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DOs and DON'Ts for Your FIRST Day

Syndicated from Jim DeMaria wrote the following DOs and DON'Ts for travel nurses for Scrubsmag.com April 5th, 2010

So you’ve thought about becoming a traveling nurse. You’ve imagined yourself basking under the desert skies of Arizona, frolicking on the sun-soaked beaches of Los Angeles — and not just for a vacation, but as your lifestyle.

But wait. Forget the exotic travel for a minute — what is the job really? Being a nurse brings enough of its own challenges, no matter the specialty. Who wants the added pressure of navigating unfamiliar hospitals with every single assignment? What if you get to a new location and you keep getting lost? What if you don’t know where anything is? What if no one will help? How many times can you go through that?

James DeMaria, Vice President of Renal Care Registered Nursing Services in Nanuet, N.Y., has been providing acute hemodialysis and acute apheresis services to some of the Northeast’s largest hospitals and caregiving facilities. Transporting equipment and providing patient care to different locations on a daily basis has made him an expert on the ins and outs of traveling nurse etiquette.

Jim made his transition to travel nursing from med surge in 2000 and has never looked back. Check out his list of first-day-on-the-job dos and don’ts to learn his secrets to managing the job and enjoying it.


**Arrive with the right attitude. Being in unfamiliar territory can quickly make you anxious. Remember to have an open mind. You became a traveling nurse precisely to break up the monotony, so embrace the challenge!

**Meet the unit secretary. Only second in importance to the floor manager, the unit secretary knows where everything is

**Learn people’s names. It’s as simple as that. Learn people’s names. Remember people’s names!

**Be helpful. When you’re helpless, be helpful. When you have a question, chances are everyone around you will be in the middle of something. Instead of interrupting a busy fellow nurse, why not offer her assistance in lifting her patient into a bed? Earn your right to be inquisitive by being a team player.

**Pay attention to detail. As the outsider, you’re the low man on the totem pole. That means when something goes wrong, fingers are going to be pointed at you. Pay extra attention to detail and fill out all proper documentation.


**Be shy. When you’re trying to learn the lay of the land, you must not be afraid to ask questions. But be friendly. As Jim would put it, “There’s a way to be assertive without being a nudge.”

**Make up your own rules. As a traveling nurse, you’re essentially a guest in someone’s house. Act accordingly.

**Be exclusive. Make every person you meet your friend and ally. “You never know what you’re going to need,” says Jim. “I work with water a lot in what I do, so I get to know the maintenance people. If they remember you as a nice guy, as a friend, they’ll help you out.”

**Take things personally. Not everyone will remember your name. Or worse, they’ll call you by the wrong name. Instead of getting irritated, diffuse the awkwardness by making a good-natured joke. Enjoy yourself. Laugh.

**Forget that you’re a great nurse. As with starting out in anything, your first experiences as a traveling nurse will be filled with some degree of uncertainty and novice anxiety. But there’s one thing you’ll always instinctively know how to do: take care of your patient. Let this relationship be your rock when everything else seems unfamiliar.


Wrong Blood in Tube. Errors in Blood Collection.

Photo by Renjith Krishnan

Syndicated from Impacted Nurse Tue, 12/14/2010

One of the more serious mistakes we can make as nurses, is to incorrectly identify a blood specimen we are sending off to pathology.

This is known as ‘Wrong Blood in Tube’ or WBIT, and can result in incorrect treatment being given to a patient based on their ‘wrong’ pathology results or even more seriously, a wrong blood transfusion being administered. Mistransfusion error is a leading cause of serious morbidity and mortality from blood transfusions.

It is estimated that WBIT occurs at a rate of around 1 in 2000 samples taken. Incorrectly identifying the patient and mislabelling the pathology tubes account for up to 15% of such errors. However, the actual number is thought to be much higher than this as many of these types of errors are ‘discovered’ prior to the specimen being sent and therefore not reported (as a near miss).

Some of the poor practices that can lead to WBIT include:

•Labelling of sample tubes away from the patients bedside.
•Failure to correctly confirm the patients identity.
•Patients with similar or identical names that have not been flagged.
•Use of pre-printed labels
•Inaccurate verbal instructions.

The Victorian Managed Insurance Authority has published an excellent manual: Reducing Harm in Blood Transfusions Investigating the Human Factors behind ‘Wrong Blood in Tube’ (WBIT) events in the Emergency Department.

Some of the factors that spoil our ability to follow best practice in specimen labelling include:

•High number of patients (with pressure on turnover)
•Urgency of individual cases.
•Ability of patients to communicate.
•Low staff to patient ratios.
•Time pressures.
•High workloads
•High stress (emotional demands of work)
•Rotating staff (implications on education and team culture)
•Fatigue (physical and mental pressures)

The ED is an environment where patient volume is high and requires that individual patients are processed quickly and efficiently. This can cause stress for staff, particularly when patients are very sick and the timeliness of appropriate treatment has the potential to impact on patient outcomes. In addition, the high physical and cognitive workload involved in long shifts can compound the stress with fatigue effects. Overnight and weekend shifts, with limited ‘back-up’, were reported in the interviews to be associated with more errors. Sometimes blood tubes were sent completely unlabelled. The unevenness of patient volume on these shifts can also place great demands on a ‘skeleton’ staff. Lack of staff redundancy results in an inability to relieve pressure when patient volume is high.

Correct ID
The study found that on many occasions nurses do not accurately identify their patients. Sometimes patient ID bracelets have not been applied or have incorrect information.
Commonly nurses asked the patient to simply confirm the information on their ID bracelet rather asking the patient to state their family name, given name and DOB whilst the nurse checks this information against the bracelet and the pathology documentation (as is best practice).
And doctors were found to be worse than nurses.

Nurses were observed to be commonly interrupted (by doctors or other nursing staff). Such interruptions and multi-tasking have recently been reported as a major cause of clinical inefficiency and error in Australian hospitals.

Fatigue is a huge issue with staff working in our emergency departments.

Fatigue affects performance by impairing; concentration, judgement, decision-making, memory function and physical coordination. It results in increased error rates and lower efficiency. All of these are threats to patient safety.

Despite these effects being well known, hospital culture often requires people to work even when identifiably fatigued. More to the point, with increasing patient throughput and demand on the health system, the luxury of being able to stop work when fatigued is generally not a viable one.

The report recommends the ideal process in a simplified form, in order to prevent WBIT error is:

1. Ensure request form is completed with all patient identifiers required i.e. full name, UR Number, and/or DOB.

2. Assemble all equipment required to collect the specimen, including sufficient patient labels (if these are used) to label specimens.

3. Identify patient using positive ID process: ask the patient to state full name and DOB and
check these details and UR Number against ID band, patient documents and/or any products.

4. Collect specimens and place into appropriate containers using appropriate technique.

5. After checking UR labels, match the patient identifiers on request form and wrist band, label each specimen and initial that each label was checked for correct patient details. Sign and note date and time on request form.

6. Place all specimens in biohazard bag and seal, placing request form in outside pocket.

7. Dispatch to pathology laboratory.


7 Habits of Highly Effective People- Habit 2

Habit 2: Begin with the End in Mind

"So, what do you want to be when you grow up? That question may appear a little trite, but think about it for a moment. Are you--right now--who you want to be, what you dreamed you'd be, doing what you always wanted to do? Be honest."

"If your ladder is not leaning against the right wall, every step you take gets you to the wrong place faster."

Habit 2 is based on imagination--

"If you don't make a conscious effort to visualize who you are and what you want in life, then you empower other people and circumstances to shape you and your life by default."

"It's about connecting again with your own uniqueness and then defining the personal, moral, and ethical guidelines within which you can most happily express and fulfill yourself."

"Begin with the End in Mind means to begin each day, task, or project with a clear vision of your desired direction and destination, and then continue by flexing your proactive muscles to make things happen."

"Develop a Personal Mission Statement. Focus it on what you want to be and do."

"Your mission statement makes you the leader of your own life. You create your own destiny and secure the future you envision."

All of these are quotes from 7 Habits of Highly Effective People.


The Six Second ECG Quiz

The Six Second ECG is the neatest site. You can learn how to correctly identify cardiac rhythms. Or you can play a game where you are given a specific rhythm and you need to identify it as fast as possible.

What other neat quizzes do you know about?


7 Habits for Highly Effective People- Habit 1

With the new year just around the corner many people are beginning to think about New Year's Resolutions. Possibly you are one of the many out there who feel like life has been lacking something, or just feeling, like you are not in the driver's seat anymore.

Stephen Covey's book 7 Habits for Highly Effective People is amazing at giving you advice on how to take back the control. Perfect for the new year!

"Your life doesn't just "happen." Whether you know it or not, it is carefully designed by you. The choices, after all, are yours. You choose happiness. You choose sadness. You choose decisiveness. You choose ambivalence. You choose success. You choose failure. You choose courage. You choose fear. Just remember that every moment, every situation, provides a new choice. And in doing so, it gives you a perfect opportunity to do things differently to produce more positive results."

Habit 1: Be Proactive

"Be Proactive is about taking responsibility for your life. You can't keep blaming everything on others."

"One of the most important things you choose is what you say. Your language is a good indicator of how you see yourself. A proactive person uses proactive language--I can, I will, I prefer, etc. A reactive person uses reactive language--I can't, I have to, if only. Reactive people believe they are not responsible for what they say and do--they have no choice."

"Instead of reacting to or worrying about conditions over which they have little or no control, proactive people focus their time and energy on things they can control."


Seriously, I have to Work on Christmas!

Kim Holland, author from Nurse Together complied this list of 10 ways to get over the holiday working blues:

1. Count it joy that you have a stable job. In these trying economic times you have an income to help pay for basics and also gifts for your loved ones.

2. Give sacrificially to someone less fortunate than you. Work with your children on some small gifts you can take into your patients on Christmas Day. You will be teaching them to give and including them in the blessing that you have of helping others.

3. Plan the pot luck for those working the holiday. Getting festive with your coworkers can be a blast and will remind you that you’re not alone.

4. Shop for the perfect set of Christmas earrings, hat or blinking pin to wear to work. You can be excited to “show it off” and cheer everyone up on the holiday.

5. Set aside special family time around Christmas. If you know you are working Christmas, you may need to consider minimizing time at grandma's house if this is not relaxing for your family. They need special time. As long as you make time with them intimate and special, they won’t mind that it is the day before or the day after.

6. Get creative and have a surprise gift delivered to your loved ones while you work. They will know that you love them and that you were thinking about them during your shift.

7. Do something special for the group that is working. If you are a manager, leave small gifts or cards with the employee’s names on them telling how much you appreciate them being there on the holiday.

8. Remember it’s just a few hours; it’s not a lifetime. Maybe it means that you were able to spend time with your family at Thanksgiving or on New Years while other nurses worked.

9. Control your feelings by controlling your thoughts. If you are obsessing about how angry or sad you are, you will be angry and sad. Instead, tell yourself working the holiday is an opportunity to show the true spirit of Christmas to your coworkers, family and patients. If you have a positive attitude, happy feelings will follow.

10. Be proud that you work holidays – you care when no one else does! Take this time to rejuvenate yourself with love and kindness for your fellow man. You are a nurse. Be a great one!!


Antibiotic Overuse

This is not a new issue by any means. However, it seems even though we have been discussing the overuse of antibiotics for many years now, and changes don't seem to be occurring.

Over at
MedScape.com they recently published an interview between Medscape authors and the CDC on November, 30th 2010.

The CDC was quoted as saying, "It is estimated that roughly 50% of antibiotics are unnecessarily prescribed in both inpatient and office settings."

The most common reasons for this abuse the CDC states are "lack of time, perceived patient expectations, and diagnostic uncertainty. For example, prescribing an antibiotic can be quicker than taking the time to counsel a patient on appropriate use and about why antibiotics are not needed for viral illnesses."

The CDC explains that these 4 communication strategies can be used to help prevent patient requests for an inappropriate antibiotic or to respond to such requests:

1. Provide a specific diagnosis to help patients feel validated. For example, say "viral bronchitis" instead of referring to an illness as "just a virus."

2. Recommend symptomatic relief and share normal findings as you go through your examination.

3. Discuss potential side effects of antibiotic use, including adverse effects and resistance. Many patients don't realize that antibiotics can be harmful.

4. Lastly, explain to the patient or parent what to expect over the next few days -- including that you will reevaluate their situation and prescribe antibiotics if it becomes medically appropriate.

So, what does this all mean in the end? Well first, we as patients, need to stop requesting antibiotics when we have things like colds, coughs etc. Then second, as medical professionals we need to not be swayed by the persistent patient that keeps asking for medicine.

We may make some patients upset, but in the long run it is better for everyone.


Top 10 Grossest ER Dilemmas

picture by Salvatore Vuono

Just had to share this post from Girlvet over at

madness: tales of an emergency room nurse

She titled it "I think I just threw up in my mouth."

And this was her post:

I mean seriously there are days we deserve combat pay. Like today.

In the spirit of grossness, I present the top ten gross things a nurse deals with:

10) feet that haven't been wash for a year

9) a heroin addict with sores

8) scabies

7) bed bugs

6) drunk heavy smoker who has peed their pants

5) rectal abscess that needs an incision and drainage

4) bad GI bleed

3) grandpa who laid on the floor for hours and is covered in dry stool

2) diarrhea from C diff



What are some of the grossest things you have seen?


Violence Against ER Nurses

photo by Kounas

A new study, released this past September, suggests that rates of violence against emergency room nurses are high, and remain steady.

The study, which was issued by the Emergency Nurses Association, states that every week, as many as 8-10 % of emergency room nurses in the United States are victims of physical violence.

The Emergency Department Violence Study also reported that 15 % of the nurses who reported experiencing physical violence said that they received physical injuries as a result, and in 45 % of the cases, no legal action was taken against the perpetrator.

“We are extremely alarmed that there are so many cases in which hospitals do not respond to violence in the emergency department,” said ENA President Diane Gurney, RN, MS, CEN.

The report however, does suggest that remedies to the problem do exist.

Panic buttons or silent alarms are associated with lowering physical violence rates. Also having an enclosed nurses’ station, security signs and well-lit areas are associated with significantly lower verbal abuse rates.

The complete study can be found at ENA.org
What are your experiences?