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How many days off are appropriate?

Private Duty   (11,907 Views | 79 Replies)
by RNathome2010 RNathome2010 (New) New

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Trachmom, I do understand what you are saying.

I have been on my case for well over a year with a set commitment of nights per week. In this whole time, I have missed maybe 2 shifts because of illness. Otherwise, apart from vacation time in which I give ample notice (at least a month), I have honored that commitment.

I do think part of the problem lies with the agency, however. They are the ones that set up the system to function as it does. If one their selling points is going to be extremely flexible scheduling, they need to have an ample supply of backup nurses to fill in for those days the regular nurses take off. There should be no reason that you should have to go without coverage.

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3 Followers; 37,055 Posts; 98,459 Profile Views

Just a comment from catching up on the posts here: I noticed, particularly with one agency, that it seemed they would get call offs for one reason or another, but fail to inform the family, at all. This was happening so often, consistently, that the parents noticed the pattern, as I did. I found it to be an embarrassing situation. It was obvious that the agency was making no effort whatsoever to find a replacement for those uncovered shifts. In one case, the mother put it to them when she beat them to the punch by asking who was going to replace her nurse on a call off that she found out about before receiving any kind of call from the agency. It isn't the fault of the nurse calling off, that the agency does not cover the shift, and doesn't even respect the family enough to inform them. Likewise, of course, there are those who are going to take advantage of agency policy that allows them to come and go as they please with no consequences for failing to meet their commitment. From my perspective, I wonder how many times I have gone without an assignment (I am reliable) when an unreliable nurse makes it known that s/he does not really care to work the hours they requested.

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15 Posts; 547 Profile Views

For me the best way to work in PDN is to have multiple cases that you go to. I currently have 3 cases, 2 are staffed 24hrs and the other pt has 16hrs. Between the 3 cases I am able to get OT if I wanted, and I am for the summer. Once my kids go back to school my hours will drop. But with 3 cases you have more flexibility and it avoids feeling guilty in taking time off.

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JustBeachyNurse has 10 years experience as a RN and specializes in Complex pediatrics turned LTC/subacute geriatrics.

1 Follower; 1 Article; 13,944 Posts; 100,165 Profile Views

Oh and no one is guaranteed shifts especially as a per diem in either agency. You may be available M-Th & S but if you call off you are replaced. It's not reasonable for one nurse to work a single case full time. These are complex kids, what happens with an inpatient stay? Family figures out how to go on vacation?

To trachmom if your agency is NOT replacing nurses that call off, especially in advance shop around for a replacement or second agency. You have that option. Short time schedule changes (car accident on way to work, parent cancelled nursing but changed mind with a couple hours notice) are nice to get covered but not a reasonable expectation. If a nurse knows a month ( or more) in advance s/he needs off (regardless if you think the reason is unnecessary, silly or frivolous) and notifies the agency, the agency should reasonably be able to find coverage. If you want one or two nurses full time on a case, that's a nice goal but not truly reasonable in complex pediatric PDN.

If a nurse that has per diem status takes off the equivalent of 6 weeks a year a day or two a month with advance notice, honestly that is not an unreasonable request by the nurse regardless of work setting (PDN, hospital, LTC) as flexible scheduling is one of the few benefits of per diem status. Per diem nurses often don't get comp pay for not needing benefits, rarely get PTO, holiday or vacation pay. In PDN the family doesn't have to like the situation, hopefully the agency has sufficient qualified nurses to staff the case.

I work several cases where the schedule is hodge podge with nurses plugged in based upon client need and availability. Mom would rather have Sue on Monday, Bob Tuesday/ Thursday, Jane Wednesday/Friday, but the odd hours and skills needed the agency is only able to staff the case with about a dozen or so different nurses with many split shifts. Mom makes special requests such as don't split the Thursday x/x day as they have plans. Is this optimal? No, but the only way the agency can fully staff this 12h/d x7d/w case with hours that start midday is a dozen qualified nurses and splitting shifts at the. 6 or. 8 hour mark. I'm sure the mother would rather not need nursing at all with venerable strangers in their home 84 hours a week.

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389 Posts; 7,159 Profile Views

This is an issue I observe with my agency and I see the aftermath with the family too. However, SDLPN is right when she says you work for the agency NOT the family. That is a different type of PDN all-together and I have done that. It is on the back of the AGENCY to provide the nurses to the family, even at short notice. My observation is some agencies handle this like a pro, offering bonus/differential/extras for nurses that cover on short notice. Other agencies, not so much. In the 9-5 word, you have people that use their allowed time and then some. Happens everywhere.

When the one agency that I work with calls me on short notice offering me $10/hr to cover and be there asap, I seriously think about it - not so much for the agency that doesn't offer it. When I did a direct to client PDN, I had to haul my behind there no matter what, except when I was so sick that it was medically detrimental to my patient to be around them.

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13 Posts; 469 Profile Views

To trachmom if your agency is NOT replacing nurses that call off, especially in advance shop around for a replacement or second agency. You have that option.

We tried this route a couple years ago. We had three alternative agencies: Maxim, which our agency (thank God) flat out refused to work with and that is now out of business in our state. And then two others - One provided only a single nurse, not a good fit; and zero nurses after that, and I checked in regularly. The other provided a great nurse who was with us for 18 months until we needed to fire this agency for being a complete nightmare. In that time, they provided only one additional nurse who filled in a handful of shifts before we dumped them. So neither of them are options. We are stuck with our agency, thankfully it's a relatively a good agency.

Short time schedule changes (car accident on way to work, parent cancelled nursing but changed mind with a couple hours notice) are nice to get covered but not a reasonable expectation. If a nurse knows a month ( or more) in advance s/he needs off (regardless if you think the reason is unnecessary, silly or frivolous) and notifies the agency, the agency should reasonably be able to find coverage. If you want one or two nurses full time on a case, that's a nice goal but not truly reasonable in complex pediatric PDN.

Normal call outs for true emergencies happen in life, I consider coverage in that case to be a true blessing.

For scheduled absences, how many of you work on cases/for agencies where there are nurses availabl to cover?

And, they'd have to be trained on the case, no? No one could reasonable step in to care for my son wihtout at least a full day of training. Are there exceptions to this?

We requested a trained back up nurse in February....... It's the end of June......

If a nurse that has per diem status takes off the equivalent of 6 weeks a year a day or two a month with advance notice, honestly that is not an unreasonable request by the nurse.... In PDN the family doesn't have to like the situation.

I understand the nurse's situation, especially after really thinking about it this past week. What I don't like is that the family has no control at all... I can't say, ok let me work to hire a substitute. Like almost everything else in the medically complex world, we are at the mercy of others to work to address our situatino. So saying we don't have to like it... yet, we're the customer, and in my case with private insurance, we are the financiers of this business exchange.

Saying we don't need to like the care we receive is exactly the problem. Who answers to us? Who sees us as the customer in this situation? Who sees us as the reason everyone in this industry is in business? Who sees our *suffering* as the reason you all are in business?

I'm a freelancer in real life, but I've got a committed client month-to-month. My benefit is that I have flexibility scheduling my time. But. I have to deliver on my product no matter what -- if I do it in the middle of the night, no problem. But it needs to get done. And I see no problem with this. I *could* just tell them, I'm taking this month off. But I wouldn't. Why? Because they are the customer. They may not fire me, though they could. But I will damage my relationship with them. So, I bend. If I miss my normal working time during the week, I make it up. Why do PDN nurses *require* more flexibility than this? Surely the needs a family with a medically complex child are at *least* as important as the needs of a corporation?

The answer is: We are a vulnerable population. We have very few options, and in many cases like mine, zero other options. We must put up with it, regardless of how unstable it is. We *can't* fire the agency, and we many times feel we can't fire the nurse -- it's slim pickings out there.

So, where normal market forces would demand higher professionalism, the market forces of the sick population is very low. There will ALWAYS be another vulnerable customer with no recourse but to put up with crappy service.

Edited by trachmom

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390 Posts; 10,448 Profile Views

Trachmom,

You *can* fire the agency. You can hire nurses directly or do entirely without nursing care like lots of other parents do.

If the agency thinks you are serious about canning them, they might be more accommodating in making sure that your shifts are covered.

You are also completely within your right as the parent to train a friend or family member to provide care in the event that you have a nursing call-off. Just as you, the parent, should be completely trained in your child's care, you can train another person.

I had a friend that I personally trained and she adored my son and admired our commitments to our foster and adoptive children. I never left her alone but on nights when we had a call-out, which frequently coincided with my military husband's duty nights or during a deployment, she'd come over and I could sleep close-by knowing that she was there.

If you have a relationship with a particular nurse or two, they might be willing to cover a call out. I had two nurses that were pretty open to taking shifts at my house with virtually no notice because they liked being here. I frequently had to demand that the scheduler call them but it generally worked out in my favor.

I don't believe there is any agency that has nurses that are just hanging around waiting for a call out. First off, she'd have to be the MOST PROFICIENT NURSE EVER to be able to intimately know every IV pump, feeding pump, nebulizer, ventilator, trach tube, compressor, Vest, cough assist, etc. which would make her extremely valuable to the agency but she'd also likely to be already assigned to a complex case. From an agency standpoint, there's no way to legitimately make an "on-call" type nursing position and from a nurse's perspective, I can't see how any nurse could afford to be that well-trained and rarely get called.

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389 Posts; 7,159 Profile Views

I get the point about the extremely complicated cases. I work a case that is not so complicated and the agency STILL has trouble filling days even when given weeks in advance. I don't understand that at all. If you can do a good lung assessment you can do that case. I see this family without nurses constantly and they are not monsters.

On the flip side, I am not getting paid this week from another case because they were out sick that week. So, PDN is obviously an imperfect setup.

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13 Posts; 469 Profile Views

Trachmom,

You *can* fire the agency. You can hire nurses directly or do entirely without nursing care like lots of other parents do....

You are also completely within your right as the parent to train a friend or family member to provide care in the event that you have a nursing call-off...

If you have a relationship with a particular nurse or two, they might be willing to cover a call out....

I don't believe there is any agency that has nurses that are just hanging around waiting for a call out. First off, she'd have to be the MOST PROFICIENT NURSE EVER to be able to intimately know every IV pump, feeding pump, nebulizer, ventilator, trach tube, compressor, Vest, cough assist, etc. which would make her extremely valuable to the agency but she'd also likely to be already assigned to a complex case...

We can't do without nursing, and my insurance will not cover privately paid nurses. I have no other agencies in the state to work with, as I mentioned, so I can't fire my agency to get these nurses that I need to work and care for my other two children, one of whom also has special needs.

We have neither a family member nor a friend who has both the time and willingness to be trained to care for our son. And I do not expect agencies to cover last minute call outs.

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390 Posts; 10,448 Profile Views

Every state has a waiver program and perhaps you need to apply for it based on your child's medical needs so that you can have self-directed care instead of agency care.

It's not easy to choose to get rid of nursing but there are numerous other families with tech-dependent children and other children, including other SN children, that do get rid of nursing.

That's unfortunate that your support system is so lacking. It's always helpful to have reliable friends and family for last minute call-outs or scheduling issues.

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smartnurse1982 has 7 years experience.

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And, they'd have to be trained on the case, no? No one could reasonable step in to care for my son wihtout at least a full day of training. Are there exceptions to this?

Yes there are.

I am able to jump in "immediately" on cases that i have had no orientation.

For instance,someone called out of a 3pm to 11pm shift tonight.

I have never been to this case,and there was not any equipment that i did not know.

As i long as I *know* the equipment,i really do not see the need for orientation.

I do, however,ask my supervisors about family temperament,what are their likes and dislikes(ex,taking off shoes,etc.

I also ask the parents(or the nurse who is leaving) about the child.

i get a small 30 minute "orientation".

There are nurses who can step in and take care of complex children within an hrs notice...

This is where the agency comes...if the agency does not offer any incentive,then yes, I will not go in.

You do realize that you can have 2 or 3 agencies in your home?

One case i have contracts with 1 agency for days,another for nights,and another one on the weekends.

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smartnurse1982 has 7 years experience.

1,775 Posts; 24,381 Profile Views

I get the point about the extremely complicated cases. I work a case that is not so complicated and the agency STILL has trouble filling days even when given weeks in advance. I don't understand that at all. If you can do a good lung assessment you can do that case. I see this family without nurses constantly and they are not monsters.

On the flip side, I am not getting paid this week from another case because they were out sick that week. So, PDN is obviously an imperfect setup.

I notice lots of cases where the family tells the agency not to send a nurse back to their homes has nothing to do with competency.

If a parent thinks somebody is incompetent,the parent could ask the agency supervisor to come out and show the nurse what to do. Or maybe show them yourself.

Most nurses have no problem with a parent showing them their way of doing things as long as it does not interfere with nursing orders.

I guess i do not get "firing" a nurse for being incompetent.

90% of cases i get "fired" from are due to personality issues.

You will not believe the reasons some parents have "fired" me..

Maybe you might need some self reflection to see if some of your reasons for firing a nurse are "unreasonable".

Nurses never leave cases they love.

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