New Grad PDN (Advice, please?)

[MissEm]

I just started a new job as a pediatric private duty nurse right out of nursing school. So, I'm looking for advice (and maybe reassurance) for the veterans here.

There have been a few scheduling problems thus far. I was hired on without a clear schedule. (As a matter of fact, I called Monday to ask about when I'd get one and was informed that I was due to work since the family needed me ASAP! Yikes! Luckily, my shift started later in the day.) During orientation, they hadn't received a schedule from the family so it seemed a bit touch and go. However, I was assured it was a 40/hr a week job.

I got there at my scheduled time (as agreed between myself and patient's mother, based off of her work schedule) and turns out, the patient was at an appointment and didn't come home for another hour and a half. So, a short day. Since the patient's mother didn't work on Wednesday, I asked if I'd be needed. I was told that I wouldn't be (at which time I stupidly shared that I preferred that, since I had a family function I'd like to attend in the middle of the day) and assumed it would be my day off.

Next day (Tuesday), I was asked to accompany the patient and family to an all-day appointment at the local medical center. Another short day. I tried to call scheduling and they were out all day. Cue the major anxiety and sleepless night. However, I called my agency and asked about the effect my shortened hours (upon the time their insurance granted them and my job) and was assured that since the patient's schedule necessitated the short hours, it was fine.

Wednesday, I call scheduling and figure that from one to nine, Monday, Tuesday, Thursday, and Friday is what the optimal time would be to care for this child. They call the patient's family to confirm.

Cue the callback, in which I was informed I was expected to work Wednesdays as well, even though the mother doesn't work. I'd get this day off, since I discussed it with them family but in the future, I'd work M-F, 1-9. (It sounded like I was made to look like I asked for this day off, which I suppose is arguable.)

My question is this: do all new cases follow along like this? I feel I was thrown into the water and expected to dictate my hours based on need and what they were allowed. Is that normal? I have to admit that it sounds strange to me, but this is my first job and clinicals took place strictly within hospitals.

Another question: is it normal, in this field, to accompany the child to all of her out-of-home appointments? At the moment, she goes to these appointments with family members, but they expressed interest in my presence there.

I feel like I may look disorganized, and I don't want to present myself in this light. Or is it simply that I'm experiencing the same thing that other private duty nurses do?

Also: My patient has seizures that aren't controlled by medications. The family was instructed by the DR to increase the medication verbally, however the only script that I have has a lower dosage. How do I communicate this while charting?

Please help? I'm feeling overwhelmed. I really like this case, but I feel like a chicken with my head cut off.

[SDALPN]

I wouldn't really call us bring "ruthless", I think we just get frustrated by the fact that new nurses come fresh out of school thinking they know enough to work alone, and don't seem to heed our warning. I mean, we kinda know what we're talking about. If anything should be called "ruthless" it would be the fickle finger of fate, ready to spring an emergency situation on a nurse who's never attended a code or recognized some other situation that warrants immediate intervention.

I spent a year in LTC and every day I was smacked left and right with new experiences and lessons that I never, ever could have imagined in nursing school. I was constantly asking questions to my colleagues and floor ADONs. The first year for a new nurse in a facility should be considered an extra year of nursing school.

Granted, a new nurse would probably be just fine working alone w a stable client and never have a problem. PDN clients are mostly stable. But I've had a few hair-raising, touch-and-go nights with kiddies who were already brittle and then got sick, and I was able to refer to lessons learned in LTC to care properly and intervene appropriately. I can count those scary nights on one hand, but they do happen. And honestly, you don't want to be the nurse on duty when a kid tanks, it's the scariest thing in the world, even w facility experience.

The parents will scare you more than a kid on their way out!

You just don't know til you know. I just recently opened a new case. No important supplies for a vent patient. Would you know what to ask for if you didn't have it? Would you know which battery holds what amount of charge and if it should be tested regularly or left alone? Would you know the proper maintenance of the equipment? How about dealing with a freaked out parent coming home with a kid on a vent? Could you answer the parents questions about different hme's and types of suction catheters? And that's just the first few minutes of opening a case recently. I find it interesting that the experienced nurses new to PDN are more nervous than new nurses. I guess medicaid/medicare must have a reason if they don't allow agencies to use new grads. Nobody is being ruthless. Ask a NICU/PICU nurse how many kids they've had come in because of bad or new nurses to PDN...its very common.

[smartnurse1982]

I think it is ok for new grads as long as you have a supportive agency.

For all i know,your area might not have many employment opportunities for new grads.

What would look better to prospective employers six months from now,a new grad who has worked Pdn or a new grad who has not worked at all?

Start with non complex cases first.

As you go along orient on more complex ones.

I guess i do not see where having Ltc experience would help someone new to peds pdn.

I can't think of one skill that i did in ltc that is similiar to peds and adult pdn.

The trachs are different,charting is different,g tubes are different,etc.

[caliotter3]

When I was a new nurse, new to home health, and new to pediatrics, yes, I didn't know what I didn't know, but I certainly took steps to think of everything I could do to bolster myself; something as simple as gathering the phone numbers of the RN clinical supervisors before I saw what paperwork was available at the home, and taking along every peds text and peds specific drug book my backpack could carry. Did as much homework as I could with the copy of the 485 provided to me. Asked those "stupid" questions, and eventually, I felt more and more confident, as time went on. It would have been better if I had X amount of paid acute care experience under my belt, but that was never going to happen. So I got my feet wet the only way I could.

[cazach0122]

I was/am a new grad who started in PDN (8 months ago) and I do agree, in a way, that it's not the best situation for new grads for the reasons stated above.

However, when you're a new grad and desperate to find work you'll take almost anything... and for me this was one of few places hiring new grads.

Fortunately my agency is very supportive and I was only put with stable patients and competent, knowledgeable families. I've never had any issues but knowing there's always the possibility of a patient deteriorating (albeit small) can be nerve wracking.

[OrganizedChaos, LVN]

I think it is daunting for new nurses to go into PDN. Between the client & the family things can go wrong FAST. I believe it is important to have at least a year of clinical experience before going into PDN. A client may seem stable but the next thing you know, you may have to call 911. Unless you have a really supportive team, most of the time it's hard to get ahold of someone when you really need them. That's when the clinical experience comes in handy. If anything happens, you are alone! No one is there to help you. You need to know your stuff & be confident. I know PDN agencies are hiring new nurses all the time but it is scary.

[CloudySue]

I guess i do not see where having Ltc experience would help someone new to peds pdn.

I can't think of one skill that i did in ltc that is similiar to peds and adult pdn.

Really? You hadn't had one LTC skill carry over to PDN? As I'm sure you know, LTC stands for Long Term Care, a facility for people who are medically fragile but relatively stable, and need daily skilled nursing. PDN is the same exact thing, only in the home setting.

Lots of procedures carry over- initial and ongoing assessments, medication admin, G-tubes, glucose checks, insulin administration, wound care, good sterile technique, trach care, vent care, nebs, proficiency w Hoyer lifts, BiPAPs/CPAPs... I also developed a high tolerance to every unpleasant bodily secretion explosion without batting an eye. Also I got used to calling up MDs who can often be very intimidating. I learned to speak to families, to educate and reassure. I've witnessed codes, I've troubleshooted (troubleshot?) equipment, cracked O2 tanks (and closed them properly), worked w a variety of brands of equipment. I've dealt w emergencies, spoke w 911, reported off to paramedics.

And- although I've had these experiences, I am still always a tiny bit apprehensive of something unfortunate happening for which I might not perform as well as I should. So if a new nurse feels perfectly confident in the home setting, that is a huge red flag that they don't know what they don't know.

Having LTC is experience in a facility establishes good habits in professional practice & good self discipline. When I'm in a private home, often parents want me to cut corners or follow their changes instead of following the doctor's orders. That was the biggest difference I'd observed between my jobs: in an LTC facility, they are always on you to do things correctly. in the home, they're always on you to do things incorrectly. A new nurse may often not have the confidence to "defy" a caregiver, and not yet understand the rationale for doing things as per the MD instead of a person who knows the client well but still has no professional medical background. It's easy to develop bad habits and make mistakes when there's no supervisor or ADON watching your every move.

I present this post w all due respect. I am an advocate of both my fellow nurses as well as the clients. I want BOTH to be safe.

[SDALPN]

It doesn't matter how supportive or how good your supervisor is. Your supervisor isn't the one in the home, you are. If you don't know to call the supervisor, its still your fault when things go wrong. Not knowing is no excuse. Are you going to tell the court when you go that you just needed a job and took what you could get? Does it not concern you that an agency will hire anyone with a warm body and a license? How do you explain committing fraud to your next employer (if you still have a license) when you are caught working PDN for medicare/medicaid with less than a year of experience? I've done hundreds of cases and have seen enough. Some of the people posting and encouraging unsafe nursing may have only worked a case or two that were really basic. But that doesn't give enough experience to understand how bad, bad is when things go wrong. Nobody really understands PDN like a well experienced private duty nurse. Its not what you think at all! Plus most parents don't want you learning on their child. Yes, we all learn somewhere. But PDN isn't the place.

[CloudySue]

If these new grad PDNs heed nothing else, it should be this one thing: make sure you have professional liability insurance. Never trust your livelihood in the hands of your employer or the caregiver, either is capable of throwing you under the bus if it suits them.

[smartnurse1982]

Really? You hadn't had one LTC skill carry over to PDN? As I'm sure you know, LTC stands for Long Term Care, a facility for people who are medically fragile but relatively stable, and need daily skilled nursing. PDN is the same exact thing, only in the home setting.

Lots of procedures carry over- initial and ongoing assessments, medication admin, G-tubes, glucose checks, insulin administration, wound care, good sterile technique, trach care, vent care, nebs, proficiency w Hoyer lifts, BiPAPs/CPAPs... I also developed a high tolerance to every unpleasant bodily secretion explosion without batting an eye. Also I got used to calling up MDs who can often be very intimidating. I learned to speak to families, to educate and reassure. I've witnessed codes, I've troubleshooted (troubleshot?) equipment, cracked O2 tanks (and closed them properly), worked w a variety of brands of equipment. I've dealt w emergencies, spoke w 911, reported off to paramedics.

And- although I've had these experiences, I am still always a tiny bit apprehensive of something unfortunate happening for which I might not perform as well as I should. So if a new nurse feels perfectly confident in the home setting, that is a huge red flag that they don't know what they don't know.

Having LTC is experience in a facility establishes good habits in professional practice & good self discipline. When I'm in a private home, often parents want me to cut corners or follow their changes instead of following the doctor's orders. That was the biggest difference I'd observed between my jobs: in an LTC facility, they are always on you to do things correctly. in the home, they're always on you to do things incorrectly. A new nurse may often not have the confidence to "defy" a caregiver, and not yet understand the rationale for doing things as per the MD instead of a person who knows the client well but still has no professional medical background. It's easy to develop bad habits and make mistakes when there's no supervisor or ADON watching your every move.

I present this post w all due respect. I am an advocate of both my fellow nurses as well as the clients. I want BOTH to be safe.

I have never worked on vents in ltc.

The ltc places around here don't have vent pts.

I also never changed a gt in ltc.

I think the main differences for me are that Pdn is mostly peds while ltc is mainly elderly adults.

Most meds given in ltc through the gt are via gravity flow,while its mainly pushing for peds.

The Rn's(i was an lpn at the time) changed the trachs.

I still do not see why a new grad can't start off with non complex cases like a kid with a gt.

My agency gives new grads 6 weeks orientation,and i had more orientation in homecare vs ltc(three days for ltc)

[OrganizedChaos, LVN]

At lot of agencies won't orientate a new nurse for that long. Even though it might not be a "complex" case, anything could happen. There's a reason they have PDN. If/when something happens, you are all alone & better be confident in your skills & charting. The family may seem to be your best friend, but it is inevitable is that they will only be out for themselves. Same with the agency. The agency may seem perfect but who's gonna be on your side should the proverbial poo hits the fan?

I worked with gtubes & did a lot in LTC. I never worked with a trach but I knew how to deal with a lot prior to PDN.

[RetrieverGirl, BSN, RN]

I also applied for my independent provider number through the Department of Medicaid in the State of Ohio to work as a private duty RN. I have been an independent PCA in home health health for 4 years now. I intended to do home care on the side, but I am struggling to find my first job as a new graduate.

[RetrieverGirl, BSN, RN]

It doesn't matter how supportive or how good your supervisor is. Your supervisor isn't the one in the home, you are. If you don't know to call the supervisor, its still your fault when things go wrong. Not knowing is no excuse. Are you going to tell the court when you go that you just needed a job and took what you could get? Does it not concern you that an agency will hire anyone with a warm body and a license? How do you explain committing fraud to your next employer (if you still have a license) when you are caught working PDN for medicare/medicaid with less than a year of experience? I've done hundreds of cases and have seen enough. Some of the people posting and encouraging unsafe nursing may have only worked a case or two that were really basic. But that doesn't give enough experience to understand how bad, bad is when things go wrong. Nobody really understands PDN like a well experienced private duty nurse. Its not what you think at all! Plus most parents don't want you learning on their child. Yes, we all learn somewhere. But PDN isn't the place.

How is it Medicare/Medicaid fraud to work as a PDN with less than one year experience as a nurse?