Advocating for my pt.

Esme12, ASN, BSN, RN · Feb 7, 2015

thread moved for best response

NightNurseRN13 · Feb 8, 2015

Seems you have done what you can, maybe try again? I have one case where there are only two nurses. The other nurse doesn't initial the mar or maintinence sheet. I am always having to text or call her asking if she did so and so. Bugs the hell out of me!

icuRNmaggie, BSN, RN · Feb 8, 2015

They are leaving the housekeeping chores for you and that is something that you have to deal with yourself. There shouldn't be backlash if you deal with them in a straight forward manner.

Ask when does she need mouth care again.

How old is that bottle of NSS, could you date it please so I don't forget to change it. I have a sharpie right here.

Were her circuits, yankauer and canister changed recently? Would you mind putting the date on them so that we don't waste equipment.

You are acting in your patient's best interest. You may get an argument or attitude. Say our policy is to do -------. Know the rationales, such as prevention of VAP and infection control issues in fragile pts.

Have copies of policies available to clear up any misunderstandings. Be polite but firm.

Do you feel personally threatened or uncomfortable? Because no one should be made to feel that way at their place of work and if that is the case, you need to bring it to the attention of your immediate supervisor.

caliotter3 · Feb 8, 2015

As long as the nursing supervisor fails to address the problem with the other nurses, nothing will happen. The other nurses have set the tone and the supervisor is playing their game. You are already identified as the troublemaker. They will exert just enough flak to ease your exit from the case. At this point, I would document your findings in writing and submit them to the agency on a schedule that seems reasonable to you. By doing this, you are putting the supervisor on notice that you will accept no blame for adverse consequences.

brillohead, ADN, RN · Feb 10, 2015

I had this issue with a case last year... I became convinced that I was the only nurse out of three on the case who was providing skin care (he had severe acne) and oral care.

He was a non-verbal mentally and physically handicapped individual, and every time I walked in his room at the beginning of a shift, he would open his mouth for me to brush his teeth. That told me that he associated me with brushing his teeth.... he didn't make that motion with any of the other nurses or his parents -- just me.

Unfortunately, the other nurses didn't work for my agency, so there was absolutely nothing I could do about the situation. I commented to the mother and charted that his gums were bleeding when I brushed his teeth my first two nights back (I worked three nights straight) every week, and then charted on the third night that his gums didn't bleed that time. Ditto with getting that white layer of scum off his tongue.... finally get the tongue pink again, and it's all white again when you come back the next week.

One night I used the last of the acne cream on my last shift, and there was a new tube for the other nurses to use on the following shifts. When I returned four nights later, the little foil seal was still on the end of the new tube of acne cream. I mentioned it to the mom, but she was in denial (probably because she didn't want to risk losing her nursing coverage for the other four nights of the week -- this case has a history of being difficult to staff).

If the employing agency and the parent won't step up, there is little that we can do as nurses. Keep leaving notes, keep doing it properly on your own shifts, and pray for improvement. If you know that things are going to be changed on a specific day while you're gone, you might pre-label things before you leave. That's probably the only way things are going to get dated -- if you do it yourself in advance.

vintagemother, BSN, CNA, LVN, RN · Feb 10, 2015

As long as the nursing supervisor fails to address the problem with the other nurses, nothing will happen. The other nurses have set the tone and the supervisor is playing their game. You are already identified as the troublemaker. They will exert just enough flak to ease your exit from the case. At this point, I would document your findings in writing and submit them to the agency on a schedule that seems reasonable to you. By doing this, you are putting the supervisor on notice that you will accept no blame for adverse consequences.

Sad to say, but yes I agree with this. There is an established "regime" of not doing things correctly and if you insist on being the "squeaky wheel", you may find yourself with a target on your back.

I am/was facing a similar situation recently and the outcome wasn't pleasant. But In hindsight, I should have expected it.

Politics are a real issue affecting pt care, sadly. ]

Alex Egan, LPN, EMT-B · Feb 11, 2015

I would advise you to ask yourself. "Is this the hill I want to die on" are these the issues that worth being labeled for and having your coworkers anxiously waiting to slide a knife in your back. Sad but true.

allnurses Guide · Feb 11, 2015

One thing about private duty nursing I have noticed is an extreme adherence to what I might call "rituals", rather than routines. These are ways of doing things that are not standard of care, have been done sometimes for many years. I find that when the family, the Primary Caregiver, other nurses who have been there for a while, and the provider who is supposed to be directing all of it don't seem to care, your battle uphill will be very steep.

The only avenues I can see at the moment is to calmly educate the family about the consequences of failing to do the things that are not being done in hopes that rationale will persuade them that this is what is best for their family members health and safety.

It's really unfortunate that the case manager doesn't care, but a case conference I find can really work wonders. You can get an idea why the other nurses are failing to do mouth care and date the supplies. You still may face a wall of resistance, but may gain insight into what they see as their role as a skilled nurse in the home.

Do you have a separate spiral notebook to leave informal updates for nurses as many times we don't meet face to face or the other nurse mumbles something for 20 seconds and rushes out the door (ie no report) It can be useful for reminders like that.

If none of the above ideas are workable, yes your only option is to assess whether mandatory reporting comes into play.

In the end, though as others have said, "she who rocks the boat" will generally find themselves off a case, though it's possible in some situations that it's worth it to get your patient/client what he/she needs.

SDALPN · Feb 20, 2015

Pick your battles. With that said, its home care. Its not a hospital. Yes, we provide hospital level care. But its in someones home. Many families don't want date labels on everything. As long as its documented somewhere, such as an equipment maintenance sheet, its fine. Its not necessary to document changing out equipment ten times.

As for laundry, you are responsible for helping with pt laundry if the family requests it. However, you aren't responsible for any laundry that doesn't belong to the pt. If its in the poc, you've got to do it. But you're never responsible for anything more than your pt, pts needs, and doing tasks for the pt that help the family.

The oral care thing is just plain nasty. But I see it all the time. I'd casually mention it to your supervisor and privately document it. Its out of your hands and up to the supervisor. But at least you covered yourself with your own documentation. In this job, supervisors change pretty often. Have patience and bring it up again with the next supervisor.

Good luck. It sounds like you care and want to give the pt great care. Unfortunately, many nurses won't offer the quality of nursing you do. Find a family that appreciates it and you'll be worth more than gold to them.

Gooselady, BSN, RN · Feb 21, 2015

One thing about private duty nursing I have noticed is an extreme adherence to what I might call "rituals", rather than routines. These are ways of doing things that are not standard of care, have been done sometimes for many years. I find that when the family, the Primary Caregiver, other nurses who have been there for a while, and the provider who is supposed to be directing all of it don't seem to care, your battle uphill will be very steep.
The only avenues I can see at the moment is to calmly educate the family about the consequences of failing to do the things that are not being done in hopes that rationale will persuade them that this is what is best for their family members health and safety.
It's really unfortunate that the case manager doesn't care, but a case conference I find can really work wonders. You can get an idea why the other nurses are failing to do mouth care and date the supplies. You still may face a wall of resistance, but may gain insight into what they see as their role as a skilled nurse in the home.
Do you have a separate spiral notebook to leave informal updates for nurses as many times we don't meet face to face or the other nurse mumbles something for 20 seconds and rushes out the door (ie no report) It can be useful for reminders like that.
If none of the above ideas are workable, yes your only option is to assess whether mandatory reporting comes into play.
In the end, though as others have said, "she who rocks the boat" will generally find themselves off a case, though it's possible in some situations that it's worth it to get your patient/client what he/she needs.

I'm two months into private duty, and have two 'cases'. I've noticed the 'ritual vs routine' and had no idea what I was seeing lol. The rituals, like all rituals, are held very dear, they are more like life savers or beacons holding back the darkness -- not to be trifled with! Almost sacred.

I go along with them, they are not the least bit harmful or contraindicated for good care (ETA: in my particular cases). They are really noticeable in the private duty setting, but they are there, come to think of it, in bedside nursing too, and specific to the nurse rather than the patient. I'm thinking of one of my preceptors, who couldn't restrain herself from tidying or straightening corners whenever something out of place or crooked assaulted her . She was good humored about how OCD she was, a nurse I'd trust with my grandbabies, but dang she was ritualistic. She never insisted her rituals were 'the only right way'. But that might happen in a home setting. People are superstitious without even knowing it, and that includes me. Whatever seems to keep your fragile six year old out of the hospital and off of a vent is what you're gonna do.

I'm still being amazed almost every time I work at how WHERE I am a nurse has as much to do with what I DO as a nurse as . . . um, what I do as a nurse

Nibbles1 · Feb 21, 2015

My case I'm on right now, the mom gets furious if dates are on things. I mean stark lunatic furious.

I've seen some of the same things you are describing. Most of the time the nurses that slack usually quit within a few months.