSN rather than ADN program, bears so little resemblance to the academic experience that I had in previous university study that I don't feel as though I've finished what I started and finally graduated from college per se. It was more like some sort of boot-camp-college-game-show amalgam for which you had to jump through successive hoops while attending classes and keeping the drill instructors happy. Although I have a full grab-bag of skills and disparate formal training, I don't feel that I've acquired a consistent body of knowledge or methodology. (The "nursing process" is too generalized and accessible to common sense to justify four years at university and tens of thousands of dollars.) At the outset, I was expecting to receive knowledge of "people as patients" and "patient care." Instead, it's a little petite medicine training, a little management, a little social science research... This makes me a little despondent. I came only for job training, but I got something else very different that's supposed to be academic and professional, but I can't define it well.

At end of the ceremony, the mace recesses down the aisle followed by the honored guests and faculty. Then the pipe band leaves followed by the newly graduated students. I had intended to get just a 30 second clip of the pipe band, but since I didn't know where they were in the line, I ended up taping the entire recessional. This has the advantage of showing almost everyone in the ceremony. The original .MOV file can be downloaded from the Vimeo site, and it should have better quality, I think.



The one part of the day I was really looking forward to was having my photo taken outside after the ceremony. Over the years, my father has brought home a stream of photos taken outside in the same place with his graduating students, so I thought it would have been nice for him to have one of me with him as the parent instead of the professor. Alas, it was not to be. By the time we got outside after the ceremony, the rain was coming down quite hard. As my mother pointed out, it was the exact same weather as the day I graduated from high school. I hope that's not an ill omen, as my post-high school plans didn't play out very well. Anyhow, family photos got relegated to the living room.



During lunch that day ("Tuscan tuna salad"--tuna, beans, onions, olive oil, wine vinegar, spring greens--it's nice to be back off the studying/library habits), I asked my father whether he had heard of artist Catherine Hartung, who I mentioned a couple posts back. He said, "Oh, you mean Kate?" It turns out she used to babysit me! The world is a small place, especially in upstate New York.

My brother had told one of the waitresses that he was going to McSweeney's that evening for dinner, so we decided to all go and then on to Harrigan's for dessert. It was a real north country eating out experience.

So now what?

...well, the first thing is to lie low until grades are finalized. Then, after I'm sure I've graduated for real, it's a marathon study session for the NCLEX. Of course, I have to figure out what I'm going to do with my life, too.

Post revised July 2009...

PSU 2009 pinning ceremony

Earlier this Friday evening was my university's nursing graduation pinning ceremony. I guess this is supposed to be a big traditional deal for nurses. I didn't go through the ceremony for a variety of reasons (e.g.: didn't want to do the whole flowers/parents/awards thing; not sure I'm actually graduating; perpetually feel excluded by, and thus resentful of, the class), but I did go to the ceremony and sit in the audience (high up in the back of the auditorium)...



Afterward, my parents and I went out to Arnie's for dinner.



Post revised July 2009...

Shoe captures tone of graduating

This Shoe cartoon pretty much captures the way I feel about graduating after yesterday's Nur464 final fiasco.

Nur464 Final: big time suck

Today (Wed, May 13) was the final in the Nur464 Care of the Adult III (critical care) course. This was my last final for the semester, and will hopefully be my last final of nursing school, assuming I pass everything, which I should (fingersXd!). The final sucked big time. It was a computerized final, so I received my grade immediately--72. That's a failure. Now, the final was non-cumulative, and, as far as I know, counted the same as the other tests in the course. So, I should pass the course anyhow, but I have done weakly in the last half of the semester. The topics for this exam were burns, chest and abdominal trauma, and organ donation/immune suppression. It shouldn't have been that hard. A couple questions I intuited correctly and then talked myself out of. One I missed because I purposefully didn't memorize a formula for calculating fluids in a burn victim (there being multiple formulas, with the assumption the formula would be given on the test, and fluids being an MD order anyhow). A couple I missed because of skipping subsections of reading I didn't think were relevant. A couple I missed due to simple lack of memory. But the ones that really bother me are the ones where I used bad judgment to arrive at the wrong answer. That was probably 1/3-1/2 of them. That sucks.

After the test, right to ACLS class, then back to the library to study for the mega-code for tomorrow.

Pandora is wow on little sleep

For those of you still in the academic world, you know it's finals time, and I've got all that crap going on. Right now, I'm going on just a little sleep and staying awake with Sudafed, caffeine pills, and polacrilex gum. This is an effective combination, and since my PA wouldn't prescribe me modafinil (I have diagnosed OSA, so don't get all self-righteous on me), it's about as good as I can do.

So, anyhow, I was starting to fall asleep a little while ago, so I switched on Pandora, starting with "Riders on the Storm", and it's taken me through stuff I've never heard before like Cream's Crossroads and Led Zeppelin's Nobody's Fault But Mine. Never having used "hard" drugs before, I don't know that feels like, but with the sleep deficit, nicotine, and whatnot, the music sounds pretty good.

Of course, give me a few days with sleep, treadmill, salmon, and water in place of coffee, and I'll probably be back to preferring Bach and Handel.

CE for bioterrorism

For Community Health course, I just took a CE course from the U of Albany called Terrorism, Preparedness, and Public Health: An Introduction. Two interesting illustrations:

Nur437 clinical immersion experience

My college has instituted a new program this year. For the last two weeks, our normal classes have been suspended while we participated in a "clinical immersion." This immersion involved working a minimum of 45 hours over two weeks one-on-one with a preceptor. It has been a useful but extremely frustrating experience. To be honest, if I had had this experience at the beginning of nursing school rather than now at the end, there's a good chance I wouldn't have continued in nursing. Or, if I had, I would have been a lot more motivated to memorize and also to practice skills in the skills lab, which I haven't done once during school (didn't seem necessary!).

I have included below the e-mails I sent to my faculty supervisor to update her on my experiences. I have changed some details in order to protect the privacy of the innocent victims of my care. If you read these, you will note my struggle with time management. I am convinced this is the result of BSN programs' failure to provide enough bedside clinical training. My max patient load previous to the immersion was two ambulatory patients for 6 hours. While I was doing the immersion, students in the final year of an associates degree program were working alongside me on the same hospital unit. They were all managing 4-5 patient assignments for an entire shift with ease.

As I have suggested before on this blog, the rationale behind the BSN program is not oriented toward producing work-ready floor nurses and this needs to change. I have no intention of going into management or research, and neither do any of the other students in my program. If professional leaders in nursing want the entry-level nursing degree to be a BSN, they need to face the fact that the BSN program needs to change in order to accommodate the different educational requirements of the floor nurse. University courses in research, management, and professional issues need to be bumped up to the MSN level. Research skills need to be changed from performing research to assessing its value and validity. The assessments course needs to be more focused on acute care unit skills rather than primary care skills. Focus on patient care planning needs to be changed from creating extensive documents to using them in the acute care setting. More clinical hours are needed.

Here's my schedule for the last two weeks:
Tue = met with preceptor
Wed = 7a-7p
Thu = off
Fri = 7a-7p
Sat = 7a-3p /3p-11p work
Sun = 7a-3p / 3p-11p work
Mon = off /3p-11p work
Tue = 3p-7p
Wed = 7a-12p
Thu = off
Fri = 3p-11p

Subject: Re: immersion experience
From: Chris xxxxxxxxxxxxxx
Date: Fri, April 24, 2009 10:40 pm
To: "Zoanne Schnell, PhD, RN"

It's very hard. I met with my preceptor Tuesday morning. My first day was Wednesday, a 7a-7p shift with 3 patients til 3p, then 5 patients 3p - 7p. Yesterday (Thursday) I read the book "Shadow Cities" by Robert Neuwirth for Nur425 Community Health. Today (Friday) I worked 7a-7p with 5 patients. Tomorrow I am back at 7a again and then again Sunday at 7a.

Since the most patients I've had in clinicals up to this point is 2 and the most hours I've been on the floor is 6, it's quite a change. I haven't been able to manage them all by myself, and my preceptor is pulling a lot of weight (doing the admissions today), but I improved a lot today from Wednesday, and I am confident that I will continue improving throughout the weekend.

I'm not sure what my schedule will be for next week. My preceptor is out of his regular shift Tuesday for the hospital's "practice council." I don't know if he works Wednesday or Thursday. Then Friday he is definitely on 3p-11p.

The biggest problem I'm having is keeping track of everything in my head. For example, when it comes time to report off for the next shift, I can't remember where every patient's Saline Lock is or what every patient's cardiac rhythm is without referring to the flowsheets. I'm trying to deal with this problem by creating a worksheet for myself to take notes on and will trial it tomorrow.

One problem I'm having is lack of exposure, although I guess this is to be expected as a student. For example, today I heard course rales for the first time and couldn't quite identify what it was since I've only heard relatively fine rales in previous clinicals. Also, I described a patient with liver failure as being extremely jaundiced, which caused some eye rolling since, apparently, the patient was only mildly jaundiced.

However, in another instance, I thought a patient was doing very poorly on Wednesday when no one else was concerned. That night, the patient declined and the priest was called for last rites, so my intuition in that case was correct.

Some critical thinking skills are lacking. For example, I could identify an ACE-I correctly today, but failed to figure out that it was for CHF. This was a case where, if I had known the patient's admission history as before a normal clinical, I would have pieced everything together. But forced to think on the fly under stress, the connections aren't quite there yet.

My charting was very weak Wednesday. Today was better, but my notes need a lot of work.

I have to keep reminding myself that I'm still a student. It's frustrating that I can work for 12 hours with only a 20 minute break for lunch and be behind when I can see that there are nurses who have time to sit at the nurses' station. Somehow, I'm losing a lot of time around the 3p shift change, but I don't know how.

Will keep trying...



Subject: Re: immersion experience
From: Chris xxxxxxxxxxxxxx
Date: Mon, April 27, 2009 10:31 pm
To: "Zoanne Schnell, PhD, RN"

Well, Saturday was a disaster, but Sunday went okay. On Saturday, I had a 5 patient assignment 7a-3p. My last 9a med pass didn't get completed until 11:45. My preceptor said it was a busy day, and we did have a scheduled paracentesis and unscheduled thoracentesis going on in the same room, but I still thought the day should have gone more smoothly. My overall charting was better but my event notes were not good (this is by my own assessment, not the preceptor). I worked that night 3p-11p and then went back Sunday for 7a. On Sunday, I had a 3 patient assignment and an admission. The day went textbook and even my notes were better, but of course it was a very light assignment.

I find that I spend my time trying to treat the computer and flowsheets rather than the patient, which is very frustrating.

My notes need a lot of work, and I think they indicate my thought processes aren't well developed. In one case where I thought a patient's mental status was deteriorating, I had taken into account a number of assessments but the event note was discombobulated, so my thinking processes weren't systematic. I think an assessment has to be systematic before severity can be assessed properly.

Anyhow, I'm hoping I can manage a 5 patient assignment 7a-7p on Wednesday, but the CCC students will be on R-3 as well, so I suspect I will only get 2-3. That will leave only 3p-11p shift left in my immersion.




Subject: Re: immersion experience
From: Chris xxxxxxxxxxxxxx
Date: Wed, April 29, 2009 10:11 pm
To: "Zoanne Schnell, PhD, RN"

I had a longer response, but when I hit the send button a few moments ago, I got logged out of webmail. It looks like it didn't go through...

Anyhow, 4 hour shift Tuesday, whole shift today, but my preceptor was charge nurse so I went home early, and 8 hour shift coming up Friday. Should have a total of about 56 hours not counting time as charge today.

Tuesday went well with 2 patients and 2 admissions.

Will update again after work Friday...




Subject: Re: immersion experience
From: Chris xxxxxxxxxxxxxx
Date: Sun, May 3, 2009 9:11 pm
To: "Zoanne Schnell, PhD, RN"


So, last Tuesday, my preceptor's shift was 7a-7p, but CVPH's "practice council" was 7a-3p. I considered attending practice council, but decided against it. I worked 3p-7p in the step-down part of R-3 with a 2 patient assignment, and I received two admissions during that period as well. My patients and admissions were stable, and this was a fairly easy shift. The thing that really stood out for me was that my preceptor had already completed and charted his shift assessments when I was starting on them. I don't even know how he did it. I was with him for all but a few moments at the beginning of shift, and I'm shocked he could do them so fast. So, I must be losing some time on my assessments. My preceptor said they are thorough, however.

On Wednesday, I was planning to do a 7a-7p shift, but when I went in to work, my preceptor was assigned to charge. I stayed until noon, but I wasn't really learning anything and felt I was in the way so I went home. As charge, I received charge report in the AM, attended a STEMI alert (similar to a code) in the emergency room, took a patient who developed an active GI bleed to the ICU, and participated in patient rounds in step-down. However, as a unit clerk on R-3, I have been working alongside the charge nurses for a number of years and already have a clear idea of their normal work day, so there wasn't much to get out of a charge experience.

On Friday, I worked 3p-11p. Unfortunately, this, my last shift, was the worst time I had during the immersion. I had a 6-patient assignment that I performed mediocre until my 9p med pass. Up to that point, I was struggling a little to keep up, but things were getting done. But I started the 9p med pass at 8:40 and didn't finish until about 10:50. During that time, I had one distraction, which was a temp spike in a patient that required a call to the MD. So, I was averaging about 18-20 minutes per patient. I can't figure out why it was taking me that long, although one thing is that it seemed like every time I went in a room, the patient and the roommate both had other things they needed me to do for them. Not sure how to manage that without essentially ignoring the patients.

However, the real problem was that when I noted how long it was taking me to get the med pass done, I started to get anxious and make mental errors that I might not have made otherwise. One was a med error. A patient with a QVAR inhaler had another patient's Symbicort inhaler in the med drawer along with an empty bag for the patient's QVAR inhaler. Not knowing what the inhalers look like, I assumed the one in the drawer was QVAR and since the barcode for the computer scanner is on the bag instead of the inhaler itself, the computer didn't catch the error, either. This was an easily preventable error since the name of the patient and the name of the med are printed on the inhaler, and since QVAR doesn't take a spacer, which was attached to the Symbicort inhaler. If I had been less anxious about finishing, I might have thought to check the inhaler or wondered about the spacer. The error was caught because the patient asked whether s/he was going to receive QVAR, too, AFTER s/he used the Symbicort inhaler!

The other mental errors I made had to do with (1) being rushed and forgetting, or (2) taking the word of others instead of verifying for myself. I had three post-cath patients, but one of them (post-procedure day 2) didn't get his groin site checked during the assessment because when I mentioned the groin site, s/he said s/he didn't have one. I assumed I must have been mistaken about it rather than looking for myself, then forgot to check my Kardexes to see who the third groin site was. In one of the other patients, the patient had several Q1hour groin checks left before the Q2hour groin checks started, but the aide doing vitals told me the Q1hour checks were done. I believed him instead of verifying for myself. Then, on that same patient, I completely forgot about performing the Q2hour checks when I got behind in my med pass. That patient also didn't receive regular turn-and-position care. In one patient, I forgot to perform a BID dressing change that I had planned to do after the med pass.

The med error was annoying, but I am really bothered at forgetting about the turns and groin checks on that one patient. Then I didn't complete the report off to the next shift until 11:25, although we kept getting interrupted. I stayed after the shift and went through all my patients med drawers to organize and order missing meds from the pharmacy. Also, although my paper charting (R-3 still uses paper flowsheets) was completed in time, my computer shift assessments didn't get done until after my shift was over. Very frustrating night, and I didn't go home until about 1am. Really, staying any more than a few minutes after end of shift is not acceptable.

It's unfortunate that this was my last shift since my self-confidence took a real blow. I have some trouble with focus and organization in general. I've always been afraid these would manifest in difficult patient assignments, and they did. In fact, right now, I feel like I'm not sure this a career I am capable of doing. I need to get back in and do a couple 4+ patient assignments adequately before I'll feel like doing anything but hanging my head. I am also extremely worried that I did something wrong on Friday that I am not even aware of, and I've been experiencing a lot of anxiety over going back to work as a unit clerk on Monday. What will I find?

Anyhow, it's over now. Will have to wait and see what my preceptor's assessment is.

Saturday night at the dive-in

Last night, the college hosted a Saturday night "dive-in" movie. They showed the classic horror flick Creature from the Black Lagoon, and showed it in the university pool so students could swim and watch the movie at the same time. It sounds like a crazy idea, but it was actually a lot of fun. I'd never seen Creature before, which was the draw for me, but I couldn't have enjoyed it any more than I did. It made me sentimental for days of hanging out with other nerdy kids at Swarthmore. It was there I was first introduced to kung fu movies by Carl Heiberg, who encouraged me to see The Legend of Fong Sai Yuk, which was being shown on campus by Justin Hall, in his film series called "Two-Fisted Films" or something. This was before Jet Li was known in the U.S., and I was pretty blown away. Ahhh... great times.

Congratulations, Lauren Caniano!

A word is in order about our Nur464 clinical instructor, Lauren Caniano (?,?,?). Lauren has been a PCU and ICU nurse, a coach for the local USS swim team, and a clinical instructor among other things. She graduates this spring from nurse practitioner school and, as you can see, will have her first child (a son) not long after. Not everything about her life has gone ideally, but she has always been an excellent co-worker who sets the bar high and expects and encourages those around her to meet it. All the best to her, even she isn't able to see our clinicals out to the end...

What to do after graduation

Well, I don't think I can avoid any longer the choices that will have to be made when I graduate. There's a good possibility I may not graduate as I am scheduled to in May due to the fact that I have outstanding work due in Nur425 Community Health, but I probably will.

I'm looking forward to finally never having to consider b.s. college work again; to being able to make some money; to reading whatever I like; to getting back to karate and kendo; to working out and losing weight; to listening to more Bach; to starting on my conversion reading list; and mostly to the summer.

It's unfortunate that my grades haven't been maintained at the level they were at in pre-nursing cognate courses (4.0), or I could consider going on for a PhD in physiology, which I think is where my real heart lies--in academia, not the hospital. However, it's not a possibility for me, so I have to consider my options for graduation:

1. work in my local PCU--this would be my #1 choice, but based on certain factors I have written about here before, I don't think it's a real option for me;
2. try to get a job in a local med-surg unit for a year to build up enough hours to take the CCRN exam, then move on to a PCU or ICU in another locale;
3. try to get a job in a telemetry or coronary care unit in another locale;
4. join the navy;
5. try to get a job overseas with a cool organization like the Global Viral Forecasting Initiative;
6. not get a nursing job and work in some other field while writing a book on men's health.

Five would be a real change in life direction for me. GVFI has stations in Malaysia and other parts of SE Asia, and it would be great to live there for a while.
Four has a lot of appeal to me, although I am still skeptical about working as a male nurse in the military.
Three is professionally appealing, but the lifestyle, involving having to find a car (for the first time) as well as housing, etc., while fending off depression (again) is not appealing.

Some combination of two and six is the most likely option, I think, although I don't know that it would be a good idea to try to work on a book and the CCRN exam at the same time.

Nur464 clinicals day 6

Things went much better today. Kept same patients from yesterday, so no extra research last night or on site at the hospital today. It was a little hectic getting the assessments and med passes done quickly in the morning, but then all of a sudden I had a lot of free time to help others out. Helped with an open heart patient who was a youngster when WWII ended--open heart surgeries hadn't even been invented yet. How cool is that!!

But now to do all the clinical paperwork this weekend, plus write a paper for Community Health, a paper for Professional Issues, study for an exam in Care of the Adult III, and work 16 hours at the hospital... woohoo!!

Nursing as a university subject

I am revisiting this post in 2011. Don't remember what I was going to say, and the link is broken:
http://www.mentalnurse.org.uk/index.php/2009/04/04/nursing-not-a-proper-university-subject/

I have mellowed about college after graduating. Two years ago, I have would have had a lot to say about whether the nursing curriculum properly fit into the liberal arts model.

Today, I would say it definitely does not, but "meh, who cares?"

After two years in the work force, I still fundamentally agree with Charles Murray's assessment that professions requiring board exams should not require school as a pre-requisite for taking the exams. Most of what I did not get out of school and learned on the job, I could never have gotten out of school. What I did get out of school, I could have acquired on my own through self-study. Allowing someone to sit for the board exams with an academic degree would not end nursing schools. The majority of nurses probably could not have gotten by with self-study, and a larger number would not want to. But letting the un-lettered sit for exams would require schools to focus on their value-added, probably improving them.

Sexual orientation vs. wrinkled uniform: non-objective standards in nursing school

Read this story on a nursing student who appears to have been forced out of school for non-objective reasons.

I also had an experience similar. In one clinical, we had a weekly clinical assessment sheet that was a list of characteristics on which we would be graded on a scale of 1-3. You had to get an average of all 2s for the semester to pass clinicals.

One week I had an argument with my instructor. The next week, I received 1s for the neatness of my paperwork even though the paperwork was filled out the same way it always had been. Since I had been receiving 2s on everything throughout the semester, these 1s would have sunk me for the whole class.

I resolved the argument with the instructor and received 3s for neatness on the next assessment list, which gave me an average of 2s for the semester and allowed me to pass. However, the whole thing was a sham.

Happy St. Patrick's Day...

...he said ruefully. It is now about mid-point in spring break of what will hopefully be my last semester of nursing school. Most colleges have spring break a little later, I think, but mine used to be on Playboy's Top Ten Party Schools list in the '70s just for the huge St. Patrick's Day bashes that were thrown here. It used to destroy the community downtown, so the college made a policy of always having spring break over the week of St. Patrick's Day so that the jungen would be home.

For me, things could definitely be going better. I was hoping that spring break would afford an opportunity for me to catch up on sleep and have a week or two of regular exercise before starting the second half of the semester, but instead I haven't been to the gym yet and my sleep schedule has been erratic. Last night I was up until after 0500 and then got up at 0800, ate breakfast and fell asleep on the couch until about 1130.

The unhappiness I had coming into spring break didn't vanish this week like the mists in the sunlight. I am feeling bitter and detached. Perhaps this is what happens to all university seniors when spring arrives, but I think this is something different. I'm not looking forward to graduation, I am absolutely dreading it and reviewing the last 3 years with a sense of regret.

Looking out a year to a year-and-a-half from this point, I would count things a success if (1) I'm working in a place with a schedule that meets my needs, (2) I've provided safe care to my patients for my first year out from school, and (3) I've completed or am near completing my CCRN certification. Getting to this point will involve three aspects of my life coming together, but instead these are spinning out of control and breaking up.

1. School. From my perspective, the whole point of schooling is to provide excellent bedside care. That's all I care about getting from school, but it's not what I'm getting at all. I've been on the Dean's List for several semesters, I've passed all my nursing courses, and I've gotten some A's along the way, too. Recently, we took Elsevier's HESI exam, and I scored in the top 15% of my class, met the recommended 900 HESI score, and am predicted to pass the NCLEX as a result. But I don't know anything! I haven't had a hospital clinical (I don't count Psych) in almost a year, and I couldn't tell you normal lab values, much of anything about meds, correct protocols for bedside procedures, etc. It's horrible. I wouldn't let myself take care of myself at this point, and I'm supposed to be graduating soon. I'm not safe. And what are we spending our time doing this semester? Building "critical thinking skills" by having to guess at what our syllabi mean (yes, we were told that straight-forwardly) and going over ethics and goal/objective setting. What a load of crap!
2. Work. As I've written about on this blog previously, work is not going as swimmingly as when I started nursing school several years ago. My hospital has started recruiting, but as of now, no management has spoken to me about applying although they all know I'm supposed to be graduating this spring. In fact, of the management who have ever taken an interest in my school work, all three have been removed in the last year or so. I joined the local chapter of AACN as a student member, and I've been totally cut out of the loop. Moreover, I'm supposed to start clinical next week on the hospital floor where I work. And, as per my discussion of school progress above, I am predicting it will be something of a disaster. Some nurses are going to expect me to know everything already since I work on the floor, and honestly, having not had a clinical for almost a year, I'm back at the stage of feeling intimidated by bed baths. It doesn't help that my clinical instructor is one of these nurses.
3. Personal. If the floor where I am now doesn't hire me, my only three other options are to try to get a position on a straight med-surg floor here, to look for jobs over an hour's drive away, or to move away from my town. Any is a losing proposition for me. My original plan was to start out on the telemetry unit and then progress to the step-down unit, where I would have at most only 4 patients. Right now, I'm not safe with any number of patients, but constitutionally, I am suited more to fewer complex patients than to more patients of low acuity, I think. I could learn and become safe in a step-down or ICU, but for me to have 7-8 patients at a time is just asking for a mistake to happen. The other option of trying to get a position on a cardiac floor a drive away is going to send me into a depression I think. Losing two or more hours a day commuting is a partial definition of hell for me, and I've never owned a car before and don't want one. To move away means leaving my family and also giving up on returning to the karate club I was attending before nursing school, where I met a lot of people I like. The two other times I have moved away from my hometown, I've ended up in deep depression, and I don't want to try it again right away.

Anyhow, tonight is corned beef, then a cigar, and hopefully to bed early so I can get a full night's sleep and be productive tomorrow. Happy St. Pattie's Day.

Epocrates... likin' it

Tonight I'm studying for a Nur464 exam and using Epocrates to look up the meds. My instructor recommended it. I can't believe I've never used this before. It's pretty damn good! I always thought this info was so difficult to compile from clinical trials that publishers had to pay for people to spend mucho hours researching. That's the only explanation I could come with for why there wouldn't be free resources on the web. But here it is for free. Cool.

Cory Doctorow: How to not be cxlxmx

I'm sitting here with a ton of work that needs to be done this weekend before I go to work, and guess what I'm doing? Surfing the web of course, and coming across an article by Cory Doctorow of BoingBoing about how to not be distracted by the Interwebs. Ha!

Most self-serving comment from an instructor

In one of our courses, there is confusion over the syllabus. What, exactly, are the assignments and when are they due? We had a post-conference tonight with a clinical instructor who said that she's done this course for seven years and that there are always complaints about the syllabus. We had to understand, she said, that the syllabus was a learning exercise in critical thinking--we're supposed to read it and "figure out" what we're supposed to be doing.

What??!!

I've been matriculated at several institutions, including a highly regarded one, and I've been taking undergraduate courses for nigh on a decade now. Never, never, have I heard such a dishonest, cowardly, self-serving comment, and never have I had a professor who has suggested that the syllabus is a critical learning tool. This program is incredible! And I mean incredible as in, I can't believe she just said that...