Are dialysis RNs responsible to PCTs actions? Can RNs be penalized for PCT negligence?

[keftirific]

Hello all!

Today I completed week four of my training as a dialysis nurse. So far, I think I like dialysis, at least in theory. My questions and issues are in regards to the blatant disregard for basic infection control, (hand) hygiene, and other protocols that I have observed from most PCTs and some of my nurse colleagues at my clinic.

Should I just look the other way and simply follow protocols in my own practice? Can their negligence negatively effect me or my license? Do PCTs work under under my license like CNAs? (I suppose I need to check with my BRN.) Should I just get my training and some experience and go work in acute care or change to PD?

I spoken up a few times about these issues. Some PCTs have acknowledged, for example, that they should wear gloves and use hand sanitizer or wash their hands. They'll do it for a minute while I'm there and then go back to their very potentially harmful ways (given that infection is the second highest cause of death in HD patients).

After I watched a PCT dump a bunch of bleach into our bleach crusted cleaning containers (they're suppose to be cleaned daily) instead of using the beaker beside her to measure the amount to make 1% and 10% cleaning solutions, I thought maybe it doesn't matter if the solutions much more concentrated. However, according to the Scripps Research Institute (https://www.scripps.edu/newsandviews/e_20060213/bleach.html and this article https://www.ncbi.nlm.nih.gov/books/NBK214356/) it does. The 1% and 10% solutions that we are suppose to make are the mark to clean and disinfect and "Improper use of bleach, including deviation from recommended dilutions (either stronger or weaker), may reduce its effectiveness for disinfection and can injure health-care workers." The next day I mentioned using the beaker to another PCT. She shrugged and said we're always in a rush.

I understand that not long ago our clinic was chronically short, but that hasn't been the case since I have been there. People get their breaks and there is downtime on the floor.

I'm planning how to bring my concerns to my FA, but as he has made clear to me, he has no clinical background and pretty much leaves that stuff to us. I am not trying to make enemies, but I think that is what will happen if I push for change.

As an RN what I know does matter is hand hygiene. Time also cannot be used as an excuse for acrylic nails. Half of the nurses and PCTs in the clinic wear acrylic nails, which is against company policy. The PCT who I followed today had overgrown nails that needed to be filled and were visibly brown and unclean underneath. To make matters worse I did not once see her wash her hands or use hand sanitizer between bare hands and gloves and she only wore gloves when she could potentially come in contact with patient's blood. She didn't want to put her gloved hand into the bleach saturated water to grab a clamp because "there some blood in there and you know." At least she wore gloves when she set up the machines. The day before I watched a PCT put a machine together without any. (I mentioned that she should and she agreed. She put some on, but later I saw her without any again.)

How important is it to wipe the graft or fistula with betadine for 60 seconds. I recall that in the OR betadine is "painted" on and that it is the contact time, not dry time that matters?? (I'll have too look that up too.) Then again it's not like I've observed a PCT wait for the betadine dry after their two or three seconds of wiping. They do like to repalpate that wet betadine...

I regularly hear about our patients dying. Three this month. Three last month. Maybe that is normal with this job given the state of so many of the patients. But I don't want to hasten anyone's trip to the grave due to carelessness. Then again, I figure these things will go on whether or not I am there. I don't have the finesse to change this culture and I think it would be dumb to try. Can what they do negatively affect my license and career? If not, maybe I should stick around just worry about the standards to which I hold myself. Be the change? Then again, maybe I should just bide my time so that I don't fall into the habits of those around me.

What do you think?

Thanks!!

[diabo, RN]

In the case of a lawsuit your license would be on the line.  Be thankful for your training and experience, but don't hold out for changes.  Been there.  I started at one private unit, and the first day the PCT drew up the iron (Infed in those days) and handed me the syringe, which I refused to administer.  She said that she always did that to"help" the nurses.  She was about to draw up insulin when I said "Whoa".  I backed out the door as quickly as I could.

[keftirific]

On 11/20/2022 at 3:28 PM, diabo said:

She was about to draw up insulin when I said "Whoa".  I backed out the door as quickly as I could.

Thanks for the reply.

What do you mean by you backed out the door? You quit?

Today my FA wasn't there. Day after Thanksgiving so I get it.

What I don't get however, is he would transfer a seasoned PCT to his other facility for the day, which resulted with us being short. Two of the remaining PCTs have only been independently on the floor going on two weeks. One had her patient load doubled. I'm not great at setting up machines, plus I was suppose to be precasting with a nurse (who wasn't even told she was precasting me today do to a change in schedule). Everything was behind. One patient left because they were tired of waiting and another lost an hour of treatment time because they had a scheduled pickup time. I was hectic to say the least and because she was so stressed, my preceptor (who barely preceptor me), said she was going to call in for the first time tomorrow and not come in.

Is this normal in dialysis? I know there are plenty of applicants for PCT positions. Why aren't there PRN PCTs to fill in? My co-worker said my FA probably saves $$ by shorting us and likely benefits himself with the company somehow by doing this. I have no clue.

[diabo, RN]

Haha.  Yes I "backed out the door" quickly, which means  I gave a three week notice until they found a replacement.  This was in the early 90's.  I was in training to be a nurse manager.  It was a small privately owned unit and the owner (in his 70's) didn't see the need to implement any changes.  He was one of those "I can beat the system" kind of guy.  He eventually got closed down after it was discovered that he was running acutes without an RO.  Yep using tap water.  Always remember your oath for Do no Harm.  That covers sins or commission as well as sins of omission.

[parolang]

Are you responsible for what PCTs do under your charge? Yes, just like any other unlicensed assistive personnel. Can RN's be penalized for PCT negligence? Depends on your FA and the command chain above them.

That said, it would be unusual for you to be held directly responsible for what the PCTs do that doesn't directly affect the patients. You are their supervisor, not their manager. Document and report your concerns to the FA.

I was a PCT for five years. I was a stickler for the rules, and eventually I just gave up because FA's are way more concerned about budget than doing dialysis correctly. They pick their battles, and if you want to continue in this environment, you have to pick yours.

When your PCT says they are always in a rush, believe them. We had five patient pods, and they were always looking for ways to squeeze the patient schedule together as much as possible. When I left, they were getting on our new FA about budget, so I can't really blame her, but she was going around cutting treatment times so that we can leave earlier.

When I was having difficulty getting my patients started on treatment in time, and I mean on a consistent basis, it eventually became about some PCTs could get them on treatment on time, and I couldn't. I didn't have time to watch what the other PCTs were doing, or not doing, and it just became a toxic environment for me in general. So I gave them my notice and quit.

Honestly, your clinic is sounding kind of toxic. I never had to work short, so I don't know what that was about.

IMO, dialysis is not what it should be, and that's why I'm done with healthcare. Just be sure to look at the bigger picture, because it is too easy to blame the front line guy, the nurse or PCT, when it's really a leadership problem, an institutional problem, or a systemic problem. For example, how are you supposed to follow all of your policies and procedures when you are working short on a regular basis? Your PCTs have to take shortcuts, because they know what happens when their patients miss treatment or cut their treatments short, because they aren't able to start their treatments on time.

Also, when you are multitasking constantly, especially during turnover, you are relying on habits. When you correct your PCT about hand hygiene, and they return to their bad habits later, you have to have some understanding about this. You are totally correct, but don't misunderstand this as a moral failing or laziness. That said, there needs to be accountability if you want the behavior to change in the long run. That requires that RN's report things to the FA, and the FA to hold them accountable. You also have to hold the FA accountable for following through and not avoiding hard conversations.

Good luck.