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Drowning in Skills

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by River&MountainRN River&MountainRN (Member)

River&MountainRN has 3 years experience .

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Before coming to Big Name Agency, my skill sets were all from SNF/LTC and clinic nursing. I had extensive G-tube experience, wound care experience, suctioning, some IV experience etc from my SNF days, but no trach/vent/TPN experience. I am really struggling to pick up cases right now because we're in a very small region and the support/orientation for these additional skills is essentially none.

I know I've had issues with anxiety in the past holding me back, but when it comes to such serious, life-altering skills if something were to go wrong (and only one shift of orientation to a particular case before I'm thrown out on my own) I just end up not even pursuing a case or backing out of taking on a case once I see everything involved.

It's not just me, though, because it seems the only cases left have been on there for multiple months because no one will take them due to either family dynamics (weird rules, treating the nurses poorly) or the high skill demand.

To give you an idea of what we're dealing with: when one of the "easier" cases went in the hospital recently, the primary caregiver/parent ended up having to essentially take over care because the patient was still very complex for our community hospital (vent, G/J tube, chest PT, cough assist, multiple rounds of suctioning, frequent de-satting, PICC, quadriplegic, etc) and the nurses didn't have a clue as to how to proceed with the patient's care. The patient ended up being turfed to the ICU to receive the same level of care that they usually receive *in the home*.

Pardon the long read, I guess what I'm asking is if all agencies/cases are like this or, if I were to move to an area of more opportunity, is 1:1 private duty care still something I could pursue. I came to 1:1 private duty care and had a great "simple" GTube/seizure/hospice case to start but, unfortunately, she passed away at 10 years old. So now I'm just left scrambling.

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Alex Egan has 9 years experience and works as a Peds PDN.

6 Articles; 22,733 Visitors; 841 Posts

Ok I'm going to try and take a crack at this one, I'm trying ton understand the root of your issue and I hope I got it.

You're looking for work because your starter case died. There are only two kind of available cases generally available at your agency are "attempting to die a lot", and "crazy families".

Your question is either how to handle these more complex cases or how to find a intermediate case that isn't bat poop crazy?

Ok well the reason these cases are open is that experienced nurses won't take them. I don't think it's becaise of the high tech skills mix. I have been in PDN for 10 years, there really isn't any skill in the home care field I'm not familiar with, I don't ever turn down a case because the the medical needs.

However I only do crazy family or "tries to die" cases at the request of the scheduler to help out. Because these cases aren't good steady work, for that reason neither are the , "just got out of NICU" or the "ive has five agencies this year" cases. If I have to take these "undesirable" cases because I'm rebuilding my roster or reentering the field I diversify. Taking 3 or so cases at a time, and orienting on as many as six. This way I get a lot of experience in different types of skills and equipment, and I'm covered if one case enters the hospital as I only loose 8-16 hours rather than a bunch. I can usually make up those hours on cases that I don't care for, but will do in a pinch (the other three I have oriented on)

Really this is how I do. Things all the time even when I have more stable cases. It keeps me from getting board and keeps me in work.

Now if you question is how do you learn these skills when your functioning solo. Well you read up on them, rehearse emergency procedures in your head, find a mentor, and then hope your training and common sense can overcome whatever situation you find yourself in.

Edited by Alex Egan

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smartnurse1982 has 7 years experience and works as a Rn.

24,037 Visitors; 1,775 Posts

Some nurses from other specialties think home care extended care shift nurses just sit around and stare at the walls.

Many come into this setting thinking it will be easy,when it is not.

But yes,most agencies are like this,in all areas. I think it depends moreso on state rather then metro area.

Some states fund Medicaid well,while some states mandate private insurance covers a child with certain illnesses and or statuses.

For example,some states do not allocate funding for Medicaid trach/vent children to have private duty nurses. Some do.

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1 Follower; 44,193 Visitors; 2,976 Posts

Ok I'm going to try and take a crack at this one, I'm trying ton understand the root of your issue and I hope I got it.

You're looking for work because your starter case died. There are only two kind of available cases generally available at your agency are "attempting to die a lot", and "crazy families".

Your question is either how to handle these more complex cases or how to find a intermediate case that isn't bat poop crazy?

Ok well the reason these cases are open is that experienced nurses won't take them. I don't think it's becaise of the high tech skills mix. I have been in PDN for 10 years, there really isn't any skill in the home care field I'm not familiar with, I don't ever turn down a case because the the medical needs.

However I only do crazy family or "tries to die" cases at the request of the scheduler to help out. Because these cases aren't good steady work, for that reason neither are the , "just got out of NICU" or the "ive has five agencies this year" cases. If I have to take these "undesirable" cases because I'm rebuilding my roster or reentering the field I diversify. Taking 3 or so cases at a time, and orienting on as many as six. This way I get a lot of experience in different types of skills and equipment, and I'm covered if one case enters the hospital as I only loose 8-16 hours rather than a bunch. I can usually make up those hours on cases that I don't care for, but will do in a pinch (the other three I have oriented on)

Really this is how I do. Things all the time even when I have more stable cases. It keeps me from getting board and keeps me in work.

Now if you question is how do you learn these skills when your functioning solo. Well you read up on them, rehearse emergency procedures in your head, find a mentor, and then hope your training and common sense can overcome whatever situation you find yourself in.

Great answer. The original post was a little confusing. Another good resource to learn "these skills" is YouTube. Very well done basic, and advanced, nursing skill videos.

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River&MountainRN has 3 years experience.

1,688 Visitors; 179 Posts

Ok I'm going to try and take a crack at this one, I'm trying ton understand the root of your issue and I hope I got it.

You're looking for work because your starter case died. There are only two kind of available cases generally available at your agency are "attempting to die a lot", and "crazy families".

Your question is either how to handle these more complex cases or how to find a intermediate case that isn't bat poop crazy?

Ok well the reason these cases are open is that experienced nurses won't take them. I don't think it's becaise of the high tech skills mix. I have been in PDN for 10 years, there really isn't any skill in the home care field I'm not familiar with, I don't ever turn down a case because the the medical needs.

However I only do crazy family or "tries to die" cases at the request of the scheduler to help out. Because these cases aren't good steady work, for that reason neither are the , "just got out of NICU" or the "ive has five agencies this year" cases. If I have to take these "undesirable" cases because I'm rebuilding my roster or reentering the field I diversify. Taking 3 or so cases at a time, and orienting on as many as six. This way I get a lot of experience in different types of skills and equipment, and I'm covered if one case enters the hospital as I only loose 8-16 hours rather than a bunch. I can usually make up those hours on cases that I don't care for, but will do in a pinch (the other three I have oriented on)

Really this is how I do. Things all the time even when I have more stable cases. It keeps me from getting board and keeps me in work.

Now if you question is how do you learn these skills when your functioning solo. Well you read up on them, rehearse emergency procedures in your head, find a mentor, and then hope your training and common sense can overcome whatever situation you find yourself in.

Thank you for understanding what I was trying to get at. Unfortunately, working all three shift schedules (for example from last week: Overnight, one day off, one AM shift, and then an evening shift, before another AM shift, etc) within the same week and being overwhelmed with the expectations of being able to handle brand new skills has left me barely treading water and a little incoherent.

No, I didn't get into private duty home care because I thought "home care extended care shift nurses just sit around and stare at the walls" or that it would be easy, but because I truly feel 1:1 home care nursing is one of the last bastions of TRUE nursing...where you get to combine skills and psychosocial care of the patient, really getting the chance to get to know your patient and their needs. Unfortunately, you get one orientation per case and are scheduled for the month ahead before you even get through the orientation and know whether it's going to be a good fit. If you back out, you get grief from the families who were promised you'd take it on and from the agency, even though they didn't invest in the training time to make sure it was a good enough fit to take on.

Essentially I was asking:

1. Do all the agencies hire nurses promising cases that match their current skills and promising "extensive" training for other skills, and then throw said nurses into essentially "whatever" without any consideration to whether skills and personalities match?

2. Since I *am* in a situation where, to make the bills, I do have to take such cases that aren't a good skills fit, how do I self-teach such additional skills (trach, vent, TPN, wound vacs, and CPI specifically)? I am given one shift of orientation and then told that I have to go it alone, period. How do I get beyond this nagging anxiety that, if I screw up with a trach or vent or TPN setup while trying also to wrangle a patient who is fighting me all the while, serious harm could come to my patient?

I just want to do a good job and do right by my patient, by their family, by my agency, and by myself.

Thank you all for your input so far. I really don't mean to come across as boorish or ungrateful; I'm just feeling incredibly overwhelmed. My schedule is a mess, the cases aren't good matches, and I'm told I have no other options to switch to other cases because the agency just doesn't have them available.

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Alex Egan has 9 years experience and works as a Peds PDN.

6 Articles; 22,733 Visitors; 841 Posts

1. Some agencies will say anything to get you in the door. Never take anything on face value. What does extensive orientation mean to them?

2. Ok so your mistake here is that you're letting the Clowns run the circus. Who's telling you one orientation day? (I usually don't need more than one but it's happened) Who is making you schedule work on cases you haven't oriented on or fully agreed to? I would bet it's a scheduler/recruiter. Do not schedule any shifts until after you have oriented. That way if you don't like it you're not breaking anyone's back. That schedule was blank before you showed up, if it has to stay blank until you're sure you like/can do the case so be it. (Took me a few times to figure this out)

A few things about our post really jump out at me.

You seem to feel your locked into one agency. Always have two. If one can't find you the cases you need I bet the other will try. You will be shocked how suddenly they can sometimes accommodate you if they are worried about loosing your hours to a competitor.

The other thing is you seem like a perfectionist. You want to be 100% confident and competent. But that's not nursing in any setting. Perfect is the enemy of good enough and while we strive for the first we often have to settle for the last. It's a balancing act, just put some thought of that my not be contributing to your troubles.

Additionally most nurses have trouble with self advocacy. No one in this industry will give you anything without you asking firmly and sometimes demanding it.

The conversation isn't "I think I need another day I'm just not confident" It's "I will need another day to get this kids routine" or "I'm not sure I'm safe to do x skill independently yet I need more training practice. How can we do that?"

It's the same with crazy schedules. I'll do them if the scheduler is good and plays ball, you jerk me around I'm busy that day. You have to claim the initiative on the relationship. Now that's easy to say when I have lots of work. If I'm work poor I have to eat it sometimes, that's a fact. However once you have ground rules down it's easier.

Here's my question to you. How much time do you spend in the office. Lots of times the nurses really don't know the schedulers and vice versa. If you can try and stop by, say hello, bring cookies. Try and actually take to your scheduler about why you didn't like a case or what skills your not so good on. Talk about your skills to a clinical manager they are responsible for your training and competency and should be able to help you.

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middleagednurse has 50+ years experience and works as a RN.

10,153 Visitors; 550 Posts

As a PP said, Youtube can be your best friend. Most of cases are trach/vent, and I learned vent care from Youtube. Yes I know a lot of you readers are shaking your heads, but really the agencies don't teach skills, they assume that you already know everything. Sometimes with crazy families you just have to grit your teeth and do what they want, until you can't stand it anymore.

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ventmommy works as a Respiratory Therapist.

10,027 Visitors; 387 Posts

PDN agencies love to send untrained nurses to families. They hire tons of new grads with absolutely no nursing experience. Many of them have only merely seen a trach change done and they are basically thrown to the wolves.

There is a lot you can learn from watching videos and asking questions here.

Trilogy and LTV have their manuals online. Please learn the difference between a setting and an output because it makes me crazy when health care professionals don't know the difference between them.

Trachs can seem complex but they really all have the same fundamental features. Neo/Ped/Adult refers to length (there are also custom lengths for people with really long or short tracheas). The number refers to diameter of the hole. Trachs can be cuffed or uncuffed. If cuffed, they are either water-filled, air-filled, or foam (which are pretty rare). Bivona and Shiley are the two most popular brands. Bivona makes some fancy trachs like a Flextend and Flextend Plus which are for kids with no necks - the adaptor for the trach sticks out instead of being right under the chin.

There are plenty of non-crazy families that have really experienced parents that are willing to train an inexperienced but kind and motivated nurse. And you can always ask more specific questions here.

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River&MountainRN has 3 years experience.

1,688 Visitors; 179 Posts

PDN agencies love to send untrained nurses to families. They hire tons of new grads with absolutely no nursing experience. Many of them have only merely seen a trach change done and they are basically thrown to the wolves.

There is a lot you can learn from watching videos and asking questions here.

Trilogy and LTV have their manuals online. Please learn the difference between a setting and an output because it makes me crazy when health care professionals don't know the difference between them.

Trachs can seem complex but they really all have the same fundamental features. Neo/Ped/Adult refers to length (there are also custom lengths for people with really long or short tracheas). The number refers to diameter of the hole. Trachs can be cuffed or uncuffed. If cuffed, they are either water-filled, air-filled, or foam (which are pretty rare). Bivona and Shiley are the two most popular brands. Bivona makes some fancy trachs like a Flextend and Flextend Plus which are for kids with no necks - the adaptor for the trach sticks out instead of being right under the chin.

There are plenty of non-crazy families that have really experienced parents that are willing to train an inexperienced but kind and motivated nurse. And you can always ask more specific questions here.

Thank you, ventmommy! I've followed some of your posts on here, and I wish more families in the area were like you!

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River&MountainRN has 3 years experience.

1,688 Visitors; 179 Posts

1. Some agencies will say anything to get you in the door. Never take anything on face value. What does extensive orientation mean to them?

2. Ok so your mistake here is that you're letting the Clowns run the circus. Who's telling you one orientation day? (I usually don't need more than one but it's happened) Who is making you schedule work on cases you haven't oriented on or fully agreed to? I would bet it's a scheduler/recruiter. Do not schedule any shifts until after you have oriented. That way if you don't like it you're not breaking anyone's back. That schedule was blank before you showed up, if it has to stay blank until you're sure you like/can do the case so be it. (Took me a few times to figure this out)

A few things about our post really jump out at me.

You seem to feel your locked into one agency. Always have two. If one can't find you the cases you need I bet the other will try. You will be shocked how suddenly they can sometimes accommodate you if they are worried about loosing your hours to a competitor.

The other thing is you seem like a perfectionist. You want to be 100% confident and competent. But that's not nursing in any setting. Perfect is the enemy of good enough and while we strive for the first we often have to settle for the last. It's a balancing act, just put some thought of that my not be contributing to your troubles.

Additionally most nurses have trouble with self advocacy. No one in this industry will give you anything without you asking firmly and sometimes demanding it.

The conversation isn't "I think I need another day I'm just not confident" It's "I will need another day to get this kids routine" or "I'm not sure I'm safe to do x skill independently yet I need more training practice. How can we do that?"

It's the same with crazy schedules. I'll do them if the scheduler is good and plays ball, you jerk me around I'm busy that day. You have to claim the initiative on the relationship. Now that's easy to say when I have lots of work. If I'm work poor I have to eat it sometimes, that's a fact. However once you have ground rules down it's easier.

Here's my question to you. How much time do you spend in the office. Lots of times the nurses really don't know the schedulers and vice versa. If you can try and stop by, say hello, bring cookies. Try and actually take to your scheduler about why you didn't like a case or what skills your not so good on. Talk about your skills to a clinical manager they are responsible for your training and competency and should be able to help you.

Thank you for understanding---and absolving---my perfectionism. It's been my best asset (like getting through nursing school) and also my biggest downfall.

Unfortunately, I live in a really small populated area. It's a very seasonal area and, in the off-season, you may very well be the only occupied house in the neighborhood (all the rest are seasonal/vacation homes). I'm definitely planning on moving soon (came here to care for family at the same time I was launching my career as a nurse, and now family has passed on so there's no real reason to stay) to a more populated area with more job opportunities. To give you the idea: "Agency B" (the other agency in the area) covends a lot of the very-same-cases.

The schedulers don't do much beyond actually putting out the month-to-month schedules for the families. The CMs essentially try to pigeonhole nurses into whatever slots are open and become really defensive if you refuse a case---even if it's for the same reason why that particular case has been open for the past 6 months!

The good news is that I'll be working with a really good preceptor on a Trilogy vent case soon, so at least I'll be able to become familiar with that on a hands-on basis. The *family* is great, too, and *requires* multiple orientations in their home...which I find *fantastic*!!!!

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Kitiger has 40 years experience as a RN and works as a private duty nurse.

1 Follower; 18,258 Visitors; 847 Posts

Many families are very eager to teach the nurse the family's way of doing things. You need two attitudes here. First, remember that there is usually more than one right way to do a skill. If their way is safe, you do it their way, even if you know a better way.

If the parent is in teaching mode, then I put myself in learning mode. After a few weeks, when they've had a chance to observe me and trust me, then I might show them my other way of doing something.

Second, you need to be honest. Don't "fake it until you make it". Tell the family what you know. Usually, they will then tell you what they need you to know.

OK, sometimes they will tell you an alternate way - another correct way. (See my first point.)

During orientation, these attitudes both apply. Show & tell the nurse what you know, and learn how it is done in this home.

Also, orientation in never finished until the person being oriented has successfully done each skill on her own, without prompts. If a skill is only done once per shift, then you may well require two shifts. The nurse might orient for two half-shifts in order to accomplish this goal.

When I'm orientating a nurse, I have her first tell me how she would usually do something, then, if needed, I teach her how it is done in this home. Then I let her do the skill. If she gets stuck, I sit on my hands if need be, to allow her time to figure it out. She will learn the skill more quickly & more completely if she is allowed to think it through and figure it out.

(I'm using the female pronouns because it's simpler then typing he/she or him//her all the time. I like the fact that more men are coming into the field.)

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1,531 Visitors; 76 Posts

Why wont you work in a hospital?

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