Too Scary For Me

[Have Nurse, ADN, RN]

Today those words echoed in my head as I sat in an interview with an Assisted Living Director.

I was being considered for a R.N. Health Manager position. At first when I arrived I noticed the air-conditioning wasn't on. It's quite warm and very humid today, which is a bit unusual for Minnesota this time of year.

Next, I couldn't help noticing how dark it was inside the entrance and reception area upon my arrival at 10:30 a.m. While the Residents present in that area were somewhat independent, I couldn't help wondering if they could see where they were going. I asked the Director, as she handed to me the job description, "It's a bit dark in here. Is it always like this?"

She looked at me oddly. "Why, you can go inside there," she said, pointing to the dining area, "It's brighter by the windows." Then she pointed to a nearby desk with a lamp. "Or you could review it here, " she advised.

I thanked her and chose to sit at the desk. Bad idea. The chair was rock hard and aggravated my back within about 30 seconds. By then, the Director had returned to her meeting in her office so I gathered myself and relocated to the sofa dining room.

I wondered with a bit of dread, when the last time was that this sofa had been cleaned and sanitized. It was made of fabric. As an Infection Control Nurse, the question couldn't help but rear its' ugly head.

I began to read the job description. I wasn't surprised by much of it, but when it stated I would regularly be working a 50 hour week, in addition to the rest, I put my foot down.

Upon my return to the office area, I could see her meeting was still going on and I did not wish to be rude. There was a young lady in scrubs standing in the hall looking at me expectantly, smiling. "I don't want to disturb her," I explained, pointing to the Directors' office. "Would you let her know that I will phone her?" I gave her my name.

"Sure," she replied, looking a bit bewildered. I thanked her went to my vehicle. As soon as I turned the key, the Director was outside, trying to get my attention.

Sheepishly I turned off the ignition and got out of my car. "I didn't want to interrupt what looked like was an important meeting, but I felt that this position is probably not a good fit for me."

"What is it that bothers you?" she asked.

"Well, at this time in my career, I am not willing to work a fifty hour week. My body won't allow that, and, I don't do sales."

"May I see that job description she gave you?" (Referring to her Assistant) I handed it to her.

"Oh," she said with some embarrassment,"we gave you the wrong one. Would you still be willing to come inside and speak with us?"

"Of course." Back inside we went.

I was introduced to 4 women, including their H.R. Representative and her Manager.

"She was given the wrong job description." she informed her colleagues. "She wants to be a Floor Nurse."

"No," I corrected her. "I do not wish to work the floor. I am done with that. From the description of what I read, it is my understanding that I would supervise, be a resource, handle residents concerns, care plans, education, Infection Control concerns, etc."

They were very quiet.

"Well," the Director slowly began, "What is your definition in Assisted Living of a Floor Nurse?"

"My understanding of working the floor is to do wound cares, pass medications- " she interrupted.

"Oh," she waved off her hand and said reassuringly,"Our Health Aides to the cares and they also pass the medications."

I shook my head. "No," I would not be able to tolerate that as a nurse. While there are many very good and careful Health Aides out there, some of them even nursing students, they have not been taught theory and how to assess if their resident is getting into trouble with their meds. That is only a nursing duty. I won't put my license on the line, even if State says it's O.K."

One of the other women chimed in: "Well, it's pretty much industry wide in Assisted Living." she informed me. I knew that. "That doesn't make it appropriate. May I ask why you don't have L.P.N.s or T.M.A.s passing your meds?"

"Cost," the H.R. person stated flatly. I nodded.

"The cost will be higher when you have a sentinal event. When a mistake happens regarding medications that involved the Aide, it falls on the nurse. Your electronic system may be fool-proof, but your staff aren't. Things happen. It isn't just the Aide who can step out of bounds regarding their duties. If nurses get comfortable with Aides giving meds, then they can get comfortable asking them to do other things outside of their scope:

National survey reveals safety issues

"A national survey of 3,455 medication aides conducted by Budden examined their role, training, and demographics. The findings showed the aides were frequently being asked to perform tasks for which they were not trained. These included administering morphine, calling physicians to change medication orders, packing wounds, giving controlled drugs, making decisions about giving or not giving insulin, and assessing patients when administering as-needed medications. These activities are all beyond the scope of an aide because they require assessment skills and nursing judgment."

Link: Medication aides: Are they practicing within their scope?

No," I smiled gently and stood up.

"I'm afraid this is a deal breaker for me. I thank you for your valuable time, but I stand firm on this." I shook their hands and departed. I am still employed where I am. But it made me appreciate the safeguards my present employer has in place.

While it may be legal to have Aides pass the medications in Assisted Living, we only use Nurses or T.M.A.s where I work. And I am grateful.

[Orion81RN]

I LOVE this!!! I'm picturing a gif of a standing ovation.

[ljconnolly8]

My mother is currently living in an assisted living facility where Med Techs pass meds. Though I don't like it, it's what we have to accept to keep her in this particular facility. She has advanced dementia and is at risk of wandering. I can tell you from experience, some of the Med Techs are more reliable than the nurses they work under. I have had to really stay on top of her prescriptions, especially when there is a change to make sure new meds are in place and discontinued ones are removed. I did have her in a facility where LPNs passed meds. I always found them in her bed, under her bed, and on the floor in her room. I would also find other residents meds in the common areas on the floor. I have made many calls to ACHA and basically it was a slap on the wrist. I applaud you for being a great nurse. I am entering nursing school myself in August.

[Possum_RN]

One of the problems that I have with med techs is that, as a former CNA, I can tell you that the line was often too blurry between a CNA/Med. tech/Nurse to be safe. You beautifully articulate how the med tech/nurse blur can be dangerous, but it also causes a problem with safe patient interactions for CNAs.

Our med techs were expected to function as CNA's when not performing a medication round. Some were AWESOME and helped me (as a CNA) tremendously, giving me insight into the meds a patient was on and how it affected them. They were true patient advocates. Others....did not function as CNA's at all - they sat at the nurses station with their buddy-nurses, and instead of having the two CNA's needed to safely turn, change, and reposition residents, we had one alone. Basically, the med tech just did two medication rounds a night, and sat on her butt the rest of the time: unlicensed to function as a nurse, unwilling to function as a CNA. And getting paid for the whole 12 hours.

How was THAT saving the facility any money?

[VivaLasViejas, ASN, RN]

I was an assisted living nurse for six years. If I'd known then what I know now, I would have never done it. I trained my aides and med techs well, but I was lucky that things never went seriously sideways. I did have one resident care coordinator who was diverting drugs and an administrator who refused to notify APS when one of the male residents was sexually harassing a female resident, but otherwise my tenure at those facilities was largely uneventful.

Now that I've had five years to reflect, I realize how dangerous this kind of nursing can be. You have to be able to trust your caregiving and med staff implicitly, and in many ALFs they are practically hired off the street at minimum wage or a little above. Most weren't even CNAs, and they barely finished high school. Then again, some of the best caregivers I ever had were people who couldn't spell 'cat' (as evidenced by their charting) but cared deeply for their residents and did a wonderful job. Still, teaching a med tech (who *could* spell) to administer critical medications, like insulin, IS scary. It's one thing to teach a patient how to administer their own insulin at home, but like a nursing facility, AL is regulated by the same entity, and there have to be policies and procedures in place to guide staff in the performance of tasks of nursing care. I remember training med techs how to draw up mixed insulins like we did before insulin pens came along---here they were, learning to do tasks in a week of orientation that took me two years to learn and practice!

That being said, I enjoyed AL nursing even though I would never do it again. I had lots of autonomy and loved it. I also got to be creative: some residents were basically inappropriate IMHO for assisted living due to being total care patients or wanderers, and I almost always found a way to make it work. It wasn't up to me (gotta love Corporate!!) so I *had* to figure out how to take care of these challenging residents. Fortunately the overwhelming majority of my caregivers were equal to the task, and I think we did as well or better than a nursing home or memory care in most cases.

[Have Nurse, ADN, RN]

I LOVE this!!! I'm picturing a gif of a standing ovation.

Thank you!

[neuron]

My mother is currently living in an assisted living facility where Med Techs pass meds. Though I don't like it, it's what we have to accept to keep her in this particular facility. She has advanced dementia and is at risk of wandering. I can tell you from experience, some of the Med Techs are more reliable than the nurses they work under. I have had to really stay on top of her prescriptions, especially when there is a change to make sure new meds are in place and discontinued ones are removed. I did have her in a facility where LPNs passed meds. I always found them in her bed, under her bed, and on the floor in her room. I would also find other residents meds in the common areas on the floor. I have made many calls to ACHA and basically it was a slap on the wrist. I applaud you for being a great nurse. I am entering nursing school myself in August.

When reading this post, I just knew something was amiss, was waiting for the 'I'm not a nurse' (yet) comment :)..I am sure that you won't find too many LPNs/RNs that loosely leave meds on the floor or casually leave other residents meds on the counter just for the hell of it. Nursing school alone will expel you for this mindset. Some nurses pass through the cracks yes, but most I don't believe so. You probably were paying too much attention to the nurses (as most people want to find 'mistakes' the nurse made) than you were to the med techs. Just my input! Good luck with nursing school.

[ljconnolly8]

The nurses didn't just leave the pills lying around, they didn't stay and witness my mother taking and swallowing the pills. That is something I might expect an untrained or careless med tech might do. I thought I wouldn't need to worry about a nurse doing it so, I didn't look for it. This issue was just that obvious. Thank you for the well wishes for my career. I am leaving a career as a business analyst to finally follow my heart and not the money. I fell in love with the medical field working in a hospital over 30 years ago.

[Have Nurse, ADN, RN]

The nurses didn't just leave the pills lying around, they didn't stay and witness my mother taking and swallowing the pills. That is something I might expect an untrained or careless med tech might do. I thought I wouldn't need to worry about a nurse doing it so, I didn't look for it. This issue was just that obvious. Thank you for the well wishes for my career. I am leaving a career as a business analyst to finally follow my heart and not the money. I fell in love with the medical field working in a hospital over 30 years ago.

You share a valid point. Especially concerning our elderly, we need to make sure that the pills were indeed swallowed. Thank you for emphasizing that.