NurseLy

We just recently heard that our hospital system is in the process of bringing international nurses in to help fill some of the staffing shortages. We haven’t got a lot of information about how this program works or what it will look like yet. The nurses are able to work through this program to gain citizenship here in America is what I have heard. I don’t know what countries the nurses are coming from. We were told they will need some extra training, that the scope of practice for nursing is different — some may not give IV meds in their countries, some may not read telemetry, the EMR and equipment will be new to them, etc. Have you experienced this in your hospital? Any specific things to consider? I am told I will be precepting an international nurse in a few months and I am curious as to what to expect.

I went back to my old job and was welcomed with open arms. I am so glad I did. That job (the people/negative environment and lack of management/organization) made me hate going to work everyday. My advice to anyone who is truly miserable at work is to jump ship. Nursing may be a crap shoot anywhere you go right now but there are better places out there with more supportive coworkers. When you know, you know. Good luck with your transfer.

Personally, I could put up with some less than ideal stuff for straight days and a 20 minute commute. Those are high priorities for me.

I believe we are still testing all patients. So people come in with other complaints — ie chest pain… but they incidentally test positive. If they have no covid symptoms we still place them in isolation but on other floors based on where they will receive the best care. Cardiac patients go to our cardiac floor versus a general medical floor.

We mix covid and not in our units. If symptomatic covid and receiving treatment we keep them between two units. We do have non covid patients mixed in the same units depending on the bed needs at the time. Positive covid patients who are not requiring covid treatment but are there for a speciality issue - cardio, neuro, etc. get placed on those specialty floors. Right or wrong I am not sure, our health system says as long as we are using our isolation precautions the patients neighboring covid patients are at no greater risk. While patient safety comes first of course, an entire unit of isolation patients is hard on the nursing staff staffing it. 6 isolation patients is a heavy load ?

We are not the patients in the scenario we are the health care providers. We have the privilege of providing care to the most vulnerable patient populations. By vaccinating ourselves we offer that safety to the populations we serve. It is or is becoming a job requirement just like every other job requirement. I distinctly remember undergoing various tb tests, vaccinations, a drug test, etc. to have the employment opportunity that I do, too. ?‍♀️

I have seen this done and I have done this before in places I have worked. Occasionally if the oncoming shift is going to be very short or especially busy we will pull meds for the oncoming shift and store them in the locked patient bin in the Pyxis. We do not pull anything controlled or anything that would be in a vial that can’t be verified by the nurse administering, like insulins. Generally we would write on a small piece of paper what meds are missing and put it with the pulled medications. If there would be an error with a medication administered it would be on the nurse giving the medication. I think it’s similar to being in an isolation room and peaking out and if your hall partner is free asking them to pull a medication for you so you don’t have to doff the PPE.. I am not saying you should do this if you are uncomfortable just sharing that it is done other places. ?

Thanks for the insight. I am sure you are right, there is a lot I don’t know and that’s keeping the work feeling very task-y right now. I can certainly understand the importance of the frequent neuro checks and picking up on those subtle changes, it’s just that for me personally, physically doing so many neuro assessments is what is boring. I have learned for my personality I need to be busy doing a variety of tasks to be happiest. I do work with some really passionate neuro nurses and that’s great, that really specific skill set is so important to the patients and families serviced.

I transferred from a surgical floor (after 4 years)to a neuro ICU. Two different hospitals but the same health system. I have oriented in the neuro ICU for 6 weeks and I think I have 2 weeks left. I really dislike a lot of things about my new job. In no particular order.. I hate the nursing care on this unit. It doesn’t feel anything like what I expected an ICU to feel like. In 6 weeks there have been only two vented patients, on different drips, who were pretty busy/complex like what I pictured when I envisioned ICU patients. The vast majority are all fairly simple. Neuro assessments done every hour. BP and sodium goals. A LOT of electrolyte replacement and then drawing labs, then more electrolytes, then more labs... We recover patients post cerebral angios, that’s just even more frequent vs and neuro assessments. While I do feel busy, I feel bored because it feels like the same few tasks on repeat all day every day. So many neuro assessments! Pretty much every patient goes to CT every day for serial head CTs. We do our own transports by ourselves pushing the patient in the bed down to ct and back. It is so annoying. There is very little experienced staff. I have been trained by a nurse with 1 year experience. She is the most senior night shift nurse. Several nights I found I have been a nurse longer than all 5 nurses working, collectively!! And I haven’t been a nurse that long. While I have a lot to learn in the ICU realm, I know basic nursing care. These nurses don’t seem phased by basic things I have always been diligent about. ie: capping IV tubing when not in use, scanning medications before giving them, not using the same straight cath a second time if you miss your destination, etc etc. I try to put this in perspective if this is just me not thinking like an ICU nurse so these things are not their priority, but quite honestly we had plenty of time to care and do these things right, it seems the culture is such that the basic nursing care is sloppy… No experienced staff also means a lot of staff left in a short amount of time. That’s a bit of a red flag in itself. I asked the staff, they claim it was just bad timing. Some nurses finished school, some left to travel, some went PRN to stay home with kids, etc. The high amount of new nurses means the few more experienced nurses are so sick of orienting that I don’t feel like I’m learning as much as I could had they not been so burnt out.. it’s a super unwelcoming feeling every shift. I swear maybe one other nurse I met is in my stage of life. The other newer nurses are all pretty young. They are still in the bar after work/party every weekend stage. My old floor I had a lot more in common with my coworkers, a lot of good friendships. I miss that. No one is designated to watch the tele monitor. On my old floor there was a monitor tech who sat at the desk and would call with any alarms, then I would be able to log in and be the one to decipher if that alarm was a true concern or not. On this floor it is the nurses who watch the monitor because the floor is small. There is no free charge though so it concerns me everyone could be in a room and miss an alarm. Even though I am orienting I saw a situation where the nurse was not alerted to a patient with several vtach alarms because the nurse who saw it determined it was not true vtach. (It was) That situation had me livid just thinking about the risk of having telemetry alarms acknowledged on MY patients but not being informed about it. I was hired for day/night but told in the interview it would be just a few nights in a schedule period. I was actually assigned to 50% nights on my schedule I just received. I questioned that and was simply told it’s not set in stone and it is what it is. I’m super dissatisfied with that and the impact it’s has on me and our family routines. In two months I have not seen my manager or assistant manager in person. I have received info twice by email, and it’s when I emailed first with questions. Neither have checked in on orientation asked how things are going, nothing. We have had no sit down check ins, which was standard the other places I have worked. So basically I’m getting ready to start a ton of education. Online modules, in person classes, etc. This is all completed on top of my scheduled 36 hours. I knew about the education and initially I didn’t mind doing it, I actually enjoy learning. I’m hesitant now though to throw so much of my time into a job I hate already. Typically you need to stay 1 year before transfer but I think right now I could transfer back to my old unit as an exception, but if I let them invest more time and money in me I will potentially be stuck for the full year. Would it be silly to try to jump ship so soon? I am leaning towards reaching out to my old manager Monday but I don’t want to regret it… I am torn between knowing that if having this one year of ICU experience it can benefit me and my future endeavors and not wanting to spend the year tired and miserable on an unsafe unit. Has you every felt the writing was on the walls and left a job before even getting off orientation?

If you are pretty confident that you want critical care I say just start applying. If you get an interview set up and it goes well, you can request an opportunity to shadow at that time. (Where I work it is not uncommon for someone to shadow a few hours immediately following the interview.)

Practice a clear and concise SBAR. Make sure the assessment data is relevant. (When I was new I would write out at times key points I didn’t want to forget to say because I was nervous!) S: patient name and room number has a change in status since the start of shift B: he/she is post op day 1 for xyz with PCA running at xyz rate A: BP is trending down, most recent value is xyz. Increased oxygen need from 3L to 5L. Include RR and oxygen saturation. Maybe pain level/orientation R: I think he/she will benefit from reducing the pain medication and repeating labs/ABGs with early morning labs (this is hypothetical based on the info provided. You say you and the doc were on different pages so you had a thought on what was wrong —- ask for whatever you think the patient needs. The worst they will say is no.) There are times when I think there has been enough of a change that the provider should know about it, but don’t necessarily need orders. In those cases I simply say “FYI or I just want you to be aware…” Talking with doctors and asking for what you think you patients needs gets easier with practice! ?

I think it’s totally appropriate to tell a patient they can not sit on a bed pan constantly. Just a thought - when I worked rehab, we absolutely did not use bedpans. It did not matter if the patient was a 2 assist, required a transfer board, used a lift, etc. We had to tell the patient it was part of their therapy program to use the restroom how they would when they are home. The more they practice transferring with whatever their new deficit is, the easier it becomes.

It sounds like you handled a tough situation well. I don’t think you did anything wrong. Just two things that come to my mind reading your post 1. Notify the appropriate provider, especially considering your concern was she arrived to the floor too soon. The provider may advise to give medication, just monitor, etc... At any rate, you can document the assessment findings following by “provider notified” to CYA. 2. There have been times I have given IV pain medication for rating such as 3/10, if it is reasonable to believe this patient would be experiencing increasing pain. Considering she was immediately post op it may be helpful to stay ahead of pain, not let the pain get to 7-10 and try to get it back down. This is probably facility specific policy, but we can give medication outside of the ordered range for specific circumstances as long as we document why we did so.

Notes should never be written with wording such as pt is argumentative and non compliant. An objective way to say the same ... pt educated on xyz, pt declines xyz at the time. I am certain you can think of a time or two when the chart should be hidden, to avoid harm. Imagine the social worker finds out a patient can’t discharge home because a family member, who helped provide care at home, died. The social worker now needs to document discharge is delayed because adequate support is not available at home. (True scenario I have recently experienced.) The patient doesn’t yet know the family member died, because family wants to come in and tell them in person. We have a no visitor policy because of covid, so we are working through the steps of getting an exception to visitation approved... There are situations we run into, that information is documented that can cause harm, so we now can hide notes, rarely but when truly warranted. And if a patient has a test result they don’t need to panic about because the radiology report says something like “can’t rule out mass.” This is not clinically correlated to the patient. The physician may know it’s not a mass. Or maybe further testing is warranted. That information is better delivered from the physician and it can be followed up with plan of what will be recommended next. And it needs done with in 24 hours. I agree patients have a right to know everything about their care but timing is everything. Agree to disagree..

Our names show up in the patient chart that they can access with our first name and last initial only. There is still an option for us to keep notes hidden. In our EPIC there is a button we can click to keep the note confidential. There has to be a good solid reason to use the button, I know one of the choices to select under keeping a note hidden is “potential to cause harm.” Not sure what all the choices are I have not used this feature personally. We were told If we use it too frequently it will be flagged. This has been a reminder that we need to keep our notes objective. When we first went live patients were getting results to imaging and tests before a physician reviewed and was able to discuss... Now our system changed and any critical results do not post to the patient access portal for either 24 or 48 hours so that doesn’t happen. I know the details might be different for other places, but we have learned there are a few work arounds we can use while still being in compliance with the new law.

From reading what you described, I think it sounds more like an issue of your body adjusting to nights which more orientation will not help. Dayshift is much busier typically - heavier med pass, physician rounding, family updates, 3 meals, consults, etc. If you feel well organized and successful on day shift I think your time management skills and system and serving you well— you just need to learn how to best function on nights. For instance I work day/night but fortunately more day than night. I have felt similar to how you feel as I have tried all different sleeping strategies to prepare for an overnight. I have stayed up all night to sleep consecutive hours during the day before shift and that use to make me feel so terrible, like you described, my head in a fog. I learned I don’t sleep well enough during the day. Now I sleep normally the night before as I normally would, and nap from 1-3 before an overnight. Then I get the kids from school and make dinner and everything before leaving for work at 6. Now I still feel tired by the morning, but this works much better for me. I suggest brainstorming different times to sleep and eat that is going to help your body feel best. Working nights (for those of us who are not night people) is so tough. It took me nearly two years of trial and error before I found a system that helps me feel the best. I’m not sure if you mentioned how often you rotate or if you have any say, but I learned I like working nights back to back. I get my required night shifts out of the way in a row rather than having a night shift each week (we self schedule.) I actually have learned to appreciate sleeping the day after a few nights. My body is so tried I can sleep pretty deep and I get the bed to myself. ?? Good luck, You will find your rhythm soon. Hang in there.

Our unit has been a covid step down unit for a year now. (We just “celebrated” having made it one year since our first covid patient came through the door) I could not agree more. We are all so mentally and physically exhausted. Even though overall our numbers are way down, our unit remains the covid cohort unit so every single patient we have is still covid. Even with (God willing) the worst of it behind us, within the last week we sent two patients UNDER 35 years old to the ICU and they both ended up vented and on ECMO before end of shift. Seeing this much sadness and tragedy in the past year is bound to start wearing anyone down. So I have nothing helpful to add, no advice. Simply responding to say I relate to everything you said and yes that’s normal. I have loved my unit and my team, but I have started considering applying for new jobs. My mental health is suffering and it is trickling into my home life. We are a small unit and the few nurses on our floor have been run ragged with no end in site. No alternating staff through, no breaks, nothing. I haven’t started job searching yet but it crosses my mind daily. We make our voices heard about how we are feeling but it continues to fall on deaf ears.....

The stress and anxiety you feel is normal and we have all felt those same feelings. The general rule of thumb is it takes 1 year to feel comfortable, 2 years to feel competent. Regardless of where you chose to work there will be increased stress while you are new and learning, so maybe spend a little time brainstorming ways to manage/ease the anxiety. Hang in there, the time goes so quickly and before you know it you will be the one comforting the new nurses. ?

Do you have a place you can refer to before completing a task, if it is something you haven’t done recently? Separate from our policies we have access to lippincot, like an online archive of nursing procedures, where it tells you step by step what to do when completing a task. Maybe see if any such resource is available to you?

Yes with a double lumen they don’t have to be compatible.. where I work we do not routinely draw blood from a picc. If your policy is such that you can, you can draw a Vanco trough the same as any other blood draw.

I am not sure why your response sounds insulted. We all know and agree that this shouldn’t be the state of schooling. I am not doubting that there are going to be hardships due to that inadequate schooling. I’m simply stating that these are circumstances out of any of our control so we have no choice but to figure out how to navigate among them. Plenty of our aides are in nursing school and they would desperately prefer hospital clinicals to hours of case studies. I empathize with them and the fact they all started nursing school expecting a typical experience and were dealt this difficult year. I don’t know exactly why hospitals shut their doors to students. I would guess the liability of more people potentially getting sick, and the need to conserve the PPE we have. But it’s of no fault of the nursing students, that is who I am trying to be supportive of (the OP). My area in particular is facing a severe nursing shortage which is of course compounded even more now by the pandemic. We desperately need these new nurses, even if we have to some how find the extra time to help them learn.

Proning patients as you said. A lot of studies show this is really helpful in increasing oxygenation and preventing people from progressing to needing more oxygen. So even a patient on only 3-4L still benefits from proning. Patients who can not tolerate proning benefit from hard side lying positions too. Our patients are getting convalescent plasma, remdesivir, and decadron. The antibodies in the plasma from people who have recovered from covid seems to help the most. We monitor lab trends— ferritin, crp, d dimer. When the ferritin and crp and trending up patients are often getting sicker. The d dimer we watch because these patients have been developing PEs and DVTs. We repeat the chest CTA if continue to be unable to wean oxygen to ensure no PE. Patients with high respiratory rate, use of accessory muscles, etc (even with SpO2 > 90, check an ABG. These patients often need HFNC for the pressure, helps decrease the work of breathing. Have a non rebreather stocked in every room. Put it on in addition to whatever oxygen they are on if acute desaturations. Sometimes this is needed with any exertion if they can’t tolerate it. We also will pre oxygenate with NRB if a person has been desating with exertion. The term “happy hypoxic” ... some of these patients desat with absolutely no signs or symptoms. Keeping them on continuous pulse ox monitoring. And just learning the signs of a patient going bad. It seems when they tank they tank quickly. When someone progresses from room air to 10L in just a few hours they are likely one who will end up needing HFNC quickly.

I felt the same way my first year of nursing when I started in rehab. someone told me, and it stuck with me, if you need an RN license to be hired for that position, that makes you are a real nurse. Other wise they would hire someone else and pay them less to do that job.?

For a transfer to the ICU it is always the physician who calls the family, in my hospital. It never hurts to ask them, just to be sure the ball isn’t dropped. Once the patient is transferred off you could ask the physician if they had a chance to call the family yet.

Considering this is a GLOBAL pandemic, every hospital and every hiring manager and every nurse preceptor to be knows that clinicals have been canceled. I work in a large teaching hospital who has essentially not allowed nursing students since March. W all know the new grad nurses will need extended orientations and hands on experience. Everyone who is speaking like this should never happen... lots of things in 2020 should never happen. I should not be trying to remote teach second grade yet here we are. Circumstances are not ideal, but no one can change that that is the reality of nursing school right now. Just go in to your first job ready and willing to learn. Most nurses enjoy teaching, when the person is open to learning. We all learn how to really be a nurse the first year — just ask questions. Your charge nurse, your experienced nurses on the floor, your nurse educator, etc. Nurses generally feel like the scariest thing is a new nurse who doesn’t ask questions. If you don’t know something you have to ask.