How to make a PDN job appealing?

Orion81RN · Jul 5, 2019

6 hours ago, nursenmom3 said:
@Crystal-WingsSorry to come back to the same post, but I'm still thinking about this question of coming to a doctor's appointment.

All of my kids' local specialists are at a Children's hospital about an hour from my home, where my kid also goes for multiple therapies, and infusion treatments. We are generally there for the better part of a day twice a week, and might have one or more therapy appointments, a doctors appointment or two, lab work, and an infusion.
So, if you were the nurse, and you wanted to be there, how would that work? Would you expect to meet us at home, and ride with us, and stay all day? Or meet us there for the appointment, in which case you'd be traveling 2 hours (assuming you live near me), for an hour of work?

First, I want to tell you that I'm still going to answer your question from my perspective on the parent doing the care while the nurse is there. I haven't forgotten. But I want to type it out in a document, copy and then paste it here so I don't lose it.

But as to your question here, what we are talking about is a scenario such as this:

Say the nurse is scheduled to work Tuesday 7am to 5pm. Your child happens to have a doctor's appointment that Tuesday at 10am. I'd be irritated if I were told to not come to work that Tuesday, missing 10 hours of pay. The way it should typically work is I would come to my shift at 7am. We would all go together in one vehicle to the appointment. If there are any new orders, I'd get the prescriber to write it down on our facility's order sheet, making it an official order that we nurses can legally carry out. Then we'd go back to your home, or wherever you want to go...and I'd continue my shift til 5 pm. I say go wherever, bc let's say you want to stop at a restaurant, or maybe go bowling like I've done with my patient and their family... We aren't expecting you to intentionally schedule an appointment during hours we are scheduled to work. But, if it happens to fall on a day we ARE scheduled, then we absolutely go. This is very common.

If an appointment is scheduled for a day where a nurse is not scheduled, then we simply expect to be told the child had an appointment. Give us any pertinent info regarding the appointment, AND keep in mind that if there are new orders that we cannot follow them unless we speak to the nurse or doctor, or have the order in writing. I hope that clarifies things.?

Kitiger, RN · Jul 5, 2019

9 minutes ago, Orion81RN said:
If an appointment is scheduled for a day where a nurse is not scheduled, then we simply expect to be told the child had an appointment. Give us any pertinent info regarding the appointment, AND keep in mind that if there are new orders that we cannot follow them unless we speak to the nurse or doctor, or have the order in writing. I hope that clarifies things.?

Excellent point, Orion. I have to either see a signed order or I have to talk to the doctor to get the order before I can carry it out. If my supervisor wants to call and get the order and then tell me, that works. too. That signed order does not have to be on my agency's form; it can be the discharge instructions that you get at the doctor's office. But please be sure that those instructions are correct. They often have typos that render them useless. And if the med is given GT but the discharge instructions say "PO" (as they often do) we have a problem.

I am not allowed to carry out an order that I get verbally from the parent (even when she is a nurse). I am also not allowed to take an order off of the medicine bottle that the pharmacist initialed.

caliotter3 · Jul 5, 2019

Nurses are expected by the agency to attend a doctor's appointment if they are scheduled to work during that time but if the parent forbids it, then the agency is ok with the client cancelling the nurse's shift. One is not expected to call a nurse in at a different time although that can occur. Nurses accompany in the client's vehicle, primarily so they can attend to the patient while the parent drives. Nurses are not allowed to drive the patient. The whole schmiel about the nurse obtaining the doctor's order while they are there is so that the order is signed and thus ready to be implemented without necessary action by the agency. It is not necessarily meant as an affront to the parent's ability to communicate the essence of the order, although many parents love to give their version instead of the doctor's. When this is done to me, I usually find the level of defensiveness necessary to work the case to be not worth it and I move on to a case where the parents are more cooperative.

Crystal-Wings, LVN · Jul 5, 2019

Don't make the nurse wait in the waiting room at appointments.

nursenmom3 · Jul 5, 2019

Thank you everyone! That is super helpful.

We haven't even requested day nursing, but if we did, we'd request on the days when I work. Our infusion schedule, and therapy schedule is set. We're always at the hospital the same two days a week, and as much as possible we try any fit doctors around that, and so of course, I never work those days.

But, you bring up a good point, which is not to cancel at the last minute. I work per diem/float, because my availability to work is too variable. But if I thought I was going to work, and then something came up (another kid was sick, or they didn't have a shift for me, or whatever), I should have the nurse work anyway.

And yes, I get that all changes are in writing, and signed, and need to be specific. Now you made me think of a few questions.

1) What happens if a shift ends and we are away from home? For example, let's say there's a one off doctor's appointment at that hospital an hour away, and it runs super late, or they decide they want to run tests that take a long time, or they admit him. You need to get back home (if you came by public transportation) or to our house (if your car is there). Can I just call you an Uber on my account? Or give you taxi fare? Will the agency cover the extra hour to get you home, or can I pay you for that hour in cash?

2) What exactly are the rules about transporting you and the child? I know you have to be in the same vehicle, and you can't be the one driving, but can you drive with anyone? Or just a parent? For example, our son likes to watch his brothers' games and practices. If a relative or neighbor offered to pick you and him up to go watch the game, assuming our permission and appropriate corificeat in the vehicle, is that an option? Also, if he wanted to go for a walk with his brothers and Grandpa to the local playground or ice cream store, could you do that?

3) How much specificity do you need about what goes in the g-tube, and how much flexibility is there? Generally, at night the g-tube is easy because it's the same formula, for the same rate, at the same amount of time each night. That's all that's on his 485 right now, because we've only asked for night nursing. But of course we'd need to change that.

But in the daytime, I make a lot of judgement calls. I decide how much to give based on how well he eats, and also on what he tells me about how he's feeling. So, for example, if the goal is 600 calories across breakfast and lunch, and he eats half of what I offer, then during his afternoon nap he gets 300 calories through his tube. I don't usually use the tube when he's awake, but if we're outside and it's really hot, I might bolus some water. If he tells me he's got nausea from a medication, I might let him take a break, but if he's actually throwing up then I might run pedialyte. . . . All of it is done with input from his dietician and medical team.

Is it possible to write a 485 that reflects those kinds of judgement calls?

nursenmom3 · Jul 5, 2019

7 hours ago, Orion81RN said:
First, I want to tell you that I'm still going to answer your question from my perspective on the parent doing the care while the nurse is there. I haven't forgotten. But I want to type it out in a document, copy and then paste it here so I don't lose it.

Thank you! I am eager to read it. Your insight here has been super helpful.

caliotter3 · Jul 5, 2019

If you are away from home at shift change, the nurse notifies the agency and they will approve the overtime as it is not her/his fault. No, you are not required to provide transportation to the nurse. They use their car from your home, or from the place of appointment, as appropriate, just as they would otherwise on any given day.

Anything where you make a judgement call, the nurse simply charts that they followed your direction if it strays from the care plan. They will inform you if they think it is too much straying so that you can do the change yourself. (But they still chart what transpired and that you did it.)

It is very possible to write a 485 to include judgement calls. Very easy to do. What you described in paragraph 2 is possible. If you have any questions, then simply clarify with the agency beforehand. As a matter of fact, it would be best for you to bring this up at the SOC so that the agency can incorporate this into the careplan from day one, (or you can bring it up to the supervisor the next time s/he comes out so that they can make the change now). No biggie.

caliotter3 · Jul 5, 2019

Another option for appointments and doctor orders: If you are going to an appointment and you know the nurse will not be accompanying you, then take an agency doctor's order form with you (with the child's id info/doctor info filled out at top) and hand the form to the doctor to fill out in addition to whatever else s/he does relating to the new order. Then, you bring the signed order back and make sure the nurse gets this the next time you have a nurse on duty. Even those agencies that have converted over to electronic charting still maintain a few blank order forms in the patient binder for situations like this and to provide a suspense copy of an order that is entered on the agency device. Of course you can't take the agency device because a nurse has to be signed on when they are actually on duty.

nursenmom3 · Jul 5, 2019

13 minutes ago, caliotter3 said:
If you are away from home at shift change, the nurse notifies the agency and they will approve the overtime as it is not her/his fault. No, you are not required to provide transportation to the nurse. They use their car from your home, or from the place of appointment, as appropriate, just as they would otherwise on any given day.
Anything where you make a judgement call, the nurse simply charts that they followed your direction if it strays from the care plan. They will inform you if they think it is too much straying so that you can do the change yourself. (But they still chart what transpired and that you did it.)
It is very possible to write a 485 to include judgement calls. Very easy to do. What you described in paragraph 2 is possible. If you have any questions, then simply clarify with the agency beforehand. As a matter of fact, it would be best for you to bring this up at the SOC so that the agency can incorporate this into the careplan from day one, (or you can bring it up to the supervisor the next time s/he comes out so that they can make the change now). No biggie.

For the bolded, I guess what I'm asking is what happens if I transport the nurse one way, away from their car, and then can't transport them back? For example, nurse is working until 5, at 2 kid spikes a fever and we decide to go to get it checked out and the hospital ends up keeping him overnight for IV antibiotics. How does the nurse get back to their car, if I'm not providing the transportation?

nursenmom3 · Jul 5, 2019

12 minutes ago, caliotter3 said:
Another option for appointments and doctor orders: If you are going to an appointment and you know the nurse will not be accompanying you, then take an agency doctor's order form with you (with the child's id info/doctor info filled out at top) and hand the form to the doctor to fill out in addition to whatever else s/he does relating to the new order. Then, you bring the signed order back and make sure the nurse gets this the next time you have a nurse on duty. Even those agencies that have converted over to electronic charting still maintain a few blank order forms in the patient binder for situations like this and to provide a suspense copy of an order that is entered on the agency device. Of course you can't take the agency device because a nurse has to be signed on when they are actually on duty.

That's a good idea. Having your forms does seem like it would make it easier.

When I say I'm not worried about the documentation piece, it's not because I mean I won't take care of it. It means that pinning down doctors and getting them to write their orders correctly is a skill I've honed over the past 15 years.

caliotter3 · Jul 5, 2019

You should discuss the first situation with your nurse beforehand and s/he should be prepared to take another means to go pick up their car. The agency would not object to you reimbursing the nurse for the cost of an Uber/Lyft ride in this instance. This is just something you need to plan out with the nurse ahead of time so nobody is caught short.

caliotter3 · Jul 6, 2019

Just an afterthought to the above: usually my agencies have specified that I remain with the patient until they are admitted in those instances when we take the child to the ER or if hospitalization becomes the course of action. The nurse just doesn't up and leave, but then they don't dally after other healthcare personnel have taken responsibility for the patient. Far too often, trips to these places, with or without travel time, run over the standard time for day shift to end. In any case, the nurse communicates with the agency to get instructions.