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Thursday, February 01, 2007

Idealism vs. Realism

(Take 1.)

A reader posed a very interesting question in a comment thread on a recent post. I had said that “idealism is what brings people to nursing in the first place, but realism is what keeps them there,” and Not Nurse Ratched asks: “how do you practicing nurses handle this clash between idealism and the real world?”.

I think it’s a great question. I'm not sure I have the 'right' answer, but I'll see if I can distill my version. My clash came from having come through a very heavily holistic yet evidence-based BSN program - we're talking the epitome of Ivory Tower Nursing - and then starting as a new grad in a very much inner-city ER, sixth-busiest in the nation at that time (we've fallen to 8th, I believe). Before I hired on, I had spent two eight-hour clinical shifts in an ER across town at one of the private hospitals, cushy as they get. Think the difference between Chicago Hope and "ER"'s Cook County General, if you're old enough to remember when both those shows were playing. I remember starting out in that environment thinking "Holy shit, this place is a zoo" yet loving every minute of it. I knew that a hectic, fast-paced, crazy environment was what I wanted. And for me, the disparities sorted themselves out one-by-one because I tried really hard to take it all with a grain of salt.

You learn in school that pain is subjective, "pain is whatever the patient says it is." You learn in real life that it's hard to believe somebody's having 10/10 abdominal pain while they're laughing with friends and asking repeatedly if they can get something to eat.

You learn in school that first you have to establish rapport with your patient, and you practice and practice that. You learn in real life that it's much, much easier than that: as simple as changing the way you introduce yourself, adjusting your speech pattern to be more comfortable for whatever type of patient you're talking to. It takes about ten seconds, most times.

You learn in school when to use clean technique and when to use sterile. You learn in real life that in a critical situation, lots of times clean is just fine.

You learn in school where the basilic vein is, and textbook IV start technique. You learn in real life to palpate the veins wherever they are, who cares what they're called, and you learn to recognize that 'tink' that lets you know you're in.

You learn in school that it’s terrible to label “drug seekers” or “drug seeking behavior.” In real life, you start to see the connections and visit patterns of a number of patients who are oddly all allergic to Tylenol, NSAIDS, Toradol, Stadol, and Tramadol, and then you start to change your mind.

You learn in school that restraints are thought of as inhumane, only a last resort. You learn in real life when a 250-pound psych patient pops you in the jaw, restraints aren't all that bad sometimes.

You learn lots of facts in school. In the real world, you learn tried-and-true pearls like: "Sick people don't bitch." "Never trust a diaphoretic patient." "End-expiratory grunting is always ominous."

You're groomed in school to think your license and your paycheck put you above paramedics and EMT's. And you learn in real life, that some of them have volumes of expertise they're happy to share, and you're wise to ask for. (And I don't just say that 'cause I'm in love with one of 'em.)

By the time you finish school, you'll have gotten a pretty good feel for where your comfort zone is. (My first year of med-surg clinicals, I remember thinking 'oh my god, i've chosen the wrong career' because I knew then that bed baths and 9:00 med passes weren't my bag. You'll know.) Once you find that comfort zone, it’s up to you to formulate your own practice philosophy: you keep the pieces you learned, that work for you, and you chuck the pieces that don’t jive. As long as you start it all out with an open mind, you’ll be fine. And an idealistic attitude won’t hurt a bit. I still have most of my original idealism too, wedged there in my little nursey heart. It’s good to tap into on crummy days when you ask yourself why.

But the most important thing, I think, once you settle into a workplace - is to keep life balance in order to stay professionally balanced. Way, way, way easier said than done. (If you read my blog often enough, you'll see that some days I flat out suck at balance.) Listen to that little voice that tells you you're working too much, if you're picking up extra shifts left and right like I do. Do things you enjoy and remember to be a whole person and not "just a nurse" - I find that when I have days like the one that spurred this lively discourse, it's usually because I'm flirting with burnout or some other poor self-care issue. Absolutely true this week, the stress of hoping for my transfer to the new hospital vs. stress about my own health vs. stress about management scapegoating me and making my life miserable vs. stress of a personal life that's gone through oceans of change in the past 6 months... you get my drift.

And now, speaking of balance… I’m going to go clean my brushes so I can finish that darn painting tonight, and then I’m gonna go pick up my kids. And I’m gonna *not* set foot in the hospital until Monday, though I’ll see half my co-workers (in cocktail attire, as opposed to the usual scrubs) at the ER Holiday Party on Saturday.

Comments welcome – I love the lively discourse that other post generated!


Anonymous said...

And THAT folks is the difference!! Well said, very well said ;) I left a few comments on NRR's site regarding the discussion/situation this all stems from and I have to say a few things here as well. As stated to NRR, I come from the Law Enforcement side of human relations and if I were to take all that I learned in the academy and expect to use ONLY those tools and suggestions, I would be DEAD by now. There really is no way they can teach to every situation that one may encounter when dealing with the HUMAN RACE. Each situation is different, which I guess is why I chose this profession to begin with. "Same shit, different day" basically doesn't work for me. I need that "something different" each day and that's what keeps me going. However, as I was saying - book smarts (what they teach) and street smarts (common sense you learn by trial and error) are two totally different aspects of learning and growing. I believe that it takes both to make a well balanced individual, but if I had to make the choice between an above average IQ and what I have learned about the "real" world (that would be the street smarts by trial and error I was speaking of) - I would choose the knowledge learned by just doing the job!! Remember the old saying..."Is it live or is it memorex?" I have to ask myself that from time to time, but what I do know - I learned from BOTH a book/instructors and LIFE as it is!! We all have bad days and sometimes life is just plain shitty - but one thing is true - we come back for more because we choose to - we want to make a difference and WE DO!! Here is a shout out to you Erica and to all of your co-workers, EMTS, Firefighters and Police Officers for a job well done. And I must also give a shout out to all those TRAINING to do those jobs.....you too will one day find that balance that works for you.

Erica said...

Amen to that.

Not Nurse Ratched said...

Thanks for this post. This discussion has really been interesting and has made me think a lot. I suppose most practical careers are like this; when I was an editor, for example, at first I aspired for total correctness in print. Then after a few years I ended up just doing the best I could with the time I had and calling that good enough, because I was the only one with the goal of total correctness (my clients had time goals or financial goals, mostly). It didn't mean I wasn't doing a good job. I was hired BECAUSE I could ferret out what was necessary and what could slide by and get something done on time, not despite it. It sounds as if you are saying that nursing is a lot like that---in other words, clinical experience teaches nurses what is imperative and what is not on a case-by-case basis. I can't wait to start clinicals so I can start soaking up information from practicing nurses! Just a few short weeks, and y'all can read about the collapse of NNR's ivory tower. ;)

The Nurse 2goto said...

I know this post is older but the title caught my attention. Great Post. I would like to add your blog to my blog.

Thanks Tina RN @

rlerza said...

There is allot of difference between idealism and realism, and in most of the cases I believe that been a realistic person will help you much better then been an idealistic person. One thing is that many times it is life that will teach you the difference.