Lack of standard care (new nurse)

LadyFree28, BSN, LPN, RN · Apr 1, 2015

When I worked in Home Health, the companies that I worked for had policy and procedures and a standard of care for most basic procedures; however, if there was a complex issue that did not fit into policy and procedure, there was always room for "nursing judgement" when, within reason, was use and a plan was put in place so that all were competent and on board for the plan.

If there was any confusion that was not related to P&P, I also made sure I informed the pt that nursing judgement can be different, but safe and effective; if it was something that the pt needed to do when there was no nursing care around; I would ask the pt, then get the other nurses involved so that the pt and the family wouldn't get confused; just so we can all be on the same page in order to safely care for the patient.

JustBeachyNurse, LPN · Apr 1, 2015

What are you specifically referring to? Did they do a dressing different than you? Set up an infusion different than you? Are you doing skilled visits (multiple patients throughout the day, for 30-90 minute visits for skilled assessment & care) or shift work (4-16 hour shifts, most commonly with pediatric clients, and most commonly referred to as private duty nursing )?

caliotter3 · Apr 1, 2015

It can be very difficult to get on the same page as other nurses on the case when there is no leadership involved. Ideally, there will be a primary nurse assigned. This person will be the person to set policies and deal with the day to day administration of the case. There will also be case conferences at the hh office, where all assigned nurses can "hash" things out away from the client's home. In lieu of a primary nurse, the clinical supervisor sets the policies and communicates changes to all involved, typically with use of the case communication book. However, you will find that often the nursing supervisor is lax in this regard. Sadly, the client and client's family see this lack of coordination amongst their staff and it sets a negative tone for the relationship with the agency. Then the agency management wonders why they lose cases to other agencies.

superjamiek07 · Apr 1, 2015

I"m not private duty but affiliated with a hospital. I do multiple skilled visits in an 8 hour day and/or admissions, dcs, resumptions, etc. We do have a policy handbook but where there is a discrepancy is where there is an order for a dressing change and wound care using specific orders for how to treat the wound but I have yet to see one of the nurses treat the wound how it's actually ordered to be treated. Or there will be a pressure ulcer with orders of how to treat and one nurse will go in and say no it doesn't need a bandage, then another will go in and say yes it does, and the order says yes it does. The RN with the assisted living is confused as to what she should actually do if the bandage falls off. We also have issues with nurses getting involved in medication management and one nurse will get an order to start one med, another will get an order to say stop that med, and yet another will start it again. As someone who is still learning its very frustrating. How am I actually supposed to be doing this? But maybe this is normal?

Libby1987 · Apr 1, 2015

It could be due to poor communication of the current treatment or why a med was changed, but over time these out of compliance patterns should be picked up in an internal audit.

Ot it could also be due to sub par practices, some nurses can be seen as sloppy compared to a detailed-oriented/thorough/perfectionist type. And patients notice and this can be picked up on internal patient satisfaction surveys. Or they will just flat out tell the perfectionist nurse how the other nurse was less _______ (fill in the blank).

Are you an RN or LVN? Working as the case mgr helps to have more control in directing care amd ensuring orders are current and accurate.

caliotter3 · Apr 1, 2015

Rule of thumb: Do what you are supposed to do, the way your are supposed to do it (follow the order), during your visit, to include documenting how you found things and/or what you are being told is 'different' by the client. If there is a discrepancy, follow your agency policy for reporting this information to the clinical supervisor (follow up in writing, if you call her/him). Do this each visit if necessary. If you find this procedure to be too straining (yes, the extra report writing because the other nurse does it 'her' way will be a PITA), then start the job search. It is almost impossible to change systemic behavior patterns and not worth the worry in the long run.

JustMeRN · Apr 1, 2015

I see a fair amount in variation of wound treatments for clients who are not wound center patients. When it is a non wound center client the field nurses for the most part decide on the dressings, and then tell the doctor what the plan is and get the order. I have found that what a nurse uses for wound care can be extremly varialbe from one nurse to the next, even with the same type of wound. Many of the nurses I work with have been doing home health for ages and wound care is second nature to them. I think the difference in my situation is clients are assigned primary nurses, who generally lay out the plan of care, and generate the orders. Anyone coming in to do a visit has specific orders for wound care. If I go to a visit and someone has developed a new wound I generate the order, or call the physicain, and I treat the wound how I think it should be done. It is not unheard of that the primary nurse will come in after the fact and decide she has a better way of doing it, so she changes the orders and manages it. Nurses who are not case managing generally don't go around changing orders at random or completly ignoring the orders and creating an alternate treatment. And I believe doing wound care without orders is a big no no.

As to the medication things, all I can say is what in the world? That sounds like a lawsuit waiting to happen. Why does the physician keep agreeing to the change. How unprofessional does it look to have multiple nurses from one agency calling asking to stop a med, no restart, no stop, no restart. Doesn't anybody talk to eachother? or read the last visit note to see what the issue was?

Mom2boysRN · Apr 1, 2015

This is why IMO the same nurse should see the patient at each visit unless it's a LPN with an RN sup. That's poor continuity of care which results in very poor patient care.

superjamiek07 · Apr 2, 2015

Thank you, you are confirming what I was thinking and we are working on making sure there is one primary nurse. I feel less lost now as to how I should be doing things. We all of course disagree on how things should be organized lol, but hopefully we can work it out if not, of course I can move on.