new grad, PDN, and experience for the hospital

SDALPN · Sep 20, 2013

I'm currently working PDN & I'm fighting for hours. I keep bugging the company for hours & cases hoping for full time & nothing. So it leaves me searching the internet & newspaper for a possible full time job. Also when I went to the homes for orientation - hah! I was there for 2 hours! I was told to not be there any longer! Good luck! :)

Very typical. Let me guess...when you were hired, the agency told you they have plenty of work and that they will give you orientation.

I don't think people really understand that it can be cutthroat until they are in the situation.

OrganizedChaos, LVN · Sep 20, 2013

Well I applied for a PRN position but that case turned sour so then I talked to them about a full time case/full time hours. It never happened & I applied with another company doing skilled nursing visits. With both companies I don't even pull in full time hours.

eeffoc_emmig · Sep 20, 2013

You most likely won't get adequate training. You will get a day with the pt if you are lucky and then you're on your own. Also, in pediatrics, the kids crash faster. There is no time to think about staying calm and to think if what steps to take. Hospital nurses also do PDN. So if you work with them and something happens, they will remember that when you try for the hospital job. The reason the agency wants to assign you to multiple patients is not what they are telling you. The real reason is that they can use you for what works for them, not for you. The culture in PDN isn't what you think. You will be fighting other nurses for hours. The agency can and will book two nurses to the same case to make sure its staffed and silo leave you and the other nurse to work it out.

Oops, hit send before I was done.
The acuity is no different than ltc. If the pt is unstable, they are sent to the ER.
The agency sounds like they are playing you already. That's typical of them as they are usually desperate for warm bodies. The office workers don't care about you're license and just want to make their bonus.
With medicaid/medicare, they require the nurses to have a year if experience. If they find out you don't have that year of experience, they can charge you with fraud.
Sorry, but people hate the truth and would rather be comforted with untruths. Read through the PDN forum and how agencies really are. Good luck.

SDALPN is absolutely correct! Couldn't have explained it better.

witty_online_moniker · Sep 20, 2013

You most likely won't get adequate training. You will get a day with the pt if you are lucky and then you're on your own. Also, in pediatrics, the kids crash faster. There is no time to think about staying calm and to think if what steps to take. Hospital nurses also do PDN. So if you work with them and something happens, they will remember that when you try for the hospital job. The reason the agency wants to assign you to multiple patients is not what they are telling you. The real reason is that they can use you for what works for them, not for you. The culture in PDN isn't what you think. You will be fighting other nurses for hours. The agency can and will book two nurses to the same case to make sure its staffed and silo leave you and the other nurse to work it out.

I've been offered positions with two different agencies. The first offers two days of in-office training, a day of orientation to the case and then they turn you loose. The second agency has you do two days of shadowing/assisting right off the bat, THEN you go through several days of in-office training and a ventilator class taught by the equipment company before you begin orienting to specific clients. I was told that the number of shadow shifts was unlimited and that they didn't have a new nurse work alone with a client unless both the nurse and the client were comfortable with the RN's ability to provide appropriate care. I'm sure that there is a limit at some point -- if it takes you 20 shifts to get comfortable taking care of a single patient, that would obviously be a concern. The first agency is a larger company, the second agency is a small, family-owned company that currently has a waiting list because they don't take on more clients than they can comfortably staff.

Oops, hit send before I was done.
The acuity is no different than ltc. If the pt is unstable, they are sent to the ER.
The agency sounds like they are playing you already. That's typical of them as they are usually desperate for warm bodies. The office workers don't care about you're license and just want to make their bonus.
With medicaid/medicare, they require the nurses to have a year if experience. If they find out you don't have that year of experience, they can charge you with fraud.
Sorry, but people hate the truth and would rather be comforted with untruths. Read through the PDN forum and how agencies really are. Good luck.

No need to apologize, I found your post informative, albeit slightly discouraging as a new grad who isn't related to someone who works at a hospital.

I wasn't aware that medicaid/medicare required nurses to have a year of experience. I'd love a link to where that is spelled out, if you can direct me to it. Is it specific to home health/private duty? With Medicare patients being everywhere, how on earth do they get around this at places that DO employ new grads, such as nursing homes? After looking through the information I have on the second agency and searching Medicare's website for them, it appears that they may not be Medicare-accredited. They are accredited by another organization, I just didn't think to write it down when I was in the office the other day. The first agency I got an offer with *is* a Medicare-approved HHA.

You have definitely given me some food for thought. My gut sense was that the second agency has a much different culture than most of the agencies that I've been reading about, including ones like the first agency that offered me a position. However, if I do accept the offer - which I may need to do out of necessity at this point - I will be sure to stay in observation mode for as long as it takes. I value my license and education too much to put myself in an unsafe situation. I feel like a 1:1 situation where I am very familiar with the client's condition and baseline assessment data is a heck of a lot safer than a 1:30 ratio in a nursing home where I'll barely have time to do a proper assessment before giving meds, much less dig into the patients' charts for a complete picture. As much as I need to a nursing job RIGHT NOW, I'm not going to stick with a job where I'm inadvertently committing Medicare fraud or work for an organization that puts me in a situation where I'm in over my head or screws me over as an employee.

I wish I could get straight into hospital nursing (or another field that is "better" for a new grad) and not be in a position where I'm taking a job that you're cautioning me against, but it's just not happening with my ADN and lack of healthcare experience. I have some reservations about starting in a field that is notorious for hiring any warm body, but I honestly don't know where else I am going to get experience as a new grad.

Sorry to hijack your original thread, OP. :sorry:

SDALPN · Sep 21, 2013

I've been offered positions with two different agencies. The first offers two days of in-office training, a day of orientation to the case and then they turn you loose. The second agency has you do two days of shadowing/assisting right off the bat, THEN you go through several days of in-office training and a ventilator class taught by the equipment company before you begin orienting to specific clients. I was told that the number of shadow shifts was unlimited and that they didn't have a new nurse work alone with a client unless both the nurse and the client were comfortable with the RN's ability to provide appropriate care. I'm sure that there is a limit at some point -- if it takes you 20 shifts to get comfortable taking care of a single patient, that would obviously be a concern. The first agency is a larger company, the second agency is a small, family-owned company that currently has a waiting list because they don't take on more clients than they can comfortably staff.
No need to apologize, I found your post informative, albeit slightly discouraging as a new grad who isn't related to someone who works at a hospital.
I wasn't aware that medicaid/medicare required nurses to have a year of experience. I'd love a link to where that is spelled out, if you can direct me to it. Is it specific to home health/private duty? With Medicare patients being everywhere, how on earth do they get around this at places that DO employ new grads, such as nursing homes? After looking through the information I have on the second agency and searching Medicare's website for them, it appears that they may not be Medicare-accredited. They are accredited by another organization, I just didn't think to write it down when I was in the office the other day. The first agency I got an offer with *is* a Medicare-approved HHA.
You have definitely given me some food for thought. My gut sense was that the second agency has a much different culture than most of the agencies that I've been reading about, including ones like the first agency that offered me a position. However, if I do accept the offer - which I may need to do out of necessity at this point - I will be sure to stay in observation mode for as long as it takes. I value my license and education too much to put myself in an unsafe situation. I feel like a 1:1 situation where I am very familiar with the client's condition and baseline assessment data is a heck of a lot safer than a 1:30 ratio in a nursing home where I'll barely have time to do a proper assessment before giving meds, much less dig into the patients' charts for a complete picture. As much as I need to a nursing job RIGHT NOW, I'm not going to stick with a job where I'm inadvertently committing Medicare fraud or work for an organization that puts me in a situation where I'm in over my head or screws me over as an employee.
I wish I could get straight into hospital nursing (or another field that is "better" for a new grad) and not be in a position where I'm taking a job that you're cautioning me against, but it's just not happening with my ADN and lack of healthcare experience. I have some reservations about starting in a field that is notorious for hiring any warm body, but I honestly don't know where else I am going to get experience as a new grad.
Sorry to hijack your original thread, OP.

You really do sound like you are trying to make a good choice and that you are doing your homework. Its a tough place to be in. The one year rule applies to PDN, not LTC. I'm on my phone so its a pain to download the pdf files and try to post it. But it is a requirement. I'd be careful about taking too much time to orient because the agencies don't view that well. The vent class from the equipment company is a basic class to get you started, but there is soooo much more to know. I would suggest waiting to do a vent case until you are comfortable doing trachs. I know one company here has RNs working CNA cases to get their year of RN experience as silly as that sounds. Then the RN moves to a nursing case after a year. Also, its the time of year for flu shots. I've heard that they hire with no experience for that. Also check out some other posts on this site from new grads having the same problem.

I have over 10 years of experience in healthcare and I'm still intimidated at the thought of LTC! I worked in a nursing home as a CNA for 2 years and there is no way I could do that again or as a nurse.

witty_online_moniker · Sep 21, 2013

You really do sound like you are trying to make a good choice and that you are doing your homework. Its a tough place to be in. The one year rule applies to PDN, not LTC. I'm on my phone so its a pain to download the pdf files and try to post it. But it is a requirement. I'd be careful about taking too much time to orient because the agencies don't view that well. The vent class from the equipment company is a basic class to get you started, but there is soooo much more to know. I would suggest waiting to do a vent case until you are comfortable doing trachs. I know one company here has RNs working CNA cases to get their year of RN experience as silly as that sounds. Then the RN moves to a nursing case after a year. Also, its the time of year for flu shots. I've heard that they hire with no experience for that. Also check out some other posts on this site from new grads having the same problem.
I have over 10 years of experience in healthcare and I'm still intimidated at the thought of LTC! I worked in a nursing home as a CNA for 2 years and there is no way I could do that again or as a nurse.

I'm usually a quick study, so I could see wanting at least two shadow shifts for a new client -- one to get the basics, the second to fill in the gaps and be able to ask specific questions. I'd expect that during a second shadowing shift, I'd be the primary caregiver and the other RN would be more of a resource. Maybe a third partial shift if the case is especially complex, but yeah, I totally get that needing an extended orientation would be a red flag on both ends.

Do you mind sharing specifically what it is about vents that makes them so challenging? Is it understanding how they work? Troubleshooting? Knowing that you'll have to manually bag a patient if the ventilator isn't doing its job? Turning the dang thing on? I'm curious to know what you found to be the steepest part of the learning curve. Other than the lab mannequin, I didn't have much exposure to trachs in nursing school, so I'm already a little bit intimidated by that. I know that once I see/deal with a few actual trachs and get some hands-on practice that I'll be much more confident with my technical skills. If I take the job, I'd love suggestions for things to brush up on before I start.

Would you believe that even the flu clinics around here want you to have paid clinical experience? Seriously. :facepalm: I have yet to see a flu clinic posting that is new grad friendly, though to be fair, I haven't been looking that hard.

Sorry I just keep on hijacking, OP....hope you don't mind the side convo!

clearblue3 · Sep 21, 2013

Of course I don't mind! :) Everything you ladies have been talking about has been interesting to read! So tricky being a new grad, isn't it?! What I wouldn't give for an "in" at one of the hospitals around here. Keep me posted on what you decide to do!

ventmommy · Sep 21, 2013

There are numerous alarms on the vent. You need to know what each of them could possibly mean and how to identify and correct the problem. If you don't have a vent with integrated PEEP, you need to know how to set PEEP and troubleshoot it. You need to know how to change a circuit and then test for air leaks WHILE BAGGING YOUR PATIENT (because your circuit could crack while you are out alone at a park, in the car, at home alone). You should know what all the outputs are.

For trachs, you need to know routine care, routine changes, emergency changes, suctioning, how to use a nebulizer with trach/vent, how to manually ventilate, how to perform CPR, the different kinds of trachs.

SDALPN · Sep 21, 2013

What ventmommy said. Also, I think nurses should know the formulas to figure out vent settings. Otherwise, how do you know the orders are appropriate? I've found wrong orders by doctors and caught them. When I worked the equip side, I went to help a nurse doing PDN. He set the tidal volume to 900 on a 6 year old with one lung!!! I reported him to his agency for that one. You should be able to understand what the vent is telling you about the pt. Would you notice if the trach came out, but the pressure alarm didn't sound because the trach was sitting just right to maintain pressure within the normal parameters? Vent malfunction? Power failure? The vent has internal settings. Most equip companies won't teach that in their class. I had a parent call me while working in DME and say the vent wasn't working. Turned out that the RT didn't check the internal settings before swapping vents. The pt had been in respiratory distress until I got the call. Most newer vents record all events with date and time. If you aren't accurate charting and something happens, the vent will tell on you. The vent records the buttons pressed.

Some of the stuff above just can't be taught in a day. And the things that aren't everyday events are hard to teach unless they happen.

ventmommy · Sep 21, 2013

If you have a patient with a back-up vent and an old trach after a change, hook up the trach to the vent and see how it DOESN'T ALARM for low pressure which will prove how a patient can be decanned with nothing alarming until he/she desats.

I agree with knowing what every number means and the formula behind them. If you get orders for that PIP should be between 33 and 35 and PC is set to 10, you should know there is a problem because PEEP should NOT be 23.

f, Vte, VE, I:E, PIP, MAP and PEEP that scroll are OUTPUTS, not settings. (I hope that's all of them, it's been a while.)

It used to drive me INSANE when nurses didn't know what I:E was or what it meant when it was inverted. It also used to drive me crazy when nurses would write down settings when the paperwork asked for outputs.

Make sure there is a COMPLETE manual at the bedside for all equipment and you read it (and make notes).

I know another adoptive mom that had her son admitted because of inverted I:E ratios.

witty_online_moniker · Sep 21, 2013

Thank you both for taking the time to share that info - definitely sounds like a lot to learn, but it's helpful to at least see some of the acronyms and ventilator-specific terminology before getting a crash course. I can't imagine how a single day of classroom training would be enough to feel truly comfortable troubleshooting something so complex. You've inspired me to for sure brush up on my knowledge of the respiratory system and trach skills prior to starting work if I accept this job.

Elle23 · Sep 21, 2013

Ventilators are scary because the patients are dependent on them to stay alive. If something goes wrong with the vent, you have to be able to act quickly and efficiently because the child will decompensate rapidly.

I worked with vents for 20 years in the NICU, and I am still a little nervous about taking on a vent in PDN. In the NICU, we had tons of backup and RTs trained in vents to help out, and if the baby started heading south, all we had to do was push a button to have a slew of people at the bedside in seconds.

In PDN, the risk is the same, but it would be just me there to deal with it. That is not something to take lightly.