Appropriate assignment??

[hoolahan, ASN, RN]

OK, I need your take.

Last week I saw an OB/post-partum pt with a history of pyschosis. I was sent b/c she had wound care for her C-sec incision. A well-mom-baby visit was first conducted by the peds nurse, so I was told I only needed to see the pt for wound care. I have never been asked to see a post-partum pt before, and we only have one peds nurse in our HH agency, so if I didn't do her Sunday visit, she would have to work on her day off. I was very nervous about it, not so much for the OB, which BTW I HATE OB nursing, only slightly more than I hate psych nursing, but I was nervous b/c the pt repeatedly asked me on the phone if I was coming alone. It gave me the willies. What was going through her head? I was thinking she would answer the door with a knife in her hand. I found out later that 2 nurses went the first visit, b/c our agency is doing a inter-rater reliability QI to see if 2 diff nurses would assess pt the same way. So, that apparently had made this psych pt paranoid. BUT, I figured, this is a rare occurance, so I agreed. Found out the day after my visit, pt checked herself into the mental health crisis center. I did not peg her as so close to a crisis. Maybe I missed something, since I am not a psych nurse? Or, maybe just being 40 yo w/ new infant and h/o psychosis was a bad combo, who knows?

Now, today, I find out, I am seeing another OB pt for a C-sec wound. I protested, saying I am not an OB nurse. They said, you have good assessment skills, you're a good nurse, you can do wound care! I said, I do not see such a pt as a wound to care for, I do a comprehensive assessment on my pt's, and I am unprepared to properly assess a post-partum pt. They acted like I was a bit*h, prima donna. TOUGH!

It's not so much that I couldn't handle this pt, b/c I think I could have, but I see this as their first step into forcing me to do something and see pt's whom I do not wish to see. I have ZERO desire to be a OB nurse, and I would not take a public health job b/c it is mostly well-mom baby visits and child abuse cases (from what I have heard, in my geographical area.) I see them as sending me to well-mom baby next "since you did so well with the others and their wounds." Next it would be peds, you get my drift. Our present peds nurse agreed to do one peds case, then another, now she is the only peds nurse, works all hours, since parents may work and kids may attend school, so she has to make visits in the winter in the dark to some very bad neighborhoods...forget it! She hasn't seen an adult in the last 2 years since she agreed to see one kid, and I am not getting swindled into this.

Now I don't like psych at all either, but the difference in taking a psych case with a wound is that I do assess psych/emotional status to some degree in every pt I see. I may not be the best nurse to talk a pt out of a delusion, or know the correct med to get the pt back on track again, but I can assess suicidal ideation, depression, and anxiety. I do NOT however, routinely assess fundi, breasts, lochia, blah blah blah to any degree on every pt. I am not an expert on post-partum depression or knowing how to identify it.

So, you tell me, am I making something out of nothing? Should I have not refused to do the visit? Another nurse volunteered to do it, so why force me? We swapped assignments. I am planning to write a letter to my supervisor to tell her of my concerns and my lack of experience and confidence in these pts. What do you think?

Thanks!

[prmenrs, RN]

I think you may have discovered a very imp't principle here:

Once it's a favor, twice it's your job!

I have no doubt you could have handled the pt., but, you don't want to do that specialty. You could've asked for a co-worker who DOES do PP to come w/you, but that wouldn't have been very cost-effective. And have you ever gone to a pt and had them ask you to look at something else "while you're there"?

Stand your ground, hoolio!!

[fergus51]

I completely agree with your decision to stand your ground! You should not have to do anything you don't feel you are trained to do.

[Polarbear]

I agree to do some thing that you do not feel comfortable/competent with is unsafe. 1 bad assessment and there goes your licence.

[P_RN, ADN, RN]

Add my agreement with the above. I got swindled into doing W.I.C. certifications one week when someone was on vacation.......anybody guess what I ended up doing the entire time I worked there? Grrrr.

I wonder if the insurance provider knows they aren't going to be getting a peds/OB nurse .Not to mention the patient........stand your ground.

[hoolahan, ASN, RN]

Thanks so much for your input, I was starting to think, maybe I am being unreasonable. I made some copies of our P&P's realted to this, now I have to go read them, was too tired last night.

I never thought about what the insur company might say, but I do know that our company got into a situation with a HMO b/c for a daily wound case, LPN's were sent out for visits. Every nurse where I work is fine with LPN's doing wound care, in HH, you get to know a lot about wounds. BUT, this insur co, c/o that they were paying for RN's to see pt's, and if LPN's went, they would lower reimbursement!! So, now they have made the charts a new color if managed care, so only RN's will go see pt's. So, it is something to think about. I also wil have to research the state reg's. The state of NJ has very stringent reg's on every little thing!

Thanks again. I thought maybe I was being unreasonable.

[nicola]

When I was doing HH in the S. Bx, we did every thing - all of us. I learned to do the PP and c-section care. It can be a trick to do fundal checks on a section cause you need to really push, but don't wanna push too hard, but you need to know if she's boggy... Hot Lips, I'm with you standing your ground, esp. of there are RN's in your agency who do OB and Peds. We didn't have specialties (a really tiny agency), so we all were generalists. (Was quite the challenge, but oh, what great experiences I had there!!)

And whoever said "once it's a favor, twice it's your job" was so right! I posted earlier (I think it was here...) that I"m bilingual and they routinely tried to sucker me into running all over NYC for Spanish speaking clients. I wouldn't have minded it TOO much, except that they wanted me to do that in ADDITION to carrying my case load in Harlem and Wash. Hts. My response was that being bilingual is NOT a specialty. It's a useful skill but other methods of translation can be used. Sigh!