Did I make a mistake? Please comment :)

[UpTheLadder12]

I am a new grad LVN, got my license a couple months ago, and yeah- the job market is dry out there. But I answered a Craigslist ad looking for an on-call LVN for a pediatric home care position, and got an interview, which was with the mom. Although she has agency nurses, she also hires extra private duty nurses that are paid for through a trust. She didn't hire me at first but told me I was next in line. Then a couple weeks later she called saying she needed a fill-in and asked if I could come in and train for an overnight shift, and then work the next overnight shift on my own (she would be home, but I'd be the only LVN).

I was SOOOOO excited. But as the night when on I got pretty concerned. I didn't have access to the chart and all med and treatment orders and feedings were on printed paper in the kitchen in list form (not actually the Dr. order or care plan from the RN). The med bottles had the Rx info on them, but there were things that were not clearly prescribed (supplements, herbals, etc). There are also several resp. treatments, and there is a g-tube . The child is stable, not on vent or anything, but still- I didn't feel comfortable doing anything that was only being relayed to me through the typed up lists, another LVN and the mom. I have to be working under the direction of an RN or MD right? I at least wanted to be able to look up certain things.

Also, the LVN that trained me relayed to me that they break up some of the pills into smaller amounts than they are scored or prescribed. Also, she set up all the meds for the whole night at the beginning of the shift, in 30ml cups on the counter. There were other things she mentioned that were "gray area" in her words. I didn't want to be some hypervigilant know-it-all, so I didn't say much, but I was thinking to myself, OMG this is my first job, I don't want to lose my license before I even get started. The whole place is on camera, too. She suggested making sure I was aware where the cameras are placed when administering the off-doses and things like melatonin (so Im guessing that one is not prescribed by the doc.....)

I know that most likely, nothing would ever happen if I gave him a vitamin that wasn't prescribed, but it just doesnt feel right. So I let the mom know that I could not do any procedures or meds without a Dr order, but Id be happy to be there as an overnight caregiver if she needed the shift filled. She declined, because she said that he needed so many meds throughout the night, she would have to get up anyway. She also stated that no other nurse had ever asked to see Dr.'s orders, and she felt that I was ill-informed. Of course, some of her nurses are through the agency, so they have access to the chart.

Did I do the right thing by acting within my scope of practice, or did I get too skiddish and blow a great opportunity get started as an LVN??? Should I have just shown up for the shift, and then just laid it out for the mom (ex. "Ok i/ll give these meds, but only the time/amount on the bottle, not the differing amounts on the typed up list. and I cant give the suppositories or herbals unless I can read a dr order for those, maybe its in the chart, would you like me to look it up", etc)

Maybe in a way the LVN scared me off by mentioning things like the mom threatening to write to the board about people, and trying to convince the nurse to give some things by mouth even though he is NPO (according to the nurse, since I never saw the chart). I guess it made me feel like I might as well let her know before coming in, because she may really not want anyone who isnt going to do it "the way its done there" type thing. So, the end result is that I did not go in for the night, and she did let me know that she was not able to get the shift covered with only about 8 hours notice. I do feel horrible about that- but at the same time, if you are hiring a brand new nurse with one day of training, doesn't it behoove you to have a back up nurse in case it doesnt work out? what if she didnt like me? And, the reason i had been called in the first place was because she couldnt get that night covered with the 5-6 nurses she already has on staff. So I feel bad about that part but not guilty about it.

Opinions?? Suggestions on how I could have handled things differently? Similar experiences??? I welcome your input.

I am so sad that I had to turn this job down

[LuvScience]

I think that you handled things just fine. I work in a facility and not home care but this sounds like a sketchy situation for a new grad and it probably wouldn't have been a long term gig anyway. My advice is not to sweat it and keep looking for a steady job where you'll have the guidance of experienced nurses.

[jadelpn, LPN, EMT-B]

How this woman chooses to care for her child herself is her business. Agency nurses are bound by their Agency procedures. (and interestingly, begs the question is this why all of the kids meds are given at night when an agency nurse is not on?) As a licensed nurse, you are responsible for the care you provide, and I would be hard pressed to "take someone's word for it" with such a complicated case in a private duty situation. Additionally, you never mentioned that there was any paperwork or charting, just cameras. You (on camera) would be seen giving a child a dose of something by mouth, even though the child can't swallow no matter how hard one would try and "hide" it. What it the child aspirated? There are so many things wrong with this picture, that you absolutely did the right thing to not get involved. I am not sure what ails this woman and her expectations of a licensed professional-- but the whole set up screams of run away, far, far away......

[nursel56]

you need to protect yourself legally first and foremost. the parent who called you ill-informed is probably not an expert on the subject herself. maybe she's used to nurses who take huge risks on a regular basis so she thinks that's normal.

when we work in this area, it's true that the type of rules you see in hospitals are bent to a certain extent in home care and that we should be flexible about such things as throwing away everything you use after one use when they have a very limited amount of supplies as backup. this was told to me by the director of nursing at my first agency during orientation.

i was interested to see what i could find in the bvnpt archives and found this booklet, which is really guidelines for the consumer, including what the lvn is and isn't allowed to do, and what he or she needs in order to practice safely and within the bounds of our scope. a helpful bit of info from it's contents is:

[color=#b22222]

[color=#696969]6. remember that the lvn or pt must

receive client care orders from your

physician.[color=#b22222]

http://www.bvnpt.ca.gov/pdf/brochure5.pdf

my other suggestion would be to do a search of the allnurses site for this as i know it has come up many times. it won't be entirely applicable to your situation, but again should head you in the right direction. best wishes and never let someone talk you into doing something you have serious doubts about! believe me they will try! :)

[loriangel14, RN]

This situation is bad news.I wouldn't go back.

[UpTheLadder12]

Thanks guys. A lot of your comments echo how I was feeling, but since I am a new grad I don't want to start off thinking I know everything about everything, so I had to check :)

I was prepared for the differences and flexibility in home care vs institution but I felt like there are certain lines that are never crossed.

Thanks for that link! I looked on the site but did not find this. Our state has a pretty incomplete and confusing set of resources online for the LVN. I was provided with a paper copy of the Scope of Practice by my school, but it is still vague and confusing about certain circumstances.

Once again, thanks for the input! I love Allnurses.com, it's like having a secret army of nurses with you at all times :)

[ventmommy]

I would wonder why the chart isn't out at all times with the 485 right in the front. It is certainly the parent's perogative to add herbal supplements so long as they are not contraindicated by the prescribed meds.

I would question why so many meds are being given at night. My goal was to leave my son as undisturbed as possible throughout the night. If he didn't need suctioning or a diaper change, I basically wanted him left alone (by alone, I mean not handled, the nurse was still in the room at all times).

If a mom or dad seems crazy with ridiculous rules, witholding info, etc., it's probably best to not risk your career. You worked hard in school. There are decent agencies (and families) out there if you want to do private duty nursing.

[UpTheLadder12]

The chart is there but i was told that since I'm not from the agency I "don't deal with the chart". I know that parents can give herbal supplements themselves, but to have the nurse give it, they need to mention it to the doctor to have it added to the plan. I am a mom myself, so i know that as the parent you still want control over your child's care, but if I had nurses working in my home and wanted them to give my child supplements, I would mention it to the Dr., because the nurse can't take those kind of orders from the parents. Otherwise the parents can give it. Also, supplements are mixed in to the formula that is made by a recipe i think the mom made (which is fine) but the mix is made in the AM and then poured into unmarked bottles for use throughout the day. Once again, not a huge risk here but- supplements not ordered should only be given by the parents, and nurses are giving a nutritional mix that isnt dated and that they didnt make or watch being made. Maybe that is one of the things that you let go when it comes to home care, but it was just on top of the other stuff.

The child was on a g-tube, so he could be given meds at night without being woken up. And some of the meds are to prevent seizure activity, some for sleep. But it was the timing of the meds that made me uncomfortable- the typed up schedule was not according to the pill bottles, which was my only available info that came from the actual physician.

[ventmommy]

I understand about the g-tube. My son had one as well. But they can still feel something going in their stomach which is why the only thing that was given at night was a seizure med.

For the formula, I made the formula every morning and it was in unmarked bottles. I don't think that is a big deal.

The chart belongs to the patient. I read the chart after every shift. The nurses read the chart from the previous shift. How are you supposed to know what's going on the with the child. Also, I always grabbed the chart for doctor's appointments and ER visits. I don't think it's okay that you don't have access to it. Maybe you can't use the agency's flowsheets and narrative paperwork but I don't see why you shouldn't be reading and leaving notes.

Like I said, if the mom or dad seems ridiculous, it's probably best to not work there. This mom seems a tad bit ridiculous to me.

[jtmarcy12, BSN, RN]

I would have RAN to the neatest EXIT!!!

[chevyv, BSN, RN]

Sounds like mom uses a lot of independent nurses. That is normally regulated by state guidelines, but because she is paying out of trust, it must be truly independent nursing. I wouldn't have taken the noc shift at all as a first. I also wouldn't take it without making sure I had my butt covered by liablilty insurance. I too would have wanted a more detailed picture of what was going on through physician orders. Also, I would want to make sure I did charting. As a first job, I too would have turned it down. Listening to your gut is always good!

[beckyboone]

where can patients and their caregivers find cut-and-dried information on what a lvn and lpn can or cannot do, as compared to a rn or an advanced practice rn?

perhaps this mother only needs some guidelines on what people she employs to care for her chronically ill child are legally able to do?

i wouldn't be wary of video cameras in the workplace, as i'm sure this mom has experienced, there is vast spectrum in the quality of care different individual caregivers provide.