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CCL"Babe" 3,795 Views

Joined: Feb 9, '03; Posts: 309 (7% Liked) ; Likes: 33

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  • Nov 14 '12

    I, too, am new to clinical teaching. What I have done in preparation for teaching is make up index cards with different questions related to the topic. Each student gets a card and is encouraged to answer, but if they are unable, the question then goes to the group. We have had some great discussions! The students look forward to our question/answer time. I usually use it as an ice breaker (at least, for me!)

  • Nov 14 '12

    I think that anyone can come here to vent and receive support. The main difference I enjoy here is that this is a flame free atmosphere. This means we are free to disagree with anyone on any type of subject matter as long as your criticism is constructive and polite. It's why I love allnurses.

    We have all worked with colleagues that are less than desirable or are less than the acceptable standard and know that any attempt to intervene will lead to personal grief and possible retaliation with passive aggressive/aggressive intimidation tactics (lateral violence) to influence and intimidate the reporter into silence.

    I would try to give the students all the support I could. I would, but then again I can never keep my mouth shut, have a "talk" with the director about the concerns I have........ or the things I have noticed and been told to me by the students....and ask for guidance on how to proceed.

    I would also remind my students that there will always be those individuals in life that are not what they should be or not that way we would like them to be......that aren't unsafe in practice but they certainly are not the best......but that is life and you need to learn how to negotiate the rough waters.....and make waves when necessary. That this too shall pass.

    OP....... I wish you the best.:wine:

  • Nov 14 '12

    Quote from MarcyRN
    Hello, all.

    I am to start a new hospice case manager position in a few weeks, and am freaking out a little bit inside. Looking for your thoughts on a bunch of questions...[SNIP]

    Oh, one more thing...what's your favorite thing about being a hospice case manager?
    Great questions:

    1. What I LIKE to wear is business casual. Draws less attention, more comfortable, doesn't scream NURSE. What I DO wear is scrubs. Both have their advantages.

    2. Worst part of the job: the paperwork is bad, but I really hate lots of driving because some scheduler made promises without considering your day. I hate night admissions because the attending physicians are so hard to find. Dishonorable mention: working with Assisted Living Facilities.

    3. SNF/ALF: it takes a good amount of work and the occasional pizza or cookie bribe to get on the good side of a facility staff, and even then, it may not help much. SNFs can be really cool and treat you like family, or they can be openly hostile. Get to be special friends with the wound nurse and the DON. If they love you, you can do no wrong. Any LPN/LVN charge nurse might resent you. I ALWAYS emphasize that we're all in this together and we're all nurses. We need to support each other. I offer help with studying for classes, I let the techs know that I appreciate the work they do, and I make an effort to not throw anyone under the bus. I had some of the best and worst times in Rhode Island, where hospice nurses could only provide recommendations and the facility nurse had to call the doctor about them. I've had orders modified by the LPN charge nurse because she thought I was "wrong" about my pain assessment. You're usually less likely to find the facility MD than if you call the attending MD for a home patient. And of course, in a facility, nothing is urgent. Unfortunately, shifting from facility to home patients can be a big mental leap so I'd rather have all SNF/ALF patients than a mix of facility and home patients.

    4. Caseload: worst place I worked was a major university health system hospice with 18-24 patients. That was hell. Best case loads were in the 9-12 patient range. Practically speaking, 12 patients a week comes out about right if your typical patient has a frequency of two visits a week.

    5. A visit should last as long as it takes to execute the plan of care. Remember you give care to the patient and the family. I always chart when supportive communications or even supportive presence are provided. Sometimes silence is a tremendous tool for helping the family feel that they are not alone. Your manager may fuss about a lot of long visits, but I try to get the vitals and review of systems done quickly so that I can just chat with the patient. It's amazing that the less rushed you seem to be, the faster they get to the real issues that they don't think to mention when you first arrive. People need time to verbalize difficult topics. After a while you'll get a sense when something is not right with a patient; its nothing magical, just spotting small changes. I like systems where they try to keep to two visits per week, because the second visit can be more focused. It also allows you to do an in-person tuck in. If you don't do a second visit, make it a priority to check in on Friday to make sure that all is well for the weekend. The on-call nurse will thank you.

    My favorite thing about being a hospice case manager is seeing the tension leaving the patient and family, so that they can actually use the remaining time to bring closure and celebrate a life well lived.

  • Nov 14 '12

    Thanks so much for your response, SCLPN! I should have clarified in my original post: I am an ICU nurse on a cardiac ICU, but I went to nursing school to work in hospice. I have finally landed my (I hope), dream position with a hospice agency. It's NOT because I need a job -- I am leaving a pretty great job for this one. Hospice is definitely my passion. Way more than cardiac nursing, for sure. I read anything and everything I can get my hands on about hospice, the dying process, etc. I just hope I'm cut out for it and have what it takes to be awesome at it. Thanks again for being the only one to respond to me! :-)

  • Nov 12 '12

    I just thought that I would let everyone know that the Lord allowed me to pass the ANCC exam yesterday. Thank you Jesus. I was not even half way through the exam and knew that I had failed it. I even randomly guessed at the last few marked questions. I went out and told the lady who gives you the results that I know I failed it. I told her it was the hardest test ever and she turned and told me " well according to the results, you passed it. I got all tore up. started crying. Thank you friends for your support.

  • Nov 3 '12

    Hi guys , I have been there and done that and wrote the book, lol. I know your pain. It was not that long ago seeing as how I graduated in May. This will be over before you know it. And yes, it is worth it! It has been worth it for me so far. Its a wealth of knowledge, but you will see the same stuff over and over and over again once you start working. You are forced to remember what interacts with what and what the indications and contraindications are for your patients. I have literally seen 100s of pts now and I can remember what I did and why every time I see them again or someone brings me back the chart. It all comes together. You are not gonna have to study like this once you get done. You can study the things that actually matter and leave all the fluff in school. Just grin and bare it for now. I know its not easy, and I am glad it was a challenge because if it were easy everyone would do it. Believe me, you can do it. You will be surprised at what you can do if you push yourself. Just walk the days down, you will look up and be a board certified NP and helping to change lives. Best of luck! You got this I have faith

  • Nov 3 '12

    On the first day of my bar review course the instructor said there are 3 levels of knowledge on a subject. Level 1 is the novice, they know just the tip of the iceberg and feel like they really "get" what they learn because they have no clue about how much they don't know. Level 2 is the intermediate level of knowledge, where you know how much you don't know and feel completely overwhelmed by it all. You have no confidence in your knowledge, because you feel like there is just too much that you don't know or understand. Level 3 is the expert, by this time you fully know your main area of content, have confidence in your knowledge and it's easy to assimilate and learn new information, because of the strong base of knowledge you already have. He then went on to tell us that we will be in a "level 2" when we take the bar exam, and that we will not feel like we know enough to pass. However, we need to just learn to accept that and study every day for the next 2 months and we will pass.

    I too am nearing the end of my NP education and feel very similar to you. It is insane how much information we are supposed to know, but I just keep remembering that I am not yet an expert and that it will get better. I just need to get through school and pass boards and things will continue to improve every year after that. The feeling of being overwhelmed will eventually go away. It's just going to take a while yet. Oh and I love your firehose analogy, that's the picture that is going to be in my head the next time I sit down to read my homework, lol!

  • Jul 14 '11

    It may sound good now, but telephone only case management is BORING. Beware being bored, as a nurse you will find that is only nice for about a year. I know, I spent 2 years at Blue Cross on the phones. It is way better to do home visits.

  • Jul 14 '11

    There is no simple answer, because quite frankly it changes with every different doctor and personality. The relationship can vary GREATLY. Here are a few different types of docs:

    1) They value your input and ability to care for the patient.
    2) They tolerate you, but aren't sure you are necessary.
    3) They don't even know you exist.
    4) They believe are a stooge of admin sent to question their medical judgement.
    5) They purposely avoid you and try to undermine you with the other docs.
    6) You are the first person they turn to when in a bind.

    I believe I can work with these 6 different docs all in a single day.

    Do they respect CMs? I feel that if you poll the majority, the honest answer would be "no". More like most "tolerate" us in the same vain that they "tolerate" the paperwork.

  • Jul 1 '10

    To the OP, I think your question has been answered. Also, you have probably figured out that instructors are not immune to giving out bad information. I'm sure she is very knowledgable on a lot of nursing subjects.

    Also, one probing question is appropriate but most instructors will feel they are being attacked if you question the validity of their information. It's best to just seek another source so that you know the correct information. In my opinion, it's not worth the pain and effort to correct an instructor who feels their authority is being threatened.

    Side note. In my classes I missed a test question because the instructor defined an attenuated vaccine as containing dead virus. Attenuated is a live virus but I couldn't win the arguement because she made the rules. I just know that if I was facing two outcomes from a procedure I'd prefer to be attenuated than dead.

  • Jul 9 '07

    Quote from earle58
    another thing i have noticed about those suffering w/cp is many are extremely anxious. even if their current pain level is tolerable, they become anxious in anticipation of returning and more severe pain levels. because of these anxieties, all sorts of behaviors are manifested. i'd like to see more of this population receiving prn anxiolytics when hospitalized. and of course, the concept of a pain specialist on board, would be heaven....for staff and pts alike.
    but in the meantime, docs/residents need to become more educated in managing these people.
    Exactly! Too often, we are not appropriately medicated while inpatients. While the responsibility for this lies at the feet of the MDs, it is the RNs who we see all day and who may bear the brunt of our disdain and anxiety. I can't speak to what things are like in Nursing elsewhere, but here, the cutbacks have killed real patient care and I'm glad I am not working anymore. Our Nurses have a growing number of patients to care for and the charting is horrendous! I've seen meds delayed by pharmacy SNAFUs, waiting for an MDs order, the RN being on a break and his/her relief being unavailable or an LPN on duty who can't give the meds. While in Rehab, I had to get special permission for Mom, who is an IDDM to have her meds at her bedside because she was regularly getting them hours late. If she weren't an RN herself, it would have been a real problem. Most patients have experience in dealing with these situations and this greatly increases our anxiety. I have actually had an RN tell me that I didn't need to be on the dosage of meds I was on and take it upon herself to try and change my script. The Doc didn't agree, thank goodness. Anxiolytics might be a good idea, but all too often we have a hard enough time just getting the emds we absolutely need, never mind tying to add another one.

    Quote from DutchgirlRN
    I know I don't let my feelings show. I have a legal and ethical obligation to give them their pain meds as ordered by their physician. If the patient feels I'm acting indifferent it's more likely because they have a guilty conscious.
    I don't have a guilty conscious. I am far too experienced and educated to suffer such. I don't mean to single you out, rather to point out that you keep going back to "a legal and ethical obligation". To me, this seems to indicate that while may you disagree with the dosing of CPers, you do so because it's required and NOT because you believe it will help the pt. There is a big difference between doing what you must do and doing what you believe is right.

    Quote from Warpster
    Chronic pain patients are used to being treated like scum, one level above a shooting gallery habitue. They will be anxious about getting their meds on time because there will be consequences. You will therefore see drug seeking behavior. However, they are in pain. They need medication.
    Even a short delay can allow for the pain to get out of control and then a larger dose of meds might be required to get it back under control. Since that "bolous" nearly never gets written, we suffer for it. Most CPers know their pain intimately and can tell when the meds are beginning to wear off. Then, they begin getting anxious about receiving the next dose. When at home, this is in their control, but while impatients, all of the control is taken from them - thus, the anxiety.

    Quote from vamedic4
    No, but breakthru pain...even for a chronic pain patient....IS. And as providers we have to remember that. Sometimes even patients with chronic pain problems have breakthru pain ..whether it's related to their chronic pain or not - and yes, the ER is occasionally the best place to have it controlled. Why? Because it's open when the doc's office isn't. Because at 3am you can't go pick up a script for Actiq. And more importantly, because there might be something much more sinister just under the surface that's causing this episode of breakthru pain - and it needs to be diagnosed and the ER.
    Ideally, this is quite true. However, in reality, it doesn't always work well. It's been years since I worked ER, but then, most of the Docs & RNs alike were put off by the "drug seekers". Generally, they operated in CYA mode and all too often fell back on the old excuse of "not masking the symtpoms". When I was Dx with Crohn's, even after they had ruled out a surgical belly, I had to beg to get something to give me enough relief to get a nap and I worked there! I was obviously not a junkie and had not yet begun my pain treatment, so I was not on any meds at all. I would like to think that this has changed, but inconversations I've had with other patients, I've been led to believe that it hasn't.

  • Jul 9 '07

    OK, this one pisses me off no end because of all the misconceptions in the OP.

    First, chronic pain patients, and I am one, do not get a buzz off the meds we are on. We do not enjoy them and we hate the side effects. We are not on meds because we are gaming the system. We are on them because we have longstanding, serious pain. Untreated pain leads to things like social isolation and depression. Chronic pain KILLS as isolated and depressed patients just want it all to end and take their own lives.

    Second, these people are not addicts. They may be dependent on those powerful drugs, but they follow their prescriptions, they don't experience addictive cravings, and they are not going to boost your car radio upon discharge. They are people whose brains make inadequate endorphins and enkephalins to cope with physcial illnesses and must be on pain medication to compensate so they can lead functional lives. Calling these people addicts is like calling insulin dependent diabetics addicts.

    Chronic pain patients on a boatload of meds do present a pain management problem postop. You will be giving them enormous doses of opiates, doses you are sure would kill a normal person. However, this is what it will take to manage their pain, and managing their pain is your JOB, isn't it? Save the lectures for church.

    Chronic pain patients are used to being treated like scum, one level above a shooting gallery habitue. They will be anxious about getting their meds on time because there will be consequences. You will therefore see drug seeking behavior. However, they are in pain. They need medication.

    My advice is to check your drug phobia at the door and try to get these folks through whatever they came in for to the best of your ability. They didn't come in for a drug lecture. They came in for surgery or other compelling reasons.

    /Rant off