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Joined Oct 17, '09. Posts: 154 (15% Liked) Likes: 46

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  • Nov 15 '14

    I am not sure if I'm repeating anything that others wrote because I didn't read their posts completely. I am a Utilization Review Nurse Consultant for Aetna. I have been there for 3 years. The position does not require any previous UR experience, just the willingness and enthusiasm to learn. Aetna is worldwide and positions are available almost anywhere in the US and many parts of the world as well. What IS required is strong clinical skills and good technical skills. I run an average of 5 different programs simultaneously in order to do my Job. Aetna offers the ability to eventually work at home once you are successful in the role. This position is much like nursing, you are trained in all aspects of the position. We perform review of inpatient cases as well as some ambulatory cases that require review. Again, this is something that you can be trained to do.

    If Utilization review is something that interests you, I encourage you to work towards that goal. If it turns out to be something you don't care for, you always have your nursing to fall back on. Also, Aetna has some positions for precertification review nurses that are LPN's. So this is not just an RN role.

    I enjoy working for Aetna, I feel they are a strong leader in the insurance industry. The benefits are outstanding, the pay is extremely competitive. You feel like you are part of the big picture in many ways at Aetna. There are different avenues you can go with Aetna other than UR. You can do training and development, case management, quality assurance and beyond. There are so many opportunities, the list is endless.

    I wish you luck.

  • Nov 15 '14

    If you have years of floor experience you have some good experience to get started. Hospital utilization review is a bit different than insurance company utilization review. I am more familiar with hospital based review than insurance. Utilization usually does concurrent reviews of what is going on with the patient during the time they are in the hospital. Most hospitals use either Interqual criteria or Miliman criteria in which the nurse follows a set of criteria to determine if the patient's stay is medically necessary and if there is an intensity of service (receiving a level of care) that justifies hospitalization. You would probably be trained in that program after being hired. You will need to have a basic understanding of how both insurance and medicare works. Many hospitals are also using utilization review as documentation specialists where the reviewers also review the physicians documentation and what is going on with the patient and then querries the doctor to make sure that what the doctor is thinking and what he is treating is accurately and thoroughly doumented so that full reimbursement can be obtained. Medicare pays more for some diagnosis than others, but doctors do not always clearly document that and revenue is sometimes lost. there is certifications available but usually you have to work in a certain field for a year or two before taking the certification. Long answer but it is a good job for us older nurses whose knee can no longer take 12 hour days running all day long. I currently work in medical auditing and that also is an interesting area much like utilization review.

  • Nov 15 '14

    The company you work for will train you. You should have a basic knowledge of what a certain kind of patient needs for a certain inpatient stay. There are two online services that insurance companies and facilities use to give guidelines based on age, service, and co-morbidities. For example a 55 year old with a total hip replacement and no medical history other than arthritis, will need a much shorter stay than an 85 year old total hip secondary to fracture with dementia and COPD. Utilization reviewers make sure the patient gets only what they need, and at the lowest level of care where it can be provided. (The 55 year old will get PT home health, the 85 yr old will go to a SNF). You are making sure services are "utilized" appropriately.
    ST

  • Mar 31 '13

    I have recently graduated and having a fair amount of time on my hands (jobless, thousands of applications filled out and resumes polished) I wouldn't mind giving an open, honest opinion of educators and the practices.

    There was a point in my college career that I loved soaking up knowledge. I would read extra books and take more time on many subjects. I loved to learn. Particularly, I enjoyed spending time with Anatomy, Physiology, and other human sciences.

    I finally get accepted to the nursing program. Suweeeet. I worked so very hard and now I'm in. I start to settle in the first semester with all the rules, regulations, unique tests, clinical, and other stuff. As I go through the first semester, I notice a chilling pattern in my instructors. I had 3 instructors teach the Nursing Fundamentals class. While each one was slightly unique in tone, and delivery, they all were teaching verbatim from the book (I'll come back to this). I have to say we were given the occasional patient story. "I remember this one time or this one patient really..." the instructors said. Most stories were interesting and insightful at the time. In our program, we were given hand-outs. Lectures consisted of power point 99.9% of the time. Most teachers had the hand-outs posted on our college website prior to the next lecture. Some didn't. No big deal.

    So there I am, lecture after lecture, having this annoying monkey on my back. I kept thinking, "This is incredibly boring. I'm being read to. Everyday, I listen to a college professor point and read from a powerpoint. Oh god, I'm literally losing my mind." Where's the real world connection? Where's the excitement? This goes on and on. I finally decided to write a letter to the faculty. I'm the type of guy that is pretty open with my opinions. I try to be professional with the delivery in this case. I write a story about how I enjoyed my education at one point. The information was exciting and neat to the listen to. A sociology professor once told my class that, "I went through my master's having been read to. I don't want the same for you." She didn't. The class was engaging.

    The overall point I'm trying to make is that I absolutely despise the powerpoint when used improperly. It was used improperly the entire program. It extremely difficult to stay remotely engaged to a lecture when I could stair at my desk and read it from the handouts or I could stay home, skip lecture, and teach myself. Nursing is a very hands-on profession as of you all know. This is no hands-on approach. The current nursing education approach seems to be like, "How much information can we shove down the student's throat in the shortest amount of time and bore the h*ll out of the them?" Truly, the nursing education is exraordinarily boring. Now, this is coming from a person who LOVES school. I don't find it to be a chore or an annoyance. If I feel this way, how do you think the people feel who despise or don't like school feel?

    I write the letter to the faculty. There were some meager changes but as a whole, nothing. I get a big dose of nursing med-surg non-sense in the intracerebral route daily. Guess how much is retained and is actually useable. Minimal. I'm not trying to slander nurse educators. Believe me please. I'm trying to wake you all up. Of course, this may not apply to most of you. But, look at your current method of teaching. Do you rely heavily on the powerpoint like I describe. If so, there is likely some folks in your class that feel the way I do but aren't willing to fess up about it. Do you see people texting? Doodling? Not paying attention? I think each subject can be approached with enough pizazz and interest to, the bare minimum, keep people looking at you, engaged, and awake.

    What happened to your love for teaching? After all, isn't that love the reason why you entered education. I hope so and not because you want to fall back on your masters or higher education. It is apparent to students if you have done so. There is no excitement, no creativity, no pizazz, or no uniqueness. We can see at the bottom of the powerpoints that are provided by the big publishers such as, "Mcgraw-Hill or Evolve." I see the convenience of using those. But, being an educator and having a "body of knowledge", I would assume one could muster up, at least, personally created powerpoints or lectures.

    I don't know when THE BIG BANG OF POWERPOINT SLAVERY occurred but it's highly overrated. If powerpoints were Jesus, nurse educators seem to be the apostles following. Well, I'm Judas and narking on Jesus. Just showing point here (not trying to be sacrilegious or offensive). Tap your creativity again, brush off the dust, and attempt to keep your students excited. How often do you get students rushing in your office door saying, "Wow. Your fluids/electrolytes lecture was fascinating. Or, I've never heard it explained like that. Now I understand. Or, do you have extra books on this subject because I'd like to read more on that." Wouldn't that be awesome?! Try new and interesting methods. There is research out there saying that the current method of classroom learning and teaching is ineffective as it is. Lecturing for endless hours is on the bottom of the totem pole of effectiveness. Ineffective Airway NANDA says? Well, "Ineffective Teaching", Andrew says.

    For instance, so I don't seem to talk the talk. I sat here for a couple of minutes thinking of an interesting way to keep people engaged.

    How about this:

    You are lecturing about CHF.

    Try starting the class with a patient report you would give to a co-worker. For instance, about a basic CHF patient. Give assessment data, medical orders, daily tests and labs, etc. A real clinical situation.

    Then lecture about this condition for 30 minutes and then quickly discuss the patient report after having talked about the cardiac theory.

    You'd be connecting theory with a clinical setting. Practice having students hear patient reports. Exposure to medical orders. And, using the nursing process. Enhance collaboration amount students to develop a quick care plan and plan nursing management. Many Benefits.


    Or....You could read S/S of CHF...pathophysiology...nursing assessments...interventions...outcomes...THEN move to next disease...S/S of cardiomyopathy....etc...etc...etc...ZZZzzz.

    Just a thought. I don't though. I'm not a teacher. Overall, the point is to quit reading to us verbatim what we can read ourselves. Lecture isn't a party but it isn't a funeral. Keep us engaged. Please don't rely on powerpoint like it's the bible. Use other strategies. Please.

    Again, I don't want to offend educators. I'm hoping to shake some out of their routine a bit. Try some new things. I'm not mad or resentful because I'm graduated (How could I be).

    Here's an honest, broke, and jobless ex-student that has too much time on his hands, spends too much time on AN, and just wants to help out. Take care.

  • Feb 19 '13

    I'm black, yet I have cared for Neo-nazis. If given the choice, I would rather treat someone who would appreciate my skills and would have just stepped aside and let someone else deal with such a hateful individual.

    Also, you can't compare sex to race. I wouldn't feel comfortable with a guy touching my private areas, but I would be very comfortable with talking about those problems with a woman. Also, certain religions are against men and women touching each other unless they are married, and that is something that DEFINITELY needs to be respected.

  • Feb 10 '13

    I don't understand why some people say "LPN is a great place to start". Why is the implication made that LPN is fine but there is something wrong with staying an LPN? I am a PN. I am proud of myslef and what I do. I have desire whatsoever to be an RN.There is no reason to feel that as an LPN you and any less of a nurse.

  • Feb 10 '13

    Quote from em1025
    I am proud of what I've accomplished even if it's not what others may want, but honestly she ruined my week....
    Nobody can ruin your week unless you allow them to have that amount of power over you.

    When I was an LPN, I've had a couple of patients and/or family members who demanded to speak to an RN because they did not think highly of LPNs. However, I was not particularly bothered by their requests because I do not allow myself to lose sleep over misguided people. If someone felt I lacked credibility because I was an LPN, I actually felt relief at having one less sorry patient on my load.

    Develop a thicker skin. Not all patients are going to approve of your title, and in my personal experience, disabled or retired RNs can be the most demanding patients. You've just gotta let certain events roll off your back. Good luck to you.

  • Jan 19 '13

    I've worked with great LPNS and Great RNs and crummy LPNs and crummy RNs. It's the person and not the letter behind their name.

  • Jan 19 '13

    She called my name down the hallway. To me, at the other nurses' station. Why she did that, I don't know. I had a phone next to me. She's the unit secretary. Why doesn't she know my extension?

    "You have a phone call. Johnson's brother. Wants to speak to his nurse"

    I call back (now we are just raising our voices at each other, how foolish) "Transfer the call over here."

    She calls back at me. "What's the number at your phone?"

    Again I wonder- why don't you know the number? But I don't ask her aloud. I reply "6015" The phone next to my computer rings and I answer.

    "Third floor, this is SarahLee, how can I help you?"

    I hear a voice, sounding far away and yet right in my ear. "This is George, Elizabeth Johnson's brother. I was wondering if you could tell me how she is doing?"



    I ask "Are you her health care proxy or power of attorney?"

    "No, just her brother," the voice seems frail.

    My HIPAA training kicks in. I search my brain and scan through the computer in front of me to see if this person is a contact. I don't see his name in the computer and the chart is at the other nurses' station. Then inspiration strikes me.

    "I'm sorry, can you hold on for just a moment?" I ask. I press hold on the phone and walk down the hallway.

    Knocking, I enter. "Elizabeth, your brother George is on the phone, wondering how you are doing. Can I give him some information?"

    Elizabeth looks up and smiles. "Oh yes! I have been trying to call him! Please tell him anything that he wants!"

    I go back to the station and the phone, press hold again and just get a dial tone. I lost him. I must have hung up on him, poor man. Another victim of my sad phone skills. Sighing, I go back down the hallway.

    "Elizabeth, do you have his phone number? I'm sorry but I think I lost him."

    She searches her brain as she is lying there on her bed: "Oh yes, it's 478, no 784, no...oh dear, I'm always forgetting it..."

    Suddenly, the overhead page is heard, "SarahLee, phone call front desk. SarahLee, phone call front desk."

    Thankful, I say "Never mind Elizabeth, that's probably him"

    I go straight to the unit secretary this time. No more fancy phone maneuvers for me. She tells me how to use her phone, I sit down and I answer it. Quick apology for hanging up on him "I never could run these phones."

    "It's ok," he laughs nervously. Then, without skipping a beat, like he was diving into a pool before he lost his nerve, he asks: "Sarah, is my sister going to die?"

    Stunned at the suddenness of such a request, I search through my brain about the woman I just left in the room. Respirations even, non labored, alert, talking, laughing, getting up as needed on her own, very limited pain. Speaking cautiously, I reply "No...I wouldn't say that she is going to die. I mean, of course, I can't see the future. She's going to need some time to recover, certainly, but no, right now she's not dying."

    Suddenly there was a silence on the other end. No talking, just deep breathing heard, in and out, in and out. I thought I had hung up on him again. Finally I say "Um..sir..are.. are you still there?"

    Deep breathing and then, a tearful voice, full of anguish, speaking in a rush now, "I got home and had a message from our other sister, they said she was doing terrible, not well at all, that she was dying...I tried to call her room several times and I couldn't get through...so I finally thought I should try the nurse...so I've been trying to get through at the desk...." Then I heard the sound of him blowing his nose.

    And there it was. That moment that comes every now and again, where I am going along doing a normal day's work and then suddenly I feel like an observer of my own life. Like I am someone who is looking through a glass at all these different people walking around and suddenly I see two people who have never met before meet at an intersection.

    Without warning, his day's crisis had smacked headlong into my day's routine. What was he thinking when I put him on hold to ask my patient's permission to talk to him and then subsequently hung up on him?

    He had thought his sister was dying.

    Did he think I had to find someone else to break the news to him? Did he think that he would never hear his sister's voice again? Did he think that the nurse didn't want to talk to him?

    When I picked up the phone, I thought that he was going to ask some general questions like "How is she doing, when can she go home, can I come and see her?"

    But his question was more serious.

    His question was his biggest fear. He didn't even know if she was dead, dying or alive.

    Our phone conversation continued and we talked a little more about her health. His tears and fears subsided. I could tell that relief was spreading right through him. I could almost see his smile over that phone line, if such a thing is even possible to say. At the end of our conversation (with the help of the unit secretary) I transferred his call to her room where he and his sister had a good conversation.

    She called me into the room later and gave me a big hug. "Thank you so much," she said. "He was so afraid" and we laughed together, as two people who knew a private joke.

    But the rest of that shift, I felt what must be one of the best feelings in the world. I felt like smiling, laughing, running down the halls like a fool.

    Because my patient wasn't dying. She was very much alive.

    I had put one person's mind at ease. And I got a hug and a thank you from another.
    What more could I ask for? So don't ever underestimate the value of the little moments in nursing, like a phone call. Small routine moments in our patient care may turn out to be one of the biggest moments in our patients' and their families' lives.

    And we get to be part of it. How amazing!

    What little moments have you been a part of?

  • Jan 19 '13

    Today is my day off after working three days in a row. However, my eyes popped open at 0530 and would not close again. My brain immediately went into review mode. Shoot! I forgot to give that detail in report! Did I do enough with that brand new admission? Should I have done more before handing over care? Did I miss anything with that patient who did not have a great urine output yesterday? My fellow new grad RN seemed so competent when she took that new ER admission. Do I seem that way to her?

    And on it goes. As a new grad RN on the step down unit of a small community hospital, I can make a full-time job out of worrying about my full-time job. Every day brings a fresh set of worries. I have been working six months now, and a new worry for me is that I am still worrying. Shouldn't I feel more competent and relaxed by now?

    Nursing school prepares you to take the NCLEX. It really does not prepare you for the reality of taking care of 5 acutely ill patients. I was lucky. My employer has a great new grad RN program, and I was gifted with 13 total weeks of orientation (2 weeks in the classroom, 11 weeks on the floor with a preceptor). This sounded like such a huge amount of time when I first started. It didn't seem near long enough when it was time for me to cut my ties with my preceptor and go it alone.

    I am a type A personality with OCD tendencies. I like things orderly and neat. Like Santa, I like to make a list and check it twice. I like to have a plan, and I like things to go as planned. The problem with all of this, of course, is that in nursing nothing ever goes as planned. Unexpected things happen all the time. And there is no TIME to make a list and check it twice. There are constant interruptions to your train of thought, and you just have to be able to roll with that. Veteran nurses may be able to roll with five patients all needing a long list of medication at the exact same time while simultaneously dealing with head-to-toe assessments, call bells, order changes, lab results, critical labs, telemetry monitoring, and charting, but this new grad nurse finds it overwhelming to say the least. On my best days, the stars align and I am able to whisk from room to room and get everything done in a timely manner. On my worst days, one or two patients can take most of my time while my other three are left to wonder where the heck their nurse is with their morning medications.

    For me, the crisis of confidence I am experiencing is the worst part of being a new grad. I am a person who came into nursing later in life (I was 39 when I graduated from nursing school). I have been successful at past vocations. I have a great work ethic and have always been considered a valued employee by past employers. I was successful in nursing school and graduated with the highest GPA in my nursing class. However, as a new grad I am constantly questioning my ability to do this job. I worry that I am annoying my coworkers with my seemingly endless stream of questions. I worry that I am annoying the hospitalists with my barrage of pages. I worry that I am not going to get any better at starting IVs. I worry that my patients are going to realize I have only performed whatever skill I am performing a few times before and that I will appear incompetent. I worry that my employer is secretly sorry they hired me. I worry that I am never going to feel more confident and improve my speed and efficiency, and then I worry that as a result I will never get to spend the time I would like with my patients, as I will always be rushing to the next thing, the next item on my mental list. Most importantly, I worry that no matter how hard I try, I am going to miss something and something bad is going to happen to one of my patients. I worry. I worry. I worry.

    In order to combat this incessant worrying, I find myself seeking constant reassurance from coworkers and fellow new grads. I hate to admit this, as it makes me sound callous, but I am comforted by the fact that my fellow new grad RN cries in the shower when she gets home. I am comforted when one of my nursing school classmates jokes, "Some days I want to drive my car into a tree on the way home." This makes me think that maybe my sobbing car rides home from work are not entirely out of the realm of normal. Coworkers in whom I have confided my feelings tell me that it will take a solid year before I feel like I know what I am doing. I find comfort in their words, but still I worry that I will be the exception.

    In the face of all of this constant worry and stress, all I can do is continue to try my hardest to be the best nurse I can be for my patients and not lose sight of the fact that I am working for them and only them. I will continue to hope that as long as I keep my patients and their safety and well-being foremost in my thoughts, the rest will fall into place, so that one day I will be the one saying to a terrified new grad RN, "Don't worry. Give it a year. You're doing well. You'll get it. Trust me. No, really. Trust me."

  • Nov 28 '12

    I'm not a single mom anymore, but I've been there. It's a tough place to be! I agree if you could go to school, raise your kids, work as a CNA, and come this far....you can do just about anything! You should definitely consider going on for your RN. While you can make good money as an LPN, I think you would have much more financial security as an RN being as though you have children to support alone. I know....easier said than done, but it's do-able.

    People told me (most my family told me, but I'm sure everyone else thought it) that I'd never finish college because I got pregnant before I was done. Not only did I finish, but I'm just now finishing up my 2nd bachelor's degree. I'm about to start my first RN job in a couple weeks and I'll be making literally about triple what I've gotten used to making. I worked in fast food mostly through college and then as a CNA when I decided to go back for nursing.

    I can't really say how it will change my life, but I can imagine that not having to worry myself to death if something goes out on my car will be one change. I had a car repair bill one time when I was a single mom that added up to more than I had in the bank. Without my car, I couldn't get to work. Without being able to get to work, I couldn't get more money to fix my car. Not having any support from family or my child's father didn't help.

    Not to mention, do you know how nice it will be not to have to answer to a housing authority or DHS worker? There's a lot of pride that comes with being self sufficient. People are quick to look at others who are in government housing or getting food stamps and say, "it must be nice." Those are people who have never been there. There's nothing nice about hoping nobody you know will see you in the grocery store or worrying that your kid will be made fun of because they get free lunch or because of where they live. I love giving my kid lunch money and not worrying that they're embarrassed about where they live, what they wear, or what I'm driving. I love it that when they talk about something they want for Christmas, even if it's not something I'm probably going to get, that it's actually a possibility!

    Congrats on making it this far! Your kids will be proud of you. Don't stop now! It's going to make a big difference.

  • Nov 28 '12

    Quote from deann52
    She did not have "dispoable income" as a CNA. She was getting handouts from the govenment. Now she has a job that gives her enough to pay her own bills so I don't have too. Sorry, but that whole paragraph with the income breakdown is a big fat welcome to the real world and grow up.


    I just wanted to be one voice, that is "for" children in need receiving govt help. I really am. It says a lot about a society in how the most vulnerable among them are cared for.
    No doubt, i'll get slammed for that opinion, but, if we can view them as "already born fetuses" sometimes that elicits more compassion. It's fairly difficult to get much aide without children to support, btw.

    I'm not sure, but i think EITC is for lower income STUDENTS only, but, i could be wrong on that one.
    an incentive to help ppl get out of poverty.
    I usually also got a few thousand back, as an RN raising two kids, for whatever that's worth. I was not on aide, but, many parents taxes do work out that they get tax refunds on only an RN income. I'd be rather surprised to hear of a single mom/RN raising kids,
    who didn't get a tax refund of several thousand dollars, really. I think Carla should consider having her taxes done by an actual accountant perhaps, if she is NOT still getting several thousand back while raising minor children.

    And the taxes we pay, will be the same, whether or not Carla's children are on or off govt aide. No reason whatsoever to resent those kids being kept from dire poverty, imo. A far far huger % of US aide, is doled out in the form of corporate welfare,
    like the $4 billion tax cuts given each year to oil cartels, for example, even when they are making record profits and gouging us at the pump. Long long list of corporate welfare recipients, most of which you'd be stunned to learn of.

    but, i guess i am going off topic, sorry,
    on with your regularly scheduled topic.


    btw, 30 years ago, i was being paid $20 per hour, as an RN in Massachusetts,
    and at the time, i was poppin proud of such fine income........til i realized, a drywaller i knew, was making $22 per hour....no college to pay off, no risk of being sued, no big stress in his job, yet,
    He was making more than i was.

    *sigh*.

  • Aug 29 '12

    Sweetheart sometimes it takes a while to find a job trust me I know. People automatically think oh I'm a nurse I can get a job tomorrow. True in some situations but not all. I myself thought that moved to Georgia in November and just got a job in August. I had put in hundreds and hundreds of resumes. Had excellent references, job stability, 5 yrs. Experience, and I have a clean record never been in trouble and it was still difficult. Now for a while I did work PRN but I needed something full-time to support my family. No call backs for a while and then in June-July everyone started calling me for an interview but no one was offering me the position. I was down and starting to give up which isn't like me but feeling like why wont anyone give me a chance. I prayed, prayed, and prayed and continued to never loose faith and finally I got that one phone call hip hip hooray!!!!! Thank you Jesus!!!!! You're going to get a million NO's but all it takes is that one YES! You may just be over thinking the whole thing, the nursing fieeld is very competitive also you don't know HR's hiring procedures yes they ahave jobs posted but they could very well already be filled or looking to promote within the company first! My job is still posted and I have been working for over a month now. Also if you have never been convicted of a felony I hope you are not putting your past run ins with the law on your application. Stay strong my fellow RN I have faith in you and remember it only takes that one YES! i wish you nothing but the best and yiur time is coming. Goodluck!

  • Feb 25 '12

    i'm sure i'm going to start a perfect storm of feces by saying this on allnurses, but here goes:

    nurse practitioners are getting dumber and dumber. there was a time when i would have used a nurse practioner as my primary health provider without hesitation; when i would have even preferred an np over an md. they were more careful, more thorough, and listened better. there was a time when i preferred dealing with nps over residents as providers in the icu. they were more careful, more thorough and listened better. those times are past.

    i'm not saying i don't work with some good nurse practitioners. i work with twelve of them on a regular basis, and three of them are excellent, one has potential. the rest . . . not so much.

    it's not just that they're young and inexperienced. youth is fleeting and inexperience can be cured. it's that they're not careful, not thorough and they don't seem to listen. worse than that, at least six of the eight seem to believe that they're "better than bedside nurses". smarter, better educated, more aware of what's going on with the patient (from their vast experience and the copious time they spend with their patients in between shopping and doing crosswords on the internet) and better able to communicate with the attending physician than we are.

    i don't deny that a nurse practitioner has a master's degree. but so do i, so does bethany, and so do some of my colleagues. one even has a phd. (ok, so it's in literature, but she has a phd.) yes, nps have more nursing education, but it seems that they have so little bedside experience they don't even know what they don't know.

    the most dangerous nurse is one with about two years experience. they've got enough experience to be competent -- barely -- but not enough to know what they don't know, and too many of them think they know everything. unfortunately, that's about the stage most of our nps were in when they graduated from their msn programs and became nurse practitioners. so what we have in the icu is eight nurse practitioners with two years or less of bedside experience, all of whom think they know everything they need to know about being a bedside nurse and most of whom think they know more than the experienced icu nurse they're working with. but they don't.

    youth is fleeting and inexperience and ignorance are curable, but arrogance is dangerous. an np who is so impressed with the initials after her name that she won't listen to the rn who has been at the bedside for ten years or more and who has been there, seen that is vastly more dangerous than a bedside rn with two years of experience. even a two year nurse who is convinced she knows everything. worse, the brand new nurses will listen to the np with all of the initials after her name, whether or not she actually knows what's going on, before they'll listen to the experienced bedside nurse responsible for their orientation.

    what brings on this rant, you ask? the np who ordered amiodorone for the patient with the paced rhythm because she was so sure it was ventricular tachycardia. "we don't need to defibrillate him because he has a good blood pressure," she said self-importantly. "but let's load him with amiodorone." she wouldn't believe it was a paced rhythm when i showed her the rhythm strip with all those cute little pacer spikes. she wouldn't believe it was a paced rhythm when i showed her the 12 lead. unfortunately, this is just one in a series of similar incidents.

    about the amiodorone -- she did believe it was a paced rhythm when i showed her what happened when i turned off the pacer. (lots and lots of cute little pacer spikes and none of those wide qrs complexes she was so sure were v tach.)

    they want to be nurse practitioners -- ok. that's great. but please listen to the experienced rn at the bedside. she just might teach you something.

  • Jul 23 '11

    We take any number of off-service patients. While we are a respiratory and infectious disease ward, we were known to be able to make a bed for anyone. Today is bipap, tomorrow is suicide protocol for a soldier from the local base. We could do it all. Sometimes, though, you wish it was just a little old lady with hankies up her sleeves.

    She arrived shortly after supper. She had the look of any new mother; tired but proud of her new son. Her bedside table held her favorite dog-eared books, including What to Expect When You're Expecting. Next to it, though, was a Holy Bible and pamphlets from our Palliative Care Team and local funeral parlours. The admission was brief. Postpartum would be supplying us a floatnurse, as many of us were unaccustomed to postpartum patients. The nursery would be brining the baby shortly, along with his own nurse.

    Mom identified herself as a Type-A lady. She had preferred to be in charge of everything. Until she received her diagnosis, at 32 weeks, that she had a large, aggressive breast tumour, she had been in charge of it all. She picked all the nursery furniture, purchased the new family friendly car, and even put her tiny cottage up for sale so she could move her family to a new home closer to the park. Her husband was not only expected but encouraged to take a backseat in all things baby. Mom had it covered.

    Now Dad was receiving a crash course in baby. Mom had waited until she had been given the report from the MRI that confirmed end-stage breast cancer with metastases to the lungs. bones and brain to give up. When Mom opted for a morphine PCA with a generous lock-out program, she chose to check out in a haze of narcotics. While Mom dozed in and out of consciousness, under the watchful eye of our nurses, Dad watched the in-house parenting class DVDs in our breakroom. He practiced holding and changing the baby with a borrowed teaching doll from the prenatal program. Dad was a mess. He cried some, smoked some, and contemplated his future.

    Our ward was great with all kinds of disasters. Patients from the federal prison who stabbed nurses with their own pens. Alcoholic patients who, despite massive doses of librium, were able to fracture skulls and noses with their fists. Lousy managers who slept in their office while nurses sank in the mire of an understaffed ward. But this was different. We needed help.

    By day three, the baby had gone home with Dad. Mom wanted nothing to do with her baby, as she was never going to be able to raise him. No amount of emotional support from our social worker and palliative counsellors would convince her to bond now while she could. Her husband was denied access as well, as Mom decided that he should stay with his son at home. (And it was a very nice home, situated next to the park, across from the large grassy playground of the elementry school, as pictures showed on her bedside table). The postpartum nurse returned to her ward, and the patient was signed off to us. No visitors came. The telephone never rang. The Mom layed in bed, pressing her PCA button like she was playing Jeopardy. By now, the books were gone from her bedside table- tossed in the garbage. The photos were turned over, except for the photo of the house.

    We wanted to be able to do something. Make her better so she could go home and start her new life as Super Mom, where she could grow organic vegetables for her baby like she had planned? That would have been wonderful. So many of our patients had been admitted at death's door, but were returned home with a new, albeit short lease on life. We wanted that more than anything. Sadly, this 25 year old new mother, with the shiny photos and the beautiful new baby that she had never held, was not that patient.

    Night shift started at 1900, as it always did. My partner and I arrived in The Pit as we called our observation unit to discover that Mom was our only patient. The other 3 had been moved to ward beds to allow for what was going to be a very memorable shift. At 1915, after report, a basinette arrived. A case of ready-to-serve formula accompanied it, along with tiny diapers and other baby items. Mom had agreed to have one night with her little family. Her high-flow oxygen kept her in the observation room for the night, with all the appropriate monitors, balances and checks. The two of us looked at eachother. What was this? We had become resigned to a grieving mother, an absent father,and a feeling of misery in the room. We were not prepared for what happened that night.

    Football runs deep. Mom was a diehard fan of her hometeam, while dad was a local hometown boy. Tonight, though, everyone was on the same team. Baby arrived with Dad shortly after 1930. Full uniform of team jammies, little matching helmet and booties. Dad had on his own jersey. Both had the family's name on the back, to show family solidarity. Mom, who had not done more than play Jeopardy with her PCA and doze for most of our shifts with her, broke out in the biggest smile of all. Bigger than even the one in the fairy tale wedding photos we had seen when she first arrived. To top it off, Mom was given her own jersey, family name on the back. It was a very comfy, cozy jammy dress for Mom. I was about to help her put it on and feed the IV tubing through the sleeves. My partner asked her if she wanted to use her button as I would need to undo the PCA tubing briefly to prevent dislodging the saline lock. Mom surprised everyone, even herself. She smiled, said no. Just take it off not to hook it back up again for a while. Mom wanted to make some memories with her family, and wanted to be clear.

    We helped Mom into her team jersey, helped her pull her hair back out of her face. Dad looked hesitant. He had made this evening happen, and didnt want to jinx anything by pushing Mom too much. He held his infant son up to his wife to show her how beautiful he was. How much better he looked than the grainy ultrasound. He pointed out all the things that baby shared with Mom. Her chin, her forehead, her kissy lips. Then he sat down, in a nursing chair from the maternity, placing baby on the nursing pillow on his lap. It was the one Mom had picked out of a baby magazine. To match the rest of the nursery. Mom teared up. She called us over.

    That night, Mom held her baby for the very first time. We padded the siderails of her bed with blankets. We wrapped her saline lock to avoid any accidental scratching she was afraid of. We prepared the bottle just as she directed, even though it wasnt breast milk and wasnt what she would have fed the baby had she really been in charge. Then Dad placed the baby on her lap, on the pillow. Mom and Dad spent the next 3 hours with their little family, with their little boy. Baby cluster fed on and off. Dad showed his wife how to burp their son, showed her how he helped with the tummy gas. It was a magical end. By 2300, Dad and son had returned home.

    Mom's highflow oxygen had stopped being enough, and she was now on bipap. Our magical moment was over and we were right back into respiratory nurse mode, with RTs and pre-code teams on the way. We directed traffic, started lines, gave meds. We moved furniture, took report and admitted 3 more patients. Business as usual.

    By next shift, Mom was gone. She had made it clear that she was to be a DNR. She passed away that morning in a private room. Her husband and son were not at the hospital, as she wanted. They were at the park, watching children play. Mom wanted to be in charge of that, too.

    We sent a photo to Dad from the previous shift, circumventing the computer rule. We uploaded a photo we took of his little family with the woundcare digital camera. His one and only family photo for his little football fan.

    Being a nurse is hard. We can't always find the moral of the story, or the benefit of every situation, but we try.


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