Taking Charge: Lessons in Leadership

I recently took a promotion to become full time Charge Nurse on my Med-Surg floor. While I was excited for the opportunity to take on a leadership role, I also felt a fair amount of anxiety about how I would be received. First of all I am young (and look even younger, to boot!), leading people sometimes 10+ years my senior both in age and nursing experience. Second, I am a relatively new addition to this floor, and I realized that many people could feel that I hadn't fully "paid my dues"yet. In spite of these things, I recognized that this new role would further facilitate my passion to support and educate nurses,  and I decided to jump in with both feet!

I've given a lot of thought to what it takes to be a great Charge Nurse. Some things are given: you know how to do and teach the skills your floor nurses use, etc. There are, however, many intangible aspects of leadership that have a great impact on your success. I've still got a long way to go to fill these big shoes, but I thought I would share some of the things I've learned so far.

1.) Respect is earned. I can't make anyone respect me or my role, but I can be a person who deserves respect. I subscribe to a servant leadership style. Med-Surg nursing in back-breaking, dirty work. When you are on the floor, it sometimes feels like you are in the absolute trenches of your profession. People are often quick to resent those "away from the bedside" who "don't know what its like". My favorite charge nurses are the first ones to answer the call lights, clean incontinent patients or take a patient to avoid overloading the floor. I strive to be that charge nurse. One answered call light says, "I'm in your corner" better than any number of conversations.

2.) My nurses are my first priority.  Charge nurses are responsible for the overall flow and quality of the care received on the floor. That means that I am in near constant contact with Bed Management, Social Services, and the House Supervisor to help keep things running smoothly. It also means that I'm rounding on patients and doing quality audits for management on a daily basis. For me, however, the most important part of my job is serving as a resource for my nurses. I judge the success of my day by the number of my nurses that get out on time.

3.) Know when to say "No".  Unlike being on the floor, Charge Nurse duties have a relatively flexible time frame, and, at our hospital, we don't take patients. That means that I can usually re-arrange my to-do list to help other nurses, and nurses know that I am their 'go-to'. However, there are eight nurses, and only one Charge so I can get stretched pretty thin on any given day or hour. I've had to learn when to say, "I can't now, but let me find you someone who can". If you juggle more than you can handle, you will inevitably drop one or all of your items. Better to take on a little less, be reliable and consistent, than to take on too much and drop the ball.

4.) Gripes go up. No floor is perfect, which means there will always be gripes about one thing or another. There will always be personality conflicts. It doesn't help unit morale in the slightest, however, to have a visible person complaining all the time. For better or for worse, it can and will impact the floor. I always made an effort disengage from work gossip or drama, but now it is essential to my role. I I try to take any concerns I have have to go to the appropriate person, up the chain of command, or keep them to myself. I learned this one the hard way.

5.) Be Sincere. People make mistakes, and in charge, yours will impact your coworkers. Apologize quickly and genuinely. Actively listen to people. Approach people honestly and you will be well received.

6.) Support your new nurses. Whether they are new grads or just new to your specialty, you have to give a little extra love to those with less experience. There is no "entry-level" nursing position, so the learning curve is steep and overwhelming for many people. Today's new grads are the nursing leaders of tomorrow. I would not be where I am if it were not for my 'mama-bear' nurses who took me under their wings while I was still mastering nursing skills and judgement. I believe that if nurses feel supported and heard, floors will have higher staff retention. The higher the retention, the more opportunity for quality team building and mutual support among staff members.

Decoding the Code

My first patient coded from a respiratory arrest when I was six months out of school. Code Blue. No amount of BLS training can actually prepare you for your first patient arresting before your eyes. You think to yourself, or maybe you even scream it out loud, "I need some help in here!" Then you realize, "Wait, I am the help", and your stomach drops into the floor.

New-grads experiencing their first code

I was called to the room because the patient was having an "anxiety attack." She was breathing 30-40 times a minute, I felt her pulse pounding at over 200 beats per minute. Then, no pulse. I was in disbelief, readjusting my fingers along her wrist thinking I had misplaced them. The only pulse I felt was mine, pounding through my fingertips. My coworker called the code and an onslaught of doctors, nurses, pharmacists and respiratory therapists flooded the room. Somebody shoved suction equipment into my hands, and I stared helplessly at it; any knowledge of this equipment that I previously held was no longer there, my mind was frozen.

Experience has shown me that an efficient code runs like an orchestra playing an exquisite piece. Everyone knows their part, and plays it effortlessly. This is the part that BLS doesn't teach you. A near-perfect code should go something like this:

The primary nurse calls the code, lays the bed flat, and begins chest compressions. Second, floor nurses should bring the code cart to the room, and set up oxygen to the bag-valve mask to begin bagging the patient. Usually by this time, the code team arrives. As soon as the code team arrives, the primary nurse should delegate chest compressions to someone else. This way she can communicate patient history and SBAR to the doctor running the code. Respiratory Therapy will exclusively manage the airway from this point. and a backboard will be placed under the patient in between rounds of chest compressions. Duties need to be assigned by either the MD running the code, the Supervisor or the Charge Nurse. Someone documents interventions, someone pushes medicines, and people need to form a line to relieve the person doing chest compressions. In reality, people usually assign themselves by calling out, "I'm writing!" or "I'm next to the IV!" A pharmacist and a Critical Care nurse manage the code cart.

Inevitably, there are too many people in a room during a code. Not having enough help will never be a problem in the acute care setting. People will be standing around hoping to get in on the action, reminding me of this vulgar Dane Cook sketch that was popular while I was in college. At some point you will have to ask people to step out for lack of space!

The biggest mistake many new-grads (and experienced nurses!) make is focusing on the wrong data. Many times you spend precious time frantically asking yourself, "what did I miss?" instead of asking yourself, "what do I do now?". There is a lot of anxiety surrounding codes. Many experienced nurses feel out of practice, and many new-grads feel totally unprepared. My approach is to know what you will personally do in a code before a patient ever arrests. For example, I like to document or "write" during a code. If that is already taken, I jump in line for chest compressions. If that's taken, I get out of the way.

What are your experience with codes? What advice do you have for the new RN or the out-of-practice nurse?

What Burnout and Burnt Food Have In Common

Working in this field comes with a price. Increased workload, high turnover, and increased patient acuity: these are only some of the issues that plague the nursing field today, and they have very real repercussions. Translation: hospitals are short staffed, and consequently their nurses are overworked. Many studies correlate understaffing with decreased patient satisfaction and increased nurse burnout. According to one 2010 Survey, the average turnover rate for RNs practicing at the bedside is 13.8%, and that number is even higher for Med/Surg RNs like me at 16.9%. The majority of these nurses leave their jobs within one year of accepting the offer. 

Burnout [burn-out]: a state of emotional exhaustion, overextension, and decreased sense of personal accomplishment associated with increased psychological distress, physical illness and alcohol and drug abuse.

Voluntary Turnover. With 8.2% unemployment nationally. This tells me that many who love nursing are finding the hospital environment unsustainable. Although the nursing workforce is growing, studies suggest that by the year 2020 there will still be a shortage of approximately 800,000 nurses. That means that the correlation between understaffing, patient satisfaction and nurse burnout is far from over.  We, as nurses, must therefore learn to cope with the strains of our profession if we are to have any longevity in our chosen career.

I advocate a simple principle: guard both the quantity and quality of your free time.  

1.)  Quantity.   A nursing professor once advised me to not work overtime during my first year out of school. It was some of the best advice I ever received. The pressure to work overtime is immense in short-staffed hospitals, and the money is good. Resist the temptation. To this day, I can count on one hand the number of overtime shifts I have worked. If we are to believe what the statistics and examples above imply, working just 36-40 hours a week is hardly sustainable for many nurses, let alone 50-60. Know your limits. To be able to provide the quality care we pledge ourselves to when we become nurses, we must also provide quality care to ourselves. That means leaving the hospital and nurturing other parts of our lives.

2.)  Quality.    As nurses, we are constantly giving of ourselves to other people. We can only give as much as we have stored. A wise person once told me that the most excellent ministry comes from our spiritual overflow. Sustainable nursing must also come from personal overflow. I don’t mean to get to philosophical here, so stay with me. We need to find activities, hobbies, etc. that give back to us, that refill our empty storehouses to the point of overflowing. It’s the classic work hard, play hard principle with a twist.

Homemade Lemon Squares

For me, that replenishing time happens in the kitchen. I hole myself away to try out delicious recipes I dog-eared months ago. Do they always turn out? No. But there is something so innately satisfying about using simple ingredients to attempt culinary magic. Cooking feeds the creative side of my brain that gets neglected during the week. There is this je-ne-sais-quoi that is simply celebratory about the kitchen, connecting you back to the holidays and special occasions that have long since past. Even the food itself, raw and earthy, is therapeutic. The fresh scents and bright colors are a welcome break from the recycled air and stale hospital light.

A while back I hit a wall. Although I rarely have a lack free time, the quality of my spare time took a serious plunge. I wasn't living inspired, and the old hobbies had lost their luster. Coincidentally, I was frequently coming home from work exhausted and frustrated. I realized that I was trying to put my work, however vocational it may be, in a place it was never meant to be. I needed to revitalize my spare time. My husband bought me a DSLR camera for my birthday with instructions simply to try it. I had often ogled at photography over the years, a pastime that reached nearly obsessive levels while we were planning our recent wedding. With his encouragement, I dipped my toe in the water of a new hobby, and with much success found my inspiration again. It even revitalized old familiar friends, like my tiny kitchen, with new life. With my creative needs furnished, work found its proper place in the rest of my life. It became enjoyable again, as it was able to meet much more reasonable expectations.

Maple Walnut Scones with Vanilla Orange Glaze

If you are a nurse or a caregiver in any capacity, you must take care of yourself or you will quickly burn out. The quality of your alone time is equally as important as the time itself. What are you doing to nurture yourself today?

On Holding Hands

I love to look at people’s hands. They are one of the most expressive parts of people. The wrinkles, age marks and scars tell a story. My mother recently received my great grandmother’s wedding ring as a gift and now wears it frequently instead of her own wedding band. “I can just see [this ring] on her hand”, she says to me with such fondness.  In turn, I have started to take special note of her hands. The specific combination of rings (including my great grandmother’s), bracelets, watches and nail polish are all very much “my mother”.  No other woman wears the stylish yet quirky combination of jewelry the way she does. I never quite appreciated how special this was to me until I received our wedding pictures. Our photographers captured this beautiful moment where I am holding my mother’s hands, exactly as I have known them my whole life, complete with scars, skin color, jewelry and all. I often find myself drawn into this picture. Morbid as it may seem, these are the details of her I will remember of her long after she is gone.

Copyright Ulmer Studios Photography

Hands connect people. When I started dating my husband, one of the first things I noticed was how well our hands fit together, almost like they were made in kind. Although I had known him for years, this was new. Aha! INSTANT CONNECTION. People hold hands for a variety of reasons: affection, support, and fear just to name a few.  Holding hands is always, without exception a voluntary activity, requiring mutual consent from both parties. This may seem trivial but, as a nurse, that last detail is the one I value the most.

Although nursing is caring, I find that often patients fight and resist the very care we are attempting to give. More often than you can imagine (if you’re not in nursing), we are restraining people for life and limb.  I’ll never forget one night shortly after I graduated nursing school. I had an elderly gentleman as my patient, pleasant yet confused during the daytime, but increasingly agitated at night. Unfortunately, all of our usual attempts to deescalate situations only seemed to spur him on (presumably from an adverse reaction to a medication). With the night only half over, it took four of us to tackle him into restraints. Each one of us was holding a limb, me holding onto his wrist for dear life while he kicked one of my fellow nurses in the ribs. I thought to myself, “This is not what I signed up for when I decided to be a nurse”.

I wish I could tell you that these situations are rare, but unfortunately I can’t. Delirium, often caused by acute infection or medication, is one of the most frequent diagnoses I encounter on my medical floor. I have bribed, flirted and even held noses in attempt to get people to take necessary medications. I do this because it’s my job, and I do it hoping that when they come back to reality, it will be worth it to them. So, when I get the opportunity as a nurse to gently take someone’s hand and offer help, I have learned to appreciate it. It may be as small as helping a weak patient from the bed to a chair, but when the patient accepts my hand, well, it doesn’t seem so small anymore. These are the moments I thought of when I decided to be a nurse, the moments you are able to help someone in need. Someone wants help and (hallelujah!) I can provide it!

Sometimes we hold hands because we don’t know anything else to do. I’ll never forget a dear patient of mine that I met the day she received devastating news that she had end stage pancreatic cancer. She was a sweet, Christian woman overwhelmed with the gravity of her situation. Although I relish the opportunity to share faith and fellowship with someone, any of the words I had to offer were just regurgitating what she already knew. Any of the medical knowledge I had to offer was not what she needed. So I simply sat next to her on her hospital bed, held her hand, and listened to her process through her thoughts. It was one of the sweetest moments in my nursing career.

It’s amazing how such a simple gesture can mean so much. It offers help and accepts help. It comforts when there is nothing left to say. It forges little connections, and those are the sweet moments in life. And in nursing.