I Don't Know My Role!

[LookingforChange]

In order to reduce my work stress while in school, I've changed jobs. I've left med/surg to do pedi pdn. Now I have a different kind of stress.

My case is a toddler who "used to have seizures". Thanks to meds, he hasn't had one in a long time but of course still could because of the condition he has. I am with him all day during which I give one med one time, assess him, and get VS once. The rest of the day he is an active, happy toddler playing and watching movies. He does have some developmental delays so to pass the time I have been trying to teach him things to bring him up to speed with other kids his age; he lost some ground when he was having frequent seizures.

There is a family member home with us during the day; not a parent but someone who provides a lot of the care when I am not there. When I am there, this person leaves everything up to me from potty training to discipline but this person follows me and the child around talking, talking, talking so that it interferes with us working on the things I think I could teach the child. I hate to ask this person to give us some space because I don't know if teaching colors, shapes, letters, how to form sentences, etc. is even what I am supposed to be doing. It's just something I started doing rather than sitting on the couch waiting for a seizure that may not come.

Anybody have any advice on what to do with a case like this? I know for a fact the other nurses on this case get so bored and aggravated by the person in the home that they pack the child up and take him home with them to spend the day. They do have the mother's permission but this is against agency policy and pretty stupid if you ask me. I am less than 2 years away from getting my BSN and I will not be jepordizing my license by driving this child around just to get away from the aggravation of the relative sharing way too much information regarding things that go on in the family. Each one of us has signed a document with our agency stating we will not transport a patient in our private vehicle so you know the agency isn't going to cover if there is an accident. So this isn't a viable alternative to me.

Also, the relative puts the toddler in the swimming pool while I am there. She suggests I bring a swimsuit and join the toddler but I am very uncomfortable with that situation. Swimming while on duty? It just seems like a foreign concept to me. But if the toddler gets into distress in the pool and I wasn't in the pool, am I in more trouble than if I were in the pool?

I guess this is so different from anything I've ever done I'm just not sure how to handle it. What would you be doing with your hours while you were there? Basically, except for the potential that is there, I am with a healthy child. But because of the "condition" the child has, the relative thinks the nurses are there to do everything. What kind of boundaries would you want to draw and how would you go about it? Looking for advice from folks more experienced than me working outside of hospital walls. Thanks!! And sorry for the length!!

[JustBeachyNurse, LPN]

Do you have a clinical manager? What do they suggest? When I'm stuck for guidelines about boundaries, responsibilities I can turn to my clinical nurse manager or our HR rep (who is awesome about clarifying policy and procedures). Is the parent aware of the relative's behavior?

As far as swimming, my one patient has family with a pool (and dad happens to be an ocean lifeguard as a side job). The child does go in the pool 1:1 with an adult relative whether it is mom, dad, grandparent, aunt. (Sorry but I am not paid enough to go to work in a bathing suit) I wait on the deck of the pool (in reasonable proximity to the patient) and I am there for support. (I would have an issue if the child was in the pool alone, say adrift on a float or if one adult was trying to watch the patient and other children which is just not realistic). I'm not sure what my agency policy is on swimming with a patient. But if the patient was in the pool and say had a seizure, I'd jump in and intervene. (A good reason to wear scrubs--they dry out quickly )

My toddler patient has siblings so there is a lot of play interaction with them. However the rest of my day is packed with medications, GJT care & feeds, therapies, exercise/stretching protocols, breathing treatments, etc. We read, sing, play music, and do a lot of therapeutic play. Though his vision has improved enough recently that he can see the tv so that is a new fascination/distraction.

I do agree with you that it is NEVER a good idea to remove the patient from the home in your private vehicle (even in an emergency there is 911 for a reason) and then take the patient to your own home. Never mind the agency but I'm betting your liability and auto insurance carriers wouldn't be too happy. Since that is clearly against agency policy, you are wise to not do the same as others in this case.

[mg2312]

One of my cases is very similar..mostly healthy active 4 y/o.

I do all of the same types of things, working on potty training, teaching her letters/numbers,take her to the park, bath her etc even though her mom is usually home all day. i also was told to bring a swim suit for their pool - at first I was uncomfortable with it but after talking to my agency and other PD pedi nurses I am more comfortable with the concept. the way my agency is, is that while I'm with the child she is 100% my responsibility even if her

mom/family is home. basically anything the mom wants me to do with her, it's my responsibility to do(obviously within reason - safety/maintaining professionalism)

PDN really does take getting used to because it's not just care for an illness but also developmental milestones - and with toddlers that's a lot of "play time," which we don't usually associate with being at "work"

hope that helps a little, to know you're not the only one in this position :)

[ventmommy]

Wow. So sad that some friends of mine that have vent dependent kids are getting their hours reduced or canceled but we have this kind of abuse of PDN services. I hope that this is private insurance and not tax dollars.

ANYONE can be trained for the signs of a seizure and when to call 911. ANYONE can be trained to take VS.

Yes, you can go swimming. You can go anywhere, in general, with the child. We brought our nurses to all sorts of places (not swimming because my son wasn't capable of that). Our nurses could take our child for a walk or ride in our vehicle. They were not allowed to drive our vehicle or take our child in their own vehicles.

[mg2312]

ventmommy,

I couldn't agree with you more!!

sadly, this is a Medicaid cAse - with the case I mentioned, I do give meds often throughout the day and Tube feeds (for whatever reason the family isn't able on keep track of meds/feeds and administer them on time) but it does seem like abuse.

on the other hand I recently had a pt. with a trach, gt, ostomy, cath, wound vac, you name it, he had it..now this case Medicaid decided did not need nursing care so the family had to struggle to pay for around the clock care on their own.

it really is ashame how our system works! care doesn't always go to the right people, and there's no reason for that to be happening

[caliotter3]

I once did a private duty weekend assignment with an extremely wealthy client. I was asked to accompany the client while he lounged in his backyard pool. Boy, I can tell you that I spent the entire time envisioning him having a diabetic crisis or cardiac event and me having to perform water rescue! I can't even swim that well to save myself!

[LookingforChange]

My case (OP) is not a Medicaid case. My state does not participate in the Medicaid program but instead has a state run program which is even a bigger mess than Medicaid. I too agree this is a waste of funds but my place is not to judge but to do my job. I am just having trouble figuring out what my job is. The nursing director is no help...she has just told me to enjoy an easy case.

MG: do you have life guard skills or any other training that would teach you how to save someone from drowning? I worry if I get into the pool with my patient, I have increased my liability. By getting in the pool, I feel a jury would look at it as I feel I am capable of rescue should he go into crisis. Were it left up to me, the patient wouldn't be in the pool when under my care as water rescue is not within the scope of my practice but it isn't up to me with the relative there. I'm not trying to insult you in any way for swimming with your patient; these are just my worries. I also know if I were swimming with the patient and he drowned, there is no way in heck the agency would back me when it went to court.

I guess coming from a hospital background I'm just more leary of lawsuits and now being in an area where the lines between nurse and family get so blurred worries me. I see my coworkers doing things that I am 100% positive the agency wouldn't cover if anything bad happened. My director is very laid back and knows some of these things go on; she just figures the nurses are smart enough to know they are risking their license. I feel should be taking a more proactive approach and stopping some of these things before a lawsuit does happen and she is held liable because she was aware, but there isn't anything I can do to change her behavior. I just have to protect myself. And I'm sure the family is going to think I'm some kind of stick in the mud since I won't do all the fun things the other nurses do but I can't help that. I have to take care of my patient and protect my license the only way I know how.

[caliotter3]

When I am asked to do something that is skirting the boundaries of sound judgement or when I witness problems, I always document my conversations with my employer so that I have a written record of what they have instructed me to do or not do. Nine times out of ten, they will say to do what the parent requests and document it or, refuse, and tell the parent to do it themselves, then document that too. When it is beyond what I care to take a chance on, I leave the case, prepared to go without work. Employers take advantage of how badly we need a paycheck. They don't care because they know that they won't accept liability. Kind of like when they lie to the unemployment people or other authorities. One really has to watch out for oneself.

[mg2312]

For a situation like swimming the way I see it is if the parents are allowing this child to swim, they are going to swim regardless if I'm in the pool or not - so either way it's my responsibility to make sure the child is safe, as I'm the only RN on duty. I am very protective when it comes to water(even while bathing the child.) This kid(4y/o) will make comments in the pool like "let me swim by myself", that's when I nicely tell her I'm going to stay right by you or you don't swim - this way she really doesn't have a chance to go under because I'm right there. Also when I'm there she has to have one of the swimsuits with a built in float.

Like cali said make sure it's within your agency guidelines and document that you had the conversation with your agency.

Some nurses suggest to be by the pool and watch over, that situation makes me totally uncomfortable, esp with siblings in the pool. God forbid she started to go underwater it would take me a lot more time to jump in and go under to get her than if I'm standing next to her the whole time with my hands right there just in case.

I've never been to court for any nursing issues so I don't have experience on the issue, but my thinking is as a PD pedi nurse we are 100% responsible for the child through out the shift, no matter what happens(and as you know these kids manage to get in to a lot!!) So as long as we're there and act within reason I don't see a problem. Without having extensive water rescue training, as nurses it is within our scope of practice to know how to handle any emergency that happens on our shift. CPR/911 etc.. I personally don't see how swimming/water rescue knowledge is different from reacting to any other emergency that may arise in the home setting.