Brain, I know it's early, but you gotta wake up!
January 22, 2013 3:48 PM   Subscribe

I'm a nurse who has trouble at the start of my shifts because my brain doesn't get up and running until I've been there for at least an hour -- but the work really requires me to be at 100% from the first minute. There are plenty of questions about how to wake up your body in the morning. How do I wake up my brain?

In the first hour of my shift, I need to get report on my patients, make sure the aides know what each patient needs, go over everyone's plan for the day, start giving medications, address any urgent needs that have suddenly come up, address any ongoing needs that the night shift didn't handle, be ready to grab the doctors when they round with any questions or needs concerning their patients, and cope with any requests for information from family members and other medical staff. All this in a work environment that, most days, resembles a three-ring circus.

For that first hour, and sometimes for longer, I'm in a bit of a fog and have a lot of trouble getting on track. There's a lot going on and I usually feel like I'm being hit with a firehose. This is all normal nursing stuff, and I've been surviving this for a year and a half, but I need better coping tools to get my day, and my patients' days, off to a good start.

- I get up at 5:10, leave the house at 6:00, get to the hospital at 6:40, and eat breakfast there before my shift starts at 7:00. (My stomach doesn't allow me to eat any earlier.) I have two coffees/teas/sodas before work -- one at home, one in the car.
- We are not allowed to clock in earlier than 7 minutes before start of shift. We are not allowed to work off the clock, which would include looking at patient charts or getting verbal report from the offgoing nurse.
- We are not allowed to have food or drink anywhere on our unit except the break room.
- I usually don't get a morning break; when I do, it's not till at least 9:30.

Do you have any strategies for getting a running start in a situation like this?
posted by shiny blue object to Health & Fitness (27 answers total) 25 users marked this as a favorite
I realize that it seems crazy to get up even earlier when you're already getting up at 5, but I would recommend morning exercise. Even just a walk around the block might help, but a 20 minute run would really allow you to wake up, clear your head, and get pumped for the day ahead. It's awful when you first start, but it does get easier. And although it's counterintuitive, getting up earlier to give yourself some time for wake-up activity really does help.

(Credentials: I've had shockingly bad insomnia my whole life, and forcing myself out of bed for exercise, when I'm able to make myself do it consistently, is the one thing that really lifts the brain fog and gets me on a good sleep schedule.)
posted by decathecting at 3:53 PM on January 22, 2013 [6 favorites]

It seems really odd to me that it takes you more than two hours to feel fully awake in the mornings, even with two cups of coffee and a full meal. Are you getting enough sleep?
posted by Sara C. at 4:07 PM on January 22, 2013

You might try going to bed earlier, and/or using a sleep calculator like this one, which tries to help you time your bedtime to coordinate with when you need to wake up. If an earlier bedtime is just not practical, maybe try getting some extra zzzz's in the morning? I've found that if I shower the night before and lay out my clothes, I really only need 15 minutes in the morning to get out of the house.
posted by rainbowbrite at 4:17 PM on January 22, 2013 [1 favorite]

Response by poster: Are you getting enough sleep?

When I work consecutive days, probably not. On those nights I get about 6 hours.
posted by shiny blue object at 4:18 PM on January 22, 2013

It does sound like you're not getting enough sleep, or that the sleep you're getting isn't recuperative enough. Six hours when you're working a very demanding job may not be enough. Everyone's different, I find I need at least 7 hours these days, and easily sleep longer when I can. Try going to bed a little earlier, and do consider exercise first thing after you get up, yoga with a dvd or something like that.

I see from your profile that you're in grey upstate NY. Do you find it harder to get going in the winter? Have you considered the possibility that you have a mild case of Seasonal Affective Disorder? I lived in the town you list on your profile for a while, and in one 90 miles from there, and the older I got the less my body liked the endless lack of sunshine. If you can go outside at lunchtime sit in the sun, or sit in your car in the sun.
posted by mareli at 4:25 PM on January 22, 2013

Maybe take the stairs up to the floor you work on to get a little exercise before starting? Also consider what you eat for breakfast, protein usually gets me off to a better start brainwise than straight carbs like cereal or toast.
posted by bookrach at 4:38 PM on January 22, 2013

Perhaps, instead of drinking sodas, coffee and tea, try orange juice or something with vitamin C. It is supposedly more efficient and you won't get much of a sugar crash later.
posted by cyml at 4:45 PM on January 22, 2013 [1 favorite]

Try cutting the 2 morning bevs down to one, and drink it only after you've started to eat. For me, getting some protein digesting before caffeine/sugar hits my tummy helps me get alert much faster.
posted by DoubleLune at 4:47 PM on January 22, 2013

I think you either need to wake up earlier and exercise or do some kind of puzzle/game OR do something non-distracting like listen to a language learning podcast in the car. You are definitely not getting enough sleep, but you should still be able to focusing on work two hours later. You just have to wake up your mind with something first.
posted by two lights above the sea at 5:07 PM on January 22, 2013 [1 favorite]

I would definitely say look at your sleep schedule and lifestyle, especially given the light factor of upstate NY, and just see if there's anything you can do throughout the day to give yourself a boost-- more vitamins, more iron, more light, etc. If two coffees before 7 AM aren't doing anything for hours every day that you're at work, that seems like more of a long-term problem.

In the morning: 10 pushups, pullups, or squats? Crossword puzzle? I find that actually forcing myself to work through a problem is much better than idling flicking through the news.
posted by jetlagaddict at 5:18 PM on January 22, 2013

Do you listen to music in the car on your way to work? Drive by yourself? Sometimes I find it helps with the mental alertness to listen to (and maybe sing with) loud and up-tempo music on the way to work.

But I agree with the others, getting more sleep or adjusting your sleep cycle will likely be a longer-term fix to the problem.
posted by dorey_oh at 5:20 PM on January 22, 2013 [2 favorites]

What do you eat for breakfast? I've started having 2 scrambled eggs for breakfast before I leave the house each morning(and then I might have a little something else after I get to work that is more carb-y) and it has helped me wake up a lot. I also take cod liver oil in the mornings. If I have something like oatmeal or cereal alone I feel totally fuzzy.

I have brain fog and SAD, and am not a morning person, but this breakfast helps a lot.

Also get more sleep. I have to read for ~30min before I can go to sleep because I need to go to bed much earlier than my brain/body would like.
posted by fromageball at 5:33 PM on January 22, 2013

Response by poster: These are all good ideas, thank you.

Not to threadsit, but -- Are normal people at the top of their game as soon as they get to work? When I had an office job, we all started the day by checking email, answering voicemails, looking over the day's schedule, drinking coffee ... There was a little bit of a buffer to the beginning of the day, rather than having to jump straight into the deep end.
posted by shiny blue object at 6:10 PM on January 22, 2013

I don't know what's normal, but I can be up, ready, out the door, and in the "deep end" at work within an hour and a half. Less, if needed.

I always enjoy jobs where I can have a leisurely morning and drink coffee/eat breakfast after arriving as I casually sort through emails and suchlike. But if I have to, all it really takes to be raring to go is coffee before work instead of at my desk.
posted by Sara C. at 6:20 PM on January 22, 2013

Best answer: It might not be brain fog; it may be a question of approach. That first hour is really about gathering info and planning. It has different cognitive demands. Consider a using a brain sheet. Pick a couple recurring tasks (eg LPN/aide tie-off, check stat orders, check labs, bedside report/intro) and make a checklist. Try to develop consistent habits for routine shift-change tasks. These are the sort of the things you can do to avoid falling into full "reaction mode" when you first hit the floor.

I really don't think nursing schools do a good job at teaching task management and the in-patient floor environment doesn't really lend itself to typical project/task planning. (I'm a former engineer, current nurse...can you tell?)

And to add the sleep pile-on: why is sleep considered some unattainable luxury in our society? Just go to bed: it's not like you can't afford a good night's sleep.
posted by klarck at 6:41 PM on January 22, 2013 [5 favorites]

Best answer: I'm a trauma ICU nurse and I work in a regional level 1 trauma center. There have been many days where I was immediately slammed as soon as I stepped on the floor. I'm talking unstable patients being wheeled up straight from OR, emergent intubations, emergent bronchs, etc. all right at shift change. There is no buffer many days. I am at the top of my game, so to speak, the second I walk on the floor because I have to be - it's the nature of the beast. I absolutely get where you're coming from.

Other people have addressed the sleep and schedule issues. While you're working on that, what you need is a brain sheet. By that, I mean a detailed flow sheet/face sheet for each patient that will help you organize and plan your day. I came up with my own very simple flow sheet, but you can find some templates here. Use the same flow sheet every day, for every patient.

Getting into a consistent, workable routine will help you get started more quickly each day. Instead of spending a few minutes puttering around the floor trying to decide what to do next, you'll immediately be able to start completing your flow sheet and coming up with a plan for the day. For example, as soon as I walk on the floor, provided there aren't any emergencies, I make a chart for each patient. One side of the chart is divided into 12 boxes, one for each hour from 2000-0700. I write down all meds and labs that are due in their corresponding hours. On the other side of the chart, I have several sections: Dx, hx, a section for each major body system, labs, and "to-do". I fill out this side of the chart during report. I also note the patient's name, age, allergies, code status, and primary team on that side. I do the same thing for every patient every evening. I don't have to think about what to do when I first start work - I just immediately begin my routine.

If you don't already, it's also useful to have smaller routines for the various tasks you do every day. Doing certain things the same way every time not only saves you time, but can also prevent mistakes. For example, I only draw up IV meds in sterile syringes - I don't draw up meds in flushes. I immediately label all meds. I do this the same way, in the same order, every time. I never end up with an unlabeled med at the bedside because I have a consistent routine. My drips never run out because I order a new bag of a medication as soon as I hang one - that way I always have an extra in my med box.

Nursing is tough! Nursing school doesn't prepare you in any way for the absolute chaos you must manage as a nurse. Being organized is essential and has saved me from crashing and burning many a time. Good luck!
posted by pecanpies at 6:46 PM on January 22, 2013 [8 favorites]

I had (have) this problem too. I find that if I listen to a mentally stimulating podcast on my drive to work, that gets my brain moving and ready to work as I get to the office. My favorite podcast for this is In Our Time. It's interesting, varied and 99% of the time, engages my intellect and curiosity.
posted by nightwood at 6:56 PM on January 22, 2013 [1 favorite]

Best answer: Also, frankly, unless you already have an excellent, consistent routine and are already well-organized at work, I don't think sleep is the main issue here. Yes, getting more sleep might help you feel more rested, but it's not going to solve the problem. No amount of sleep is going to make bedside nursing less hectic, stressful, or chaotic. I worked at a desk job prior to nursing. My busiest day at my desk job was less hectic than my slowest day as a nurse. There is just no comparison.
posted by pecanpies at 6:58 PM on January 22, 2013 [3 favorites]

It sounds like pecanpies has some great nursing-specific suggestions, but since you asked generally about 'other jobs', I thought I would mention my strategy. I don't do anything that is as critical as healthcare, but I do have fast-paced milestones and I arrive an hour later than my manager and my direct reports, so things are usually in full swing when I arrive and I have to deal right away with any problems or developments that have arisen. During my commute everyday, I just naturally wander in my thoughts to what has happened yesterday/recently. When a lot is going on, I do this in a more systematic wayu, just mentally review every issue I can think of and what the general plan in for dealing with it. By the time I'm at work, my thoughts have already been there for ~30 min.
posted by Tandem Affinity at 6:58 PM on January 22, 2013

Well, my work isn't as challenging as yours, but it does demand attentiveness in a fast-paced work environment with lots of interruptions and opportunities to get distracted and make mistakes. Along with the other suggestions here, I would suggest adding L-theanine to your morning ritual along with your coffee. It has cognitive benefits and energetic benefits, kind of like getting more relaxed and attentive at the same time. It works synergistically with caffeine. People isolated this out of tea, apparently looking for the reason people found tea a useful drink. I feel like my attention span has gotten better and I feel mentally energized the entire day where with just caffeine, I seem to get a little jittery and don't really get the benefit I want from it alone. Google this for studies and more info.
posted by diode at 7:58 PM on January 22, 2013 [1 favorite]

I'm halfway through nursing school and (thankfully) my program really emphasizes the use of a brain sheet. It has helped me keep on track more than anything else I've tried and was my first thought when I read your post.

Klarck and pecanpies have it spot on, I think, if you're not using a brainsheet already. It's really helped me get things started on early morning shifts to be able to look down at 0700 and see "Take report, vitals, chart vitals"...

Keeping in mind, of course, that my brain sheets have all sorts of crap written on them that y'all remember without even thinking about it :)
posted by Pantengliopoli at 8:12 PM on January 22, 2013

It might sound too simplicistic but bright light really helps me wake up in the morning.
posted by dawkins_7 at 8:38 PM on January 22, 2013

Park your car far away from your job so you have a good long walk before starting work. Spend the time walking thinking about what you need to do when you begin work.
posted by conrad53 at 9:09 PM on January 22, 2013

Things I do on a regular basis to wake up OK:

1] Morning ritual of coffee. the ritual aspect seems to be more important than the caffeination of the coffee. Filling the water reservoir and coffee grounds really seems to pull me together with it being a several-step task.
2] Minty shower gel. The smell and the tingling seem to work to give my brain something to do.

Things I've done in the past but that I don't recommend doing on a regular basis:

1] Scary alarm clock. I used to have an alarm that went NEE NEE NEE NEE quite loudly, right by my head. It was quite a jolt of adrenaline to wake up to. It got to the point where I'd wake before the alarm went off. On those mornings, I was definitely awake but it wasn't the most pleasant of things.
2] Cold shower. Nuff said.

Anything that your body can perceive as a threat will cause your mind to wake up.
posted by Solomon at 2:32 AM on January 23, 2013 [1 favorite]

It sounds to me to be almost entirely due to not getting enough sleep. Try going to bed 60-90 minutes earlier and waking up 30 minutes later.
posted by turkeyphant at 3:19 AM on January 23, 2013

Response by poster: I had been using brain sheets, but since we went to all-electronic charting (Epic) 6 weeks ago, management doesn't want to see us using paper -- "It's all in the computer!" Yeah, right.
posted by shiny blue object at 6:52 AM on January 23, 2013 [1 favorite]

Best answer: I am another former desk-job person who switched to med-surg nursing, and I agree that your piece of paper is key. Our charting is all electronic (in Epic, even), but everyone still has a "brain sheet" (it's weird to me that nobody I work with calls it that; we all just say "my paper"). I have friends who work at other area hospitals whose management tried to say "no paper" when they switched to electronic charting, but they backed off quickly when the nurses pushed back.

One thing that I've really noticed is different about nursing vs. my previous desk jobs is that it's much harder to mentally prepare for the day. When I developed software, I always had at least a vague sense of what I'd be working on that day when I got to work. As a nurse, I have no idea what patients will be there for me to care for, in particular on the first day of a stretch of work. Does your unit allow you to keep the same patients day after day, if you work a stretch and the same patients are still there? I've found that it's easy to throw up your hands and say "I can't plan my day until after report, and by then the call lights are all lighting up," but if I'm getting mostly the same patients back for my next shift I honestly can plan at least a bit of what will need to be done. Don't fool yourself into thinking you can't plan anything, just because you can't plan everything.

Unfortunately nursing is a lot more reactive than planning, especially on the extra busy days. One way I'm trying to manage that balance is by planning for the process to be reactive. Instead of planning "At 10am I'll get that lady up for a walk," I plan "When that lady calls to go to the bathroom, we'll also go for a walk in the hall." I try to notice if somebody's prn pain meds will be available again at X time, and I go ask if they need pain meds before pulling out the scheduled meds that are due around the same time.

OK, but I'm way off topic of your original question, which was about feeling foggy in the morning. Personally when I'm working a stretch of day shifts, I need at least 8 hours of sleep each night to feel ok. And that means going to bed at 9:30, which feels to me like being sent to bed before the sun went down when I was a kid. Ugh. But if I can force myself to do it, the mornings are so much better. Here are some strategies I try to use to get myself to bed on time:

- Don't over-plan the evenings before a day shift! Dinner doesn't have to be an ambitious from-scratch recipe, I don't really need to go to Target until my day off, etc.

- Do the bedtime routines that I don't like, earlier than bedtime. For me this means scooping the cat litter box early in the evening, rather than sitting on the couch until 9:15, 9:30, 9:45 avoiding going to bed because I don't want to scoop the litter box. Sometimes I'll even brush my teeth and wash my face as soon as we're done with supper, so the only thing standing between me and sleep by the time I'm actually tired is to get into bed.

- Find a good book that I'm excited to get into bed to read. For me it's easier to put down a good story to go to sleep, than it is to talk myself into getting into bed. If I can motivate myself to be in the right place for sleeping at a reasonable hour, then I get to sleep at a reasonable hour.

- Get my husband to read to me. This one is a pretty awesome way to fall asleep, if you can talk someone into it. We just finished the Harry Potter series.

- Don't sleep in too much on the day off before a day shift. It's impossible to go to sleep at 9:30pm if you got up at 10:30 am.

- When I don't follow that last piece of advice, I'm not above popping a benadryl around 9pm so I get sleepy. But I try not to make a habit of it.

And for actually waking myself up in the morning, singing along to ridiculous music in the car is the best thing I've found. I suspect that the exercise thing would work too, but not at the expense of 45 minutes of sleep. And I don't think I can bring myself to go to bed at 8:45pm. Good luck!
posted by vytae at 7:34 AM on January 23, 2013 [3 favorites]

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