3 Things I Wish I Knew Then As a Nurse That I Know Now

 

As life unfolds and the years pass, I learned many lessons as a nurse that I wish I had known when I first entered the critical care unit. I was timid, afraid, and filled with insecurity and doubt. Yet, I held a license to carry out physician orders and assist in caring for patients admitted to the hospital with cardiovascular disease, specifically in a unit caring for patients waiting for heart transplants and caring for patients who were recipients of a heart transplant but were in rejection. 

Medicine has come a long way in managing situations after an organ has been transplanted to minimize the incidence of the body responding adversely to the newly transplanted organ by administering particular medications to patients to prevent what Mehra (2018) defined as cellular non-acceptance. However, in worst cases, when a patient presents with a swift onset of organ rejection, patients can deteriorate rapidly, and what we call in critical care circles patients sometimes "crash and burn." 

The learning curve in the unit was steep, but reflecting on it now, I realize I could have been potentially dangerous enough to make someone worse, but I persevered in becoming a competent nurse through blood, sweat, and tears. Nearly two decades have passed since those early experiences, and now I can reflect on them and share at least three insights I wish I had known as a new graduate. Although these thoughts have no specific order, they have all become prominent over time.

Chronic Illness

Number one is understanding the severity and impact on adults with chronic illness in the United States. For Americans, these are cardiovascular disease, kidney failure, strokes, uncontrolled diabetes, obesity and disorders of metabolism, and cancer (CDC, n.d.). They are prevalent and affect adults with an unprejudiced advance on human health. When left untreated or poorly managed, they can be debilitating at the least and increase all-cause mortality. 

As a cardiovascular care provider, heart failure management is the disorder that I am most familiar with, and in caring for patients with heart disease, patients become weakened, especially when untreated. When the heart is sick or failing, it affects all other body systems, notably breathing and respiration. Imagine the difficulty one has when not able to get a whole gasp of air into the lungs or the inability to walk up stairs because of being short of breath.

Not All Doctors Are The Same

Doctors rely on you to be knowledgeable about your patient. Early in my career as a nurse, I believed that medical doctors were the pinnacle of healthcare management, clinical diagnoses, and treatment expertise—and they are. However, as a new graduate in an academic institution, I did not fully comprehend the heterogeneity of medical training: internship, residency, fellowship, and attending levels of our physician providers. Their skill set and privileges perplexed me. 

On average, a patient could have numerous physicians on the healthcare team involved in the treatment plan. As the patient's nurse, you are tasked with interpreting all of their notes, prescriptions, and diagnostic tests that they have ordered. Additionally, I was slow to learn the necessity of all the diagnostic tests and procedures they would order, but they are clear to me now.

I gradually realized that while medical students are bright, enthusiastic, and eager to apply their knowledge, they are still academically differentiated from their peers who are interns. Mark & Wong (2018) explain that there is a distinction between general and specialty knowledge in physician training. While interns are on their path to becoming proficient residents, their hierarchy continues to evolve even as a first-year resident has fewer experiences than a second-year resident. Often, they will graduate and become general practitioners, and some will continue their training through specialty fellowship programs. Fellows need to gain specialized knowledge, training, and experience, particularly when they become attending physicians and join a physician group practice, for they will be the ones calling the shots.

Importance of Self-Care

Finally, I needed to learn how critical self-care is. In the hospital, nurses are presented with first-hand experiential, in-vivo observation of the practice of medicine. In simple terms, you can see how medicine works on patients at the moment they are administered. For instance, when titrating doses of medications that affect heart rate and blood pressure, you can observe the intended effect of certain medications or the pharmacological mechanism of action. In addition, and to conclude my point about self-care, seeing what poor self-care can deteriorate into and, by extension, the effects on patients from nonadherence and non-compliance will wrap up the article.

The American Heart Association has established guidelines for a heart-healthy lifestyle. Following these recommendations as Lloyd-Jones & McKibbin (2018) describe efforts to manage food choices and portion sizes, incorporate daily exercise, maintain a healthy weight, quit smoking, monitor blood pressure, and keep cholesterol and blood sugar levels in check—can contribute to increased longevity and improved quality of life. Navigating health challenges can be incredibly tough, and I remember being a young healthcare provider, feeling somewhat naive about the struggles individuals face in managing their well-being. 

My time in the hospital has deeply influenced my understanding, echoing what Atul Gawande (2014) articulately expresses: our approach to self-care is often shaped by our awareness of the time we have left to live. I recall my experience in my twenties, serving in the Marine Corps, where I felt invincible, almost bulletproof. Yet, now, at fifty, I've realized how profoundly my perceptions of the years ahead affect how I care for my body. It's a journey that many of us experience, where our views on life can inspire us to treat ourselves by making healthy choices or continue to plague ourselves from some of our poor decisions in terms of those modifiable risk factors such as not smoking, for example. 

References:

Centers for Disease Control and Prevention. (n.d.). Fast facts: Health and economic costs of chronic conditions. Centers for Disease Control and Prevention. https://www.cdc.gov/chronic-disease/data-research/facts-stats/index.html

Gawande, A. (2014). Being mortal: medicine and what matters in the end. Picador.

Lloyd-Jones, D. M. & McKibbin, K. M. (2018). Promoting Good Health. In J. Larry Jameson & Anthony S. Fauci & Dennis L. Kasper & Stephen L. Hauser & Dan L. Longo & Joseph Loscalzo (20th Eds., Vol. 1), Harrison's Principles of Internal Medicine (pp. 8-13). McGraw-Hill Education. 

Mark, Daniel B., & Wong, John B. (2018). Decision-Making in Clinical Practice. In J. Larry Jameson & Anthony S. Fauci & Dennis L. Kasper & Stephen L. Hauser & Dan L. Longo & Joseph Loscalzo (20th Eds., Vol. 1), Harrison's Principles of Internal Medicine (pp. 13-22). McGraw-Hill Education. 

Mehra, Mandeep R. (2018). Cardiac Transplantation and Prolonged Assisted Circulation. In J. Larry Jameson & Anthony S. Fauci & Dennis L. Kasper & Stephen L. Hauser & Dan L. Longo & Joseph Loscalzo (20th Eds., Vol. 2), Harrison's Principles of Internal Medicine (pp. 1797-1801). McGraw-Hill Education. 

Tips for Securing Your Next Role

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There is much talk about VUCA in our current healthcare industry. From one point of view, as a nurse manager, the healthcare business has volatility, married to day-to-day uncertainty and complexity, all topped by the ambiguity in delivering evidence-based practice to patients (Sherman, 2024). In short, it is everchanging, evolving, and moving at a pace and rhythm that is hard to keep up with.

One area of the VUCA challenge is keeping up with the uncertainty of staffing shortages that all healthcare systems face from daily operational needs. Additionally, employee absences, vacations, non-paid time off, and extended leaves of absence influence fluctuations in daily staffing to meet core needs. At a basic level, it is a supply and demand model, and backfilling when staff absences exceed the ability to deliver safe care with appropriate patient-to-provider ratios contributes to the challenge.

Operational efficiency and patient care are the normal state of affairs in any hospital. However, suppose you are a new grad nurse or an experienced veteran looking to be the solution to your next employer's staffing dilemma. In that case, the following are some tokens and tributes your next employer is looking for.

Competency

Let us distill the qualities and traits into three for focus: competencies, behavior, and teamwork. First, competency is congruent with clinical expertise. Fineout-Overholt et al. (2019) described the professional nurse's expertise as possessing the techniques, education, and proficiency combined with best practice knowledge to care for patients. As a hiring manager, articulating your career experience and discussing your abilities and competence in caring for patients can help fortify your opportunity and be the linchpin in securing your presence in the minds of the interviewing staff.

Attitude

Second, but no less critical, is behavior, undifferentiated from professionalism. Scholars have divulged and distilled concepts surrounding professionalism. Gathered from Hood (2018), elements of a professional include but are not limited to the following.

• Committed focus on patients
• Caring about the work that helps patients and team members
• Demonstrating empathy to patients
• Having self-confidence
• Acquiring and displaying competence
• Possessing technique
• Ability to communicate clearly
• Applying critical thinking skills
• Capacity to be resilient in uncertainty and change

Collaboration

Last is teamwork, or organizational citizenship. It is often understood as the ability to cooperate with others for a common purpose and to put oneself behind the mission. These character qualities, or the soft skills of personal relationships and communication, are as critical as your skills, abilities, and academic achievements. Character, attitude, and behavior are in high demand.

As highlighted by Jim Collins (2001), concepts of high-performing organizations boil down to who will do the organization's work rather than what must be done in an institution. It is often heard in organizational circles, "This is how company XYZ is?" or "This is the company's way of doing things!" An organization's heartbeat, rhythm, and culture are the people, not the tools, equipment, walls, and foundation.

No matter the task, having the best team members steers any organization in the right direction. A company may have a great mission statement, but what can be expected if the wrong people work for the company? This continues to be a subject of undying debate.

So, if you are searching for that next role, promotion, or simple change, remember to keep abreast of current trends and educational endeavors to keep your skills and career fitness up to speed. As mentioned, behavior and teamwork attributes are desirable and coveted. Although autonomy, self-determination, and independence are qualities that harmonize with most working professionals, working together, collaborating, and sharing organizational commitment is the currency of high-performing organizations.

References:

Collins, J. C. (2001). Good to great. Harper Collins Publishers Inc.

Fineout-Overholt, E., Long, L. E., & Gallagher-Ford, L. (2019). Integration of patient preferences and values and clinician expertise into evidence-based decision-making. In Melnyk, B. M., & Fineout-Overholt, E (4th Eds.), Evidence-based practice in nursing and healthcare (pp. 219-232). Wolters Kluwer.

Hood, L. J. (2018). Leddy & Pepper's professional nursing (9th ed.). Wolters Kluwer. 

Sherman, R. O. (2024). Upskilling your nurse leaders. Nurse Leader, 22(5), 484–485. https://doi.org/10.1016/j.mnl.2024.07.007

Arm Chair Philosophy

Everything I know is being tested right now. I had a birthday back in September, which was on 9/11. I bet you can remember what you were doing on that day and the horrible images burned in your mind of the planes crashing into the World Trade Center. I bet you even have images in your memory of the people who fell from the upper floors to escape burning to death and those who jumped. I hope I never have to be in that position to choose to jump or burn alive from the inability to escape a fire. 

I would jump.

Although, that is not why I am writing today. I am writing because I still believe I have something to say, give, or contribute to the world, although the words needed to write well will not be present, or that is what I think. For that matter, reading the raw material here is like getting in shape. At first, it hurts, the muscles are weak, and the body can't breathe because it is out of shape, but with persistence, the physical body tones up and is in better shape than before had no action been taken.

The worst part of writing what I want to say is fighting the urge to resist putting my sentences into an AI writing app and taking the help and assistance of the knowledge and database of the resources on the internet to help me sound better than I am or to look up synonyms to replace my default vocabulary.

Also, I always compare myself to excellent authors, like C. S. Lewis or my favorite books on my shelf, which I turn to incessantly and habitually to feed my mind and soul. I have books I go to all the time, notes in the margins, dates jotted down to remind me of when I was there and read it last and highlighted sentences and paragraphs that stood out at the time of the reading, often at the first reading of a book. 

However, I still go back to my books, dust off the pages, and inhale deeply from time to time to feed my mind. I reread them to my surprise, catch something I missed the first time, or go back to them purposefully and intentionally to solidify, validate, and reaffirm what I know, believe, or hold as a conviction. 

Do you do that?

So, with this gut feeling in my ribs, I refuse to quit the writing process. Quitting is not the right word, but I stopped writing regularly for a while now; unfortunately, I stopped writing because I needed more confidence. Do I write what others would like to read?

I don't think so. I still need the confidence. Even rereading what I have here appears foolish and immature. 

Quite frankly, some things that I want to write about are that I have been afraid of telling the story in fear of what others would think because it may jeopardize my situation or have a negative professional impact; if I am going to write, am I supposed to censor myself?

That isn't cool. 

How do I describe the way I experience the world in words?

How do you wrestle with that?

I like commentary, and for that matter, reading bible commentaries helps me better understand concepts, ideas, and motifs in the scriptures. With that, I have recently read a commentary on Ephesians and was captured by the words that are now my new blog title. At first, I thought that others would be scorning me for changing the title or restarting the blog; I can hear it now, "Writing again, Brian, wasn't your blog about the Lean Forward life? People perceive me as inconsistent, unstable, or indecisive. That could be true, or life consists of fits and starts, setbacks, and losses. I tell others that I mentor; we are either winning or learning. 

And then again, others would be like, what blog, Lean Forward? What is that?

You're kidding yourself, Brian; no one has read a single verb or adjective you have ever written.

Seriously? I'm kidding myself here.

I have always stayed in the learning phase. 

How can I quit on myself at five decades old, even though the bitterness and coldness of self-doubt encircle me every day of my life? 

If I ask myself this question in ten years, what will the result be? 

Can I be satisfied with never publishing anything or not having a single reader except my wife? 

She will read what I say because she loves me, purely for that reason alone, and sees the good in me when others may view me as an indolent recluse and my dog Winston. 

He loves me, but he can't read. 

We read what E. K. Simpson (1980) describes as how the palate and pabulum of a disciple change after conversion in his Ephesians exposition. The scripture refers to the disciple that has been sealed with the Holy Spirit, and as such, when there is a different spirit about a person (The Holy Bible, New International Version, 1999, Ephesians 1:13), the desires and inclinations of a person change their affections.

As a disciple, I have a distinct taste preference for what I read or like to entertain in my thought life, and my palate has morphed toward food that will nourish me. That's it, and as such, if I now possess an affinity for nourishment that helps me in my spiritual journey, how much more can I avoid writing the same things for others to read that help me? 

I can not quit on myself at this time because my time is short.

What would you do if you were 50 and had similar thoughts?

You don't have to answer that.

Therefore, I am giving you the renamed Leanforward blog. 

Although probably a pipe dream, the new palate and pabulum platform will nourish your soul and mind as much as it helps me, at least therapeutically, to write it down.

Brian

References:

Simpson, E. K. (1980). In Commentary on the Epistle to the Ephesians (Vol. The New International Commentary on the New Testament, p. 35). essay, WM. B. Eerdmans Publishing.

The Holy Bible: New International Version. (1999). Cornerstone Bible Publishers. (original work published 1973).