Interviews 101: Answering that CULTURE Question!

I’ve got interviews on the brain this week.

One of my FAVORITE parts of being a clinical instructor is participating in exit interviews as the associate degree of nursing students graduate – nurses who are just about to graduate and take RN boards. They come in and are interviewed by several instructors to practice interviewing for a real job.

It is so fun to see students that I’ve had in clinicals and known throughout their time in the nursing program check off their final task on their checklist on their way to graduation. We are holding a pinning ceremony for them on Thursday which is also one of my favorite parts the semester and then I’ll start in January with a new group of students!

Throughout the interviews this week, a few things really stuck out to me and I wanted to share them with any new grads or really any nurse who is job seeking. I’m going to do a series of tough interview questions that nurses are usually asked in interviews. Today I’m focusing on that culture question.

The Culture Question

Culture is defined as the customs, arts, social institutions, and achievements of a particular nation, people, or other social group.

We live in rural northeast Iowa – I mean RURAL northeast Iowa. In 2017, the major city/town I work in had a total of 93.8% WHITE alone residents. Most of the population we work with APPEAR to have the same culture as I do as a white woman. I cannot honestly think of a black man or woman who works in our facility. My students have very few opportunities to work with students of “other cultures”… or so they think.

Usually the question comes up in interviews about how the nurse would provide trans culturally congruent care across the life span in a variety of healthcare settings. So many of my students said “I’ve never worked with anyone of a different culture.”

WRONG. Pediatric patients are their own culture. Elderly patients are their own culture. Childbearing women are their own culture. Farmers are their own culture. The list goes on and on. We may appear to be the same, we are not. Just because we are white, does not mean we belong to the same culture.

I have a friend who grew up with a single mom and has no idea who her dad is. I have a friend who was adopted. I have a friend who is a twin. I have a friend who is a vegetarian. I have a friend who is a Jehovah’s Witness. I have a friend who has a deaf mom. I have a friend with autism. I have a friend who grew up in the military and moved frequently. I have a friend who has survived childhood cancer.

Each of us bring our own unique set of experiences and values to the table. We may appear the same, but we do not all belong to the same culture.

Can you imagine the difference in my Thanksgivings?

I have my family – I am the youngest of 5, both of my parents came from families of 5 or 6 children, we can’t possibly fit our entire family in one building. It is loud and we drink alcohol and graze all day and the boys end up in the garage smoking.

On Craig’s side of Thanksgiving, we can fit his entire mom’s side at one kitchen table. He has a Great Grandpa, a Grandpa and Grandma, and both parents. I don’t even have a full set of parents and my two grandparents that I knew passed away before I graduated high school.

But Craig is white and I am white so some might assume we belong to the same culture or set of beliefs.

I would not approach caring for an elderly demented patient the same way I would care for a woman who just had a baby. I wouldn’t even care for a woman who had her 7th baby and a woman who just has had her first baby the same way.

How to Answer the Interview Question

The safe answer to this question is first acknowledging that we all bring our own set of beliefs and culture to the table regardless of what we look like or where we grew up.

The best way to make sure you are honoring your patient’s beliefs and wishes is to get to know them. That way you can identify any language barriers, educational barriers, maybe they are under a huge amount of stress etc. This can help you coordinate resources and make sure you’re providing effective teaching. You can also identify any barriers they may have for caring for themselves and for maintaining compliance with medications and self care.

What if I haven’t taken care of someone with a different culture than mine?

Re-read what you’ve just read – you HAVE taken care of someone of a different culture!

Talk about having to float to a different department and caring for a subculture of patients you aren’t used to such as caring for OB moms.

Talk about having to tailor your care/conversations to dementia patients by playing along in their world.

Talk about the important role the chaplain has played in your facility and how incorporating the patient’s cultural beliefs in the dying process is not only important for the patient but also for the family.

Talk about how you will always respect the patient’s wishes and beliefs even though you may not share those same values.

Make sure you sound politically correct

I’ve had a couple students say “the patient was Spanish.” Well that’s not exactly the proper terminology. While I don’t claim to be the most politically correct person in the room, “Spanish” is a language and does not always properly explain the patient’s ethnicity.

Not only that, but they may all speak Spanish but have their own accent or way they speak the language – just like we have a northern accent, a southern accent, a British accent, and English accent etc.

For example, the patient may speak Spanish but is actually from Guatemala which would make them Guatemalan. Or they may speak Spanish but be from Mexico making them a Mexican. They may speak Spanish but be from Honduras.

Now you may not know all of the right ways to pronounce every culture, but if you know that you want to talk about a patient interaction with a childbearing Somalian woman, when you are rehearsing your answers for the interview make sure you look up the proper way to describe their ethnicity.

AND OF COURSE…

The proper way to summarize and conclude any interview question is with “And that is how I provide culturally congruent care” or “And that is how I blah blah blah” so the interviewers know you are DONE with your response. “and so yeah” is not a proper conclusion.

When you’re TRULY busy…

As an ER nurse, one of my most valuable skills is my ability to go with the flow and be flexible. I found this meme on Facebook and I felt it in my BONES people!

As an ER nurse, I say bring ’em on down!

I feel like this is a skill that is overlooked. ER nurses have the ability to adapt and change their course of action as patient conditions get more critical or census gets higher. Whatever comes our way, we will make it work.

Often times, I hear other nurses say, “I could never work in ER because I don’t know what comes in next!” That’s what I love about it. Navigating my way through a full lobby of sick patients, all of our beds full, and the ambulance bringing in a critical patient tests my critical thinking, triage skills and flexibility. I’m confident in knowing I can make just about anything work and I can handle it.

This is a learned skill and if you’re used to working in a pretty steady and even paced environment, chaos comes with a lot of fear leaving many nurses at their witts end screaming “I CAN’T TAKE THIS ANYMORE!” But YOU CAN!

The next time you feel like you can’t handle anything else and the patient load gets piled on thick, critically think! Here are a few tips I have:

First of all, is this safe? Is this a safe patient load? Don’t get this confused with “I don’t want to take another patient” but really think about it: is it safe for me to take another patient? Can I give all of my patients the attention they need?

Second of all, you’re never alone. Know your team’s strengths and weaknesses and use them to your advantage.

Delegate. Delegate. Delegate. If you are swamped you should NOT be completing TASKS. Tasks include getting vitals, starting an IV, helping someone to the restroom, fetching things, etc. You focus on assessments and documentation – things you cannot delegate.

Believe in yourself. Shake off the mindset of “I’m drowning” and jump into “I’m handling this like a BOSS!” The power of positive thinking is incredible.

What resources do I have? Could I request a float nurse? Is someone on call that can come in? Is another department slow? Could someone come in early? Could this admission wait?

Don’t let anyone go unseen. Triage people in your lobby. Get in and get a set of vitals on your new admission. Lay eyes on your patient as soon as you are able to get a good baseline assessment. If you don’t and things go south while you’re away, well, that’s bad.

Hang up the phone! So many times I’m getting pulled out of a patient’s room for a phone call or spending my time on hold. No one ever tells you how much of nursing is just waiting on the other end of a parked call. Either ask someone to hold for you, ask them to take a message, ask to call them back, or just transfer it to someone who can help them. So many times we get calls from people wondering “Should I come in?” or “Can I take this medication for a headache?”or “I was seen there earlier and have a question..” While I would love to take these calls in my downtime, I have to take care of the people who are here and under MY care right now.

Ask for help. Recognize signs that you are behind or that you’re not doing well. If you’re distracted and unable to focus on your medication pass, you need to ask for help. If you’re catching yourself almost making a mistake because your mind is so overwhelmed, you need to ask for help. If you feel your patient load is unsafe, you. need. to. ask. for. help.

Make a list of things that need to be done and prioritize – back to AIRWAY BREATHING AND CIRCULATION. Treat PAIN. Make a schedule. When you enter a room think to yourself: I can allow 15 minutes to complete this med pass. I have to be out of the room by 4:45 – even consider setting a silent alarm on your watch if time management is becoming a problem for you.

Often times when I feel overwhelmed and I feel like I have so much to do but once I actually sit down and think about what needs to be done, I’m doing just fine. Give yourself a reality check. Take a deep breath. And press on. A good way to consider this is, “If I had someone to delegate to, what needs to be done right this second.” Usually, I can’t think of much.

Finally, when the department is bogged down, LET YOUR PATIENTS KNOW. I have a few different scripts I like to use to explain delays:

“We have a critical patient who just came in” or “We are experiencing an unusually high ER census at the moment and we are doing our best to take care of critical patients.”

“I don’t want you to feel like I’m not paying attention to you. I will be back as soon as I can be but in the meantime I brought you a glass of water and a warm blanket. If you have any questions or concerns, the best way to get a hold of me is to push this call light button because I may be tied up for a bit before I can come back in here. Please let me know if you need anything at all – especially if you start to feel worse.”

People are usually very understanding if they know there is a delay and how to reach you if they need you. Tell them where the bathroom is. Thank them for their patience. Get them a warm blanket. Offer a glass of water. Give them a time estimate if you can.

This is a great example of when I love my iWatch. I will tell the patient: “I’m going to set an alarm on my watch to come check on you in 15 minutes to see how you’re doing” or “The pain medication should be kicking in in about 20 minutes. I’m going to try and be back in here at 2:20 to see how you’re doing.” and then set an alarm. This has helped me keep up on my documentation as well.

That’s all folks! I’d love to hear some other time management tips from the nurses reading this! Leave a comment below or on my Facebook!

Nurse Hours

I wanted to do a post explaining how nurses hours work. I try to make sure I have this conversation with my nursing students before I set them free into the nursing world because it can be difficult to understand.

A lot of nurses work in FTEs. Each 0.1 FTE is 4 hours. For example I work a 0.9 FTE that means I work 36 hours in one week or 72 hours in one pay period. (9×4=36)

If I was a 1.0 FTE I would work 40 hours in one week.

If I were to be part time I would usually only work a 0.6 FTE and I would only work 24 hours per week or 2 – 12 hour shifts.

Usually positions that work below a 0.75 FTE (depending on the organization) are not eligible for full time benefits or they have to pay more for their benefits that they receive. Sometimes when you are new, your only option is to wait until a full time FTE opens up to get all of the hours you want and take a lesser FTE like a 0.6 to get your foot in the door.

I personally enjoy working my three days a week and then having the other four off. If you were to group all of your days together, for example, if you work Monday, Tuesday, Wednesday, Friday, Saturday, Sunday you would have the next week off because you worked all of your 72 hours in one week which is what I’m doing this week.

As I’m trekking through a long week of work – here’s a glimpse into my work schedule:

Monday – 12 hours – day shift

Tuesday – 12 hours – day shift

Wednesday, Friday, Saturday, Sunday – 12 hours – overnights – that’s working the next 6/7 days – a 72 hour work week.

It also gives you an opportunity to pick up major overtime in your scheduled week off. I’m averaging 48 hours a week for December with my overtime.

Various organizations have incentives to pick up extra hours. Sometimes you can earn $3-$4 an hour extra just for picking up a shift but you can earn time and a half every hour worked over 80 hours.

There are also weekend package options which is where you work 4/5 or 5/6 weekends – Friday, Saturday, and Sunday, they are eligible for full time benefits, and then earn either time and a half or a dollar amount more per hour depending on the organization.

We do self scheduling where I work and I love it. A blank schedule goes out, all nurses take the time to fill in which hours/days you’d like to work, and then it gets tweaked by our supervisor. I would say I get 90% of the shifts I write down or sign up for. There isn’t much overlap because we are all on different weekend rotations.

You would think this would be a difficult way to schedule nurses but it actually works out great. Many of our nurses WANT overnights and many WANT day shift. Personally, I’m a flip flopper. I don’t like to work only days or only nights so I usually end up working Monday and Tuesday day shift and Thursday night overnights with my every third weekend rotation.

We call it “hell week” at work because if you work all of your shifts in a pay period in one week you get the next week off completely without taking PTO which is great!

It’s also nice because I can still take a week off of work for a vacation without having to use my paid time off. I just schedule myself accordingly but that may also mean I work the “hell week.”

I’m sharing this with you just to give you some more information on how nurses “crazy hours” actually aren’t that crazy and they definitely have their perks!

In conclusion, to my nursing friends, I want you to consider and ask a few questions before you take a new job with new hours:

Do they consider seniority when making the schedule?

How many weekends will I work?

Is there an opportunity to decrease FTEs to part time?

On average, how long does it take to get the shifts/schedules I want? (for example, does it take several years of night shift to get seniority to move to day shift?)

How many FTEs do I have to work to gain full time benefits?

What works best with my family’s schedules?

How long am I willing to work the shift I don’t want to work to get to the shift I want to work?

That’s all I have for today folks! I hope this is helpful!

P.S. I also wanted to touch on what it means to be PRN – PRN means AS NEEDED. Many nurses, when transitioning to a new job stay PRN at their old job which means they can still pick up hours and they are still an employee of the hospital. You can have a full time job and work PRN somewhere and pick up hours!

10 Reasons I LOVE Being an ER Nurse!

In honor of Emergency Nurses week which lands October 6th-12th, here are 10 reasons why I love being an ER nurse!

1. Shifts go by FAST

(For the most part). When we are super busy it feels like time flies! I work 12 hour shifts and I love it – I either work 7 am to 7 pm or 7pm to 7am! I love both shifts equally and I flip flop shifts a lot – often in the same week! People call me crazy but we do self scheduling in our emergency department and I sign up for the rotating shifts! I have to work 3 – 12 hour shifts a week – I wouldn’t want it any other way!

2. Emergency nursing is all about TEAMWORK!

Each day I work, my team consists of a doctor, another nurse, and an assortment of EMTs and paramedics. We coordinate with ancillary departments such as lab, radiology, social services, and EMS. Every team member plays a vital role in the care of our patient and it is well known that we can’t do our job without the other team member(s). We all hold a mutual respect for each other’s role.

My coworkers/team members are amazing. They make my job so much fun. They also understand what it is like to work in an emergency setting: the frequent flyers, the rude patients, the safety concerns, the disrespect, the heartbreak, the trauma, the things you can’t unsee, THEY GET IT. I can lean on them for support in a way I can’t lean on my husband or my friends.

We all know each other’s weaknesses and strengths. We are all invested in the care of the patient and want the best outcome. Being a member of the emergency healthcare team is such a privilege and I do not take it for granted.

3. You never know what is coming through the door!

When I ask nurses why they wouldn’t want to work in the emergency department, this is the #1 answer: I don’t know what will come through the door next.

THAT’S WHAT I LOVE! I LOVE knowing that things can change any second. I love the challenge of managing several critical patients showing up at the same time. I love the rush. I love the unknown. More than that, as I’ve become a stronger nurse, I love knowing that I can HANDLE anything that comes through the door.

This may sound arrogant but…..

  1. You have to be confident in your skills – what if I said “I don’t think I can handle anything that comes in.” That isn’t reassuring.
  2. I am NEVER alone – refer back to reason I love ER nursing #2 – I have an amazing team.

4. You get to work with every population!

I work in a general critical access hospital – this means that it is a small hospital. We have 25 beds between med-surg floor and OB. The ER has 10 beds. We average seeing about 25 patients a day. I work with every type of patient of every age of every background. We have quite the diversity of patients – more than you’d expect in the rural midwest. Each population brings its’ own unique problems and considerations so my day NEVER looks the same!

5. I LOVE starting IVs.

Seriously though, I LOVE starting IVs. If I ever work in a bigger hospital, I think I would apply to be on the IV team! I start an average of 0-10 IV’s a day. The ER nurses and paramedics serve as a resource to the rest of the hospital for difficult IV starts. There is nothing more rewarding than being able gain IV access on the first stick of a difficult patient – all the way from newborn babies to the elderly.

6. You get to work with EVERY body system and learn how one affects the other!

From the relationship between magnesium and potassium, to the interactions of ace inhibitors and why it can have a cough as a side effect, I’m such a NERD when it comes to how medications effect the body and how each body system effects the other. If we aren’t sure how compazine works, why does it cure a migraine? Does this medication act as an anticoagulant or a anti platelet? Why is toradol more effective than narcotics when treating kidney stones? Why is a beta blocker given for a STEMI instead of a calcium channel blocker? Just when you think you have a handle on it, a new medication or disease process comes along!

7. You get to know frequent flyers!

Frequent flyers is sometimes used as a derogatory term in emergency departments. For me – I love my “repeat customers.” I get to know them, their health history, their chronic problems, their families and I feel like I can take the best care of them! I “sign up” to take them right away – they are relieved when they see me and I take pride in knowing that I am the best nurse to care for them!

8. You get to see some cool stuff.

This one is obvious. Every time I tell someone I’m an ER nurse their first response is usually “I bet you see some cool stuff.” Yes, I do. Sometimes I’m laughing all the way home, sometimes crying. Some days I spend all day learning and some days the cases are pretty predictable. I have to be really careful how I word this answer. Obviously I don’t WANT people to get hurt and have really cool injuries but it happens and sometimes I come across a really interesting case – traumas, medical mysteries, deep deep lacerations, incision and drainage of cysts, gun shot wounds, etc.

9. I get to develop my multitasking skills everyday!

I LOVE this part. My mind automatically multitasks and develops to do lists and can go a mile a minute – I didn’t start off like this but my management and multitasking skills get stronger every time we have a crazy busy day with truly critical patients and only 10 beds and an ambulance coming in and going out and an IV start in CT and a GI bleed who needs blood hung and a helicopter landing and a suicidal patient requiring one on one care and that little tot just threw up in the lobby and med surg is ready for report and I haven’t peed in 8 hours and forget a lunch break – I LOVE days like that.

10. I’m a resource to other departments.

I love starting pediatric IVs. I did not used to. I used to beg the paramedics to step in for me or send someone else with more experience down to start baby or kiddie IVs until one day a good friend of mine said “you won’t learn if you don’t try.” I spent the next year taking EVERY possible IV start and pediatric IV start available. I studied it, I watched other experienced medics, I would assist whenever I could, and now I’m a resource. I’m a relief to others who are scared like I used to be. Am I perfect? NO. I don’t get nearly enough exposure but by taking every opportunity to learn I have built my confidence and I’m now a resource to my coworkers and other departments. This is an example of how I reach to be the best nurse I can be for my patients. I also try to offer as much experience as I can to other departments. If we have a critical patient, I’ll ask med – surg to send down a “newbie nurse” and I’ll walk through treating the patient step by step so they are more prepared and understand how to handle critical situations such as hanging drips, giving RSI medications, or working through a code. Be the mentor you wish you had.

That’s all folks! Thank an ER nurse this week! I’ve also seen that it is PEDIATRIC NURSES WEEK! ❤️❤️ so show them all the love you can too!

“Mommy, Why Do You Have to Go?”

“Mommy why do you have to go?”

That sentence comes out of my 3 year olds pouty lips as he’s gently tugging on my black scrub bottoms.

He cries when I put on my scrubs. He knows I’m leaving again. He doesn’t understand why.

He doesn’t understand there are patients who don’t even know they will become a patient today who need me.

He doesn’t understand that there are people waking up this morning who are going about their morning routine as if they aren’t going to get tboned and airlifted on their way to work.

He doesn’t understand that a mother is waking up to find her teenage son on the brink of death from an overdose in an attempt to take his own life.

He doesn’t understand a woman is unknowingly about to become a widow today and right now she’s having coffee with her husband.

He doesn’t understand that they need me.

To hold their emesis bag and hold their hands
To give life saving medications and hand out band aids
To give compressions until I’m out of breath and wait with a patient as they take their last

They need me. And he needs me. And he doesn’t understand.

“With loyalty will I devote myself to the welfare of those committed to my care”

“One more night and I’ll be home with you” my voice quivers through choked down tears.

I want so badly to be the mom he needs me to be.
I give him a hug and a kiss.

Despite his protest I’ll take my coffee and head to work.

And I’ll spend my shift wondering who really needs me more.

So, you just made a medication error…

Rest assured good friend. Everyone makes medication errors. After you’ve emotionally processed the fact that you’ve just made a medication error, you need to take action. Each facility will have it’s own policy and procedure but here is a general guide to help ease through a sticky situation.

Step 0 – if the medication is infusing – STOP IT.

Note the time – it may sound strange but look at the clock and make a mental note of the time that you found the medication error and the time the medication error was made.

Tell someone. Tell your coworker, tell your charge nurse, tell your house supervisor, tell your DON, whoever would be most appropriate in your facility. This is an important step and only takes a second. You need a second set of eyes because if you’re anything like me, you’re upset and maybe not 100% on your game. Maybe they can come assess your patient with you. Maybe they can start the event reporting process. Maybe you need a second set of eyes to see if you actually made the error you think you did. Maybe they can work on getting the doctor on the phone. Maybe they can make some calls while you move on to step #2.

Assess your patient. When I say assess your patient, I do not mean delegate vitals to your nursing assistant. Go in the room as soon as possible and assess them head to toe including a full set of vitals. Ask them how they feel. Ask them if they have any new symptoms. When you call the doctor (in the next step) you need to have a solid assessment in front of you and ready to roll off of your tongue.

Call the doctor. Give a report using SBAR. Side note – I HATED SBAR but now SBAR is my FRIEND. If you haven’t heard of SBAR, a quick google search will fill you in. You sound professional and organized. You sound prepared. You seem put together and less frazzled than you might be feeling.

Prepare for them to be frustrated or maybe even a little scared themselves. Prepare yourself to take responsibility for your error. It may sound something like:

“I understand you’re frustrated and I’m frustrated with myself. Please know I will be thoroughly reviewing the error and identifying what went wrong with my supervisor. I will learn from this and work to make sure this doesn’t happen in the future.”

See how I didn’t apologize a million times over? I didn’t even apologize once in that statement. As my fifth grade teacher says, sorry doesn’t feed the bull dog. Tell them what you’re going to DO. Don’t waste their time with repeating “I’m sorry” until you’re blue in the face. They know. Be remorseful but let them know you’re taking action.

The doctor will likely give recommendations or orders such as “monitor vitals every hour for 24 hours” or “hold their evening dose of Metoprolol” or “they need to go to the ER” or they may even say, “so what?” Have a pen and paper ready!

Do some research on the medication yourself! Critically think and look up the onset of the medication. When should I expect symptoms and what should I expect?

Did you give a double dose of Metoprolol ER? You’re going to be checking vitals OFTEN but maybe not for a few hours! Did you give 2 mg of Dilaudid instead of 0.5 mg? You’re going to want capnography at bedside and have the oxygen and Narcan ready! Did you give 10 units of Novolog instead of 10 units of Lantus? You better be checking blood sugars and force feeding orange juice.

Continue to monitor your patient for adverse side effects, toxicity, new symptoms, and changes in level of consciousness. How long you monitor your patient will depend on the medication and the severity of effects the error had on your patient.

Sit down with your supervisor or charge nurse, debrief, and identify what happened. Simply put, which of the 5 rights of medication administration did you betray? Who else should be involved in the debriefing? Find the holes in the swiss cheese! (my BSN friends will get this!)

Did the pharmacy package the wrong concentration? Were you short staffed? Did the barcode not work? Was your computer down? Was the package labeled wrong? Were you distracted? Were you floated to a unit you weren’t comfortable with? Don’t BLAME others, but critically think about WHAT HAPPENED that could have been prevented.

RaDonda Vaught – a Tennessee nurse who was tried for reckless homicide for administering vecuronim – a paralytic agent instead of versed – a sedative resulting in the patient’s eventual death at Vanderbilt University Medical Center.
While her mistake was fatal, she was NOT the only one at fault.

The final step is to LEARN from your mistake. Admit to your mistake. Tell others about how to avoid your mistake. Show grace to other nurses who make a mistake. Come up with a plan to avoid the circumstances the contributed to your mistake.

Finally, forgive yourself. We are all human. We all make mistakes. We will make mistakes again. If you are struggling with your confidence or doubting your abilities or staying stuck in the “I’m so DUMB” shame spiral for too long, please reach out and talk to someone. Reach out to your education department for resources, maybe your hospitals employee assistance program to help coordinate some counseling, a close coworker or the best option yet would be your supervisor.