Low acuity patients when traveling

weirdscience · May 21, 2015

At my hospital you have to certify to take these devices. Usually if you've had them before, it's just a buddy day so they can check you off for competency. Have you talked to the charge(s) about what you've done, and asked for more critical patients?

Also, if you're not at the same hospital consistently, I imagine you may continue to get the step-down patients. It's hard for the charge to keep track of which traveler has which skills, especially in an ICU with a large staff. I do think it's the norm, at least in my ICU, for travelers to get the lower acuity patients.

Argo · May 21, 2015

your a traveler, if you want those patients I am sure the other staff does too. If you don't want the ones your getting, I am sure the other staff don't either. The hospital staff will get the choice of assignment first, if you want those luxuries you will have to be staff again....

Bluebolt · May 22, 2015

My counter argument to the two similar perspectives you both offered would be that by keeping your travelers with constantly low acuity transferring patients you are reducing the effectiveness and use of your well paid travelers. I have told the charge nurse and management that I'm well trained on these specialty devices and would be comfortable taking them.

I understand that first priority patients go to staff, as it should be, but usually if you have one high acuity patient they will give you one low acuity to balance it out. Instead they give two high acuity patients to the staff (potentially dangerous) and two low acuity to the travelers (boring and mundane).

Another issue with a facility doing this is that if you don't train your travelers on your protocols and drip titrations (etc) then what happens when one of your low acuity patients goes bad and you're unfamiliar with what drips to start, highs and low limits, do they do routine wedge pressures?, what advanced vent modes should I be on? (this situation actually happened last week). Management and the charge nurse was all worried and in my room because they realized my patient was crashing and I hadn't been trained on which pressors they start first, what sedation do they usually push, how often to draw ScVO2's, etc. All my patients had been stable transferring out patients and didn't have the experience in their facility to function in the role I needed to function.

Another example was a nurse got sick a few days ago and wanted to go home, well I only had one patient and could have picked up hers but because the patient was high acuity they debated about making the sick nurse stay!

So as you can see by never giving the competent and educated traveler orientation and time with at least some of your high acuity patients the facility is just shooting themselves in the foot. Of course this is just my opinion from life experience.

PacoUSA, BSN, RN · May 22, 2015

There is also the issue of the traveler getting accustomed to the routine of the unit, even weeks into an assignment, like where things are and remembering codes for doors and stuff, which in some ways bites into the acuity of the traveler's assignment. That has been my experience anyway. I mean, I have been grateful for lower acuity patients when I still am trying to figure out who the doctors are I need to contact to change orders. But I know what you are saying, you want to keep up your skills. Perhaps you are a more seasoned nurse than I am, as I am only 8 months into traveling and still sometimes feel like a new grad looking for where the supply room is on each unit, etc. Nursing is nursing tho, that is not my challenge, its getting used to the new environments and charting system. I am in a float pool, which is an extra element of adjustment to a new hospital but I guess I enjoy the challenge of that (for right now and the next 10 weeks). But by the time I have a hang of it, I am ready to go. By the way, I have decided I dont exactly love floating every day. I prefer a home unit with the occasional floating so hopefully my future assignments can be geared that way.

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Bluebolt · May 22, 2015

I agree that the first 3 to 4 weeks of your assignment should definitely be lower acuity patients. You need time to adjust to the flow of the hospital, where your resources are, codes to doors, supply room stock locations, personalities of co workers, etc. I feel like after that 3 to 4 week adjustment where the staff and management have had time to evaluate you they should bring on medium to higher acuity patients.

As for this trend I'm seeing of travel nurses being put into some massive non descript "float pool", I dislike it as well. I'm currently on contract at a large hospital that has an ICU float pool with 6 different ICU's totaling 84 ICU beds. Learning 6 different units, policies and ways of doing things, typical patient populations, charge nurses, MD groups that round there, stock rooms, codes for everything, phone numbers.... it's ridiculous. To make things 300% worse, they will also pull these ICU floats out onto medical floors where they can give you up to 4 patients. So then you have to learn a complete different style of nursing, MORE codes to doors, phone numbers, MD's who round, policies and procedures, meds you can/can't give on the floor, etc.

I've worked in 4 hospitals in the last 12 months and this is the first that suggested the traveler float to almost everywhere in the hospital even if the traveler had no background or training/orientation in that area. I won't be taking a contract like that again.

wanderlust99 · May 23, 2015

Yep. I learned as a traveler to avoid any ICU float position because the majority of hospitals will float you to tele. I worked one where I floated 75% of the time to tele, it was pure hell. This same hospital would then put me in the CVICU and give me heart transplants and other really high acuity patients when I have very little cardiac experience. Then other days I would float to the neuro ICU, where they would give me low acuity patients and in report nurses would say "do you know what mannitol is?" even though I have more neuro experience than the majority of the staff. Frustrating to say the least!

It's just part of the crap you deal with as a traveler. Though I do feel strongly I am a better nurse and gained more expertise working as a traveler all these years than I would have as staff somewhere.

Argo · May 23, 2015

That is a beauty of working OR, there isn't much floating outside of the dept. In the dept I am competent and comfortable in any service line so it doesn't matter to me what I do day to day. The manager knows this and has a fairly young/inexperienced staff so she uses me more as a resource person for all of them to learn from.

shoegalRN, RN · May 23, 2015

I have found this to be true as well being a traveler working in the ED. I usually work trauma centers, I have TNCC and ATCN as well certified with doing EJ's, art and fem sticks. I am also Triage First trained as well and I do SANE. The trauma centers I usually work requires travelers to have TNCC and PALS but will not allow travelers in traumas. It was ok for the first two assignments because I didnt know the trauma teams, nor the trauma policies for those facilities. If I didnt have my home job in my level one teaching facility that I work in between assignments, I would have lost all my trauma skills.

I have learned that in traveling, specifically in the ED, you are either given the most sickest patient (ICU hold waiting on bed assignment), or you are given the psych holds waiting on placement. There was an assignment I completed where they started putting me in the critical area towards the end of my assignment. They asked if I wanted to extend if I would be willing to continue to work in their overflow trauma and critical area. I declined.

When I interview for an assignment, I will ask how many patients are holding in the ED and does that facility uses travelers to take care of those patients. I will also ask what is expected of the traveler in relevant to the skills they are requiring of the traveler.

Ruby Vee, BSN · May 28, 2015

Staff gets first pick of the "interesting patients." Travelers get first crack at the chronic patients. That's the way it's been everywhere I've ever worked, as staff or as a traveler.

weirdscience · May 29, 2015

Bluebolt, I see your points and I'd be scared of losing my skills, too. But it's the reality where I am...including making the travelers float more often (usually staffing our step down units.) I don't know what the answer is.

Budget wise, I know we have to have a certain number of patients in order to buddy someone with a trainer so they can get checked off on a device. I can see why they wouldn't pay to buddy travelers if they are only staying for 13 weeks or so.

catholicrn · May 30, 2015

Yep, try getting a contract in ICU and being floated to MED/SURG a.k.a. "THE FLOOR" with 5 patients...EVERY shift!! Yep, that's right....start with 3, admit 2 from ER, discharge 1 and then get a transfer/direct admit. You can bet I'm worried about losing my skill set. Meanwhile, I'm getting schooled and raked over the coals most mornings when reporting off to the dayshift regular staffers....wanting t know why I hadn't called the MD on a K+ of 3.4 for replacement...WHAT??? I would never call a doc for that unless it was critical...well, it's an unpublished expectation of the day shift nurses...on the floor, mind you. No CNA at night (11p-7a) but they have them on the other two shifts. The traveler does 12's while staff do 8's...worst place ever....