OldPhatMC

What your paying for is for someone to put the medications together and test them for risk to pregnant women. You're paying for someone else to take the fall in case of a birth defect. If a doc were to just say "take B-6 and Unisom" for an off-label reason, the doc becomes responsible for anything that happens to babby.

In hospice nursing we make evidence-based recommendations all the time. Many attending physicians are not well versed in hospice care and they actually ask for recommendations. If they don't like it, they will explain way. Some physicians will become irritable if you don't have some sort of plan in mind. Occasionally we end up asking for something and it ends up being a phone call from the hospice medical director to the attending. If you develop credibility and rapport with the doc, you'll very rarely get a poor response. Add to that the obvious: try to be respectful of their time, so save little things for the morning and call on stuff earlier rather than when things have gone downhill.

Head shots require placing the round in an area about 1/3 that of the chest "kill zone". They're hard in a controlled environment like a combat pistol shooting course, and nearly impossible with a handgun in real combat. And the very real risk of bystander death is still an issue. I'm sure you've heard the term "overconfidence kills" in your weapons training. They mean you, not the bad guy.

Former cop here. There is no way a single person with a weapon could have countered the shooting in San Bernadino, or even in many of the shooting that have occurred over the last year. Having a gun is the least important part of being a protector. Situational awareness, developed skill, practiced coordination with other protectors, practiced plans and good communications are far more important. Yep, you might have pulled the weapon out and neutralized one of the two shooter, but the other shooter had as good or better a chance at getting you first. And even if you succeeded, how sure are you that you would have not been treated as a threat by the professional responders? We're seeing a move by police to shoot first, which is wrong and illegal but is happening with sickening regularity. And a nurse on the floor has a lot of distractions from maintaining overall awareness of what's happening in their surroundings. If you're being continually vigilant for threats, how are you doing your job with your patients? And unless you're carrying the weapon on you, you'll have poor odds of getting a gun from your locker. Armed individuals, when they've been present in recent shootings, really have not contributed anything to limiting deaths, but they are excellent targets and cannon fodder. If you're feeling unsafe, either management has to step up, or you need to find a safer workplace.

Something that wasn't mentioned is that it's not just the family that needs your compassion. It's your team members as well. Your preceptor was probably in a place where he/she would liked to have processed the experience with you. Part of that may have been sharing humanity, and who knows, maybe your preceptor wanted to get a feel for you as a person. There is much in the education of a practitioner that is still intangible. To answer your question, if you're in health care, your compassion must be limitless, but your ability to manage your compassion must be very, very strong. By the way, I like that you want to have a fuller role in the care of your patients. As a nurse you get to see the big picture. But I envy your RT training; RTs are awesome and make great partners.

The Department of Justice was working on the issue of home health nurses being shorted pay for working off-clock. As has been pointed out by others, it is illegal to for an employer to insist on this, and you should be compensated for the hours worked. As a travel nurse in home health and hospice, I have the added layer of protection that comes from my agency. They insist that I list all hours worked for the company. If your employer insists that you're "Salaried, Exempt from Overtime", you can contact your state department of labor for a determination. More likely though, you would be better off getting ready to leave. I've found that employers that have a culture of insisting on abusing salaried employees rarely have much respect for their employees and ultimately are not good places to work. I know that there are good home health and hospice agencies out there and you should keep plugging until you find one of them.

I agree that you should have the skills. IV skills save lives. Been there. Even better, having the advanced skills that go with midlines, PICCS, all the many med ports and dialysis shunts would make a big difference on your floor and your career. I'm concerned that the manager is sensitive to people trying to improve themselves. This suggests that the environment in which you work is likely to lack a basic level of trust. Ultimately that floor is not where you belong. Having said that, I'd look at what else you could learn that would not threaten the manager. Will she support you in taking ACLS or dialysis courses, or is that also considered "disloyal"? Can you use this job as a place to park until you've finished your next degree, or is that also not "important"? If the manager has a specific idea of "how you should become a better nurse", it may be worth riding it out, if the skills are useful elsewhere. If the manager feels that experience is more important than education, you're going to get bored and lose your enthusiasm. Another side issue you mentioned is technically illegal in the US: working off the clock in another department for skill improvement, even if voluntary, places your employer in violation of wage-hour law. You can't volunteer for an employer. All hours have to be paid. If you were told that you had to work overtime and not get paid for it, you'd balk. I can tell you that whenever I did IV skills work at any hospital, it was on the clock. You deserve your compensation and respect for you as a professonal. If you do want to volunteer and gain a lot of IV experience, I'd go find a rescue squad that will train you to an avanced level. Most of the time the IV skills are taught in conjunction with the hospitals that support the trauma program. I know I got a lot more experience with IVs as an EMT than I did in nursing school. Best of luck to you.

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.

needshaldol has said a lot that, as a hospice RN of several years experience, I think needs to be clarified for the readers: The medicare billing: Medicare gets billed at a standard rate. They pay at a much smaller standard rate. Currently a patient on routine care is paid at $168 dollars a day. That is all nursing, all assistance care, continence supplies, medications related to the hospice diagnosis, durable medical equipment, and of course the hospice medical director, social worker, and spiritual care visits. Assisted living: Yes some of this may seem to duplicate the care provided by an assisted living facility, but it's a rare ALF that has an RN on more than one shift. I will also state that NONE of the Assisted Living Facilities I've ever worked with were truly capable at end of life care. This is a bold statement, but when you consider that in almost every state a medication technician cannot assess a patient, cannot give a narcotic, nor can they even change a complex dressing, then it makes a lot of sense. Also, it does take experience, training, and resources to be effective at end of life care. In that most assisted living and even skilled facilities have no specific mission to assist in a dignified, peaceful death -- in fact, state laws may limiit what they can do for dying patients, and force the facility to treat the dying patient as a failure for paperwork purposes -- it becomes the hospice team's job to educate the staff and to make sure that the appropriate medications and assessments are done. I have found that I can build a strong, caring partnership with a facility team and the patient's care is excellent. But I know that if I wasn't their, the patient would get get lesser symptom management. I'm sure I'd see actively dying patients force fed and aspirating. Hospice educated physicians: Most facility attending physicians won't cough up oxycodone tablet orders. They're afraid of the DEA. A patient may need flexible dosing schedules of morphine suspension, or a PCA pump, or medication for terminal agitation. The physician needs to understand that the dying patient metabolizes differently. Sometimes a narcotic is the wrong drug to use. Cancer patients do well with dexamethasone. A hospice physician will use steroid therapy where a non-hospice physician may pull back. Not all doctors are equally well trained in end of life care and I can say that I"m proud to know each and every hospice MD I've ever met. What everyone needs to know: hospice is not a trip to the vet. We neither speed the end of life nor hold it back. Sometimes hospice care is so effective that the patient can remain on service for years. We don't go "oh hell, your six months are up, off you go!" If a patient ceases to decline, we can discharge them back to regular Medicare. All patients have the right to revoke the election of hospice care. Bluntly, if they find a treatment they'd like to try then I encourage them to revoke, but thoughtfully. People don't die they way we see on television. The natural death process takes a few days to a few weeks. There are documented waypoints that mark patient transitions and they certainly help in anticipating death. But the exact death of a patient? Never predictable. Morphine sometimes will extend life by slowing the rate of energy consumption, but its the natural shift of the body metabolism as kidneys and liver fail that causes the patient to shut down. I haven't gotten into the benefits of having social work and spiritual care available. But it's important that the entire family get appropriate care, good preparation, and ongoing support. Seeing a five year old boy hug his daddy that last time, or fighting siblings set aside their issues to give mom a peaceful last week, well.. it keeps me doing this. Granted, it may be possible to die well without hospice, but everyone should have the opportunity. We're good at removing surprises. We're great at providing comfort. Thanks for considering my viewpoint. TL;DR your loss if you didn't read this, not mine.

I used to identify myself as a nurse, but since I wasn't a member of the Emergency Department cool kids club I got treated with very variable levels of respect in the ED. So now I conceal it if at all possible when I go with someone. My doc and podiatrist like to talk shop but I never mention it to the office staff. I think that's an outgrowth of the bad experience from the ED. Damn shame ain't it?

I've had this experience with patients. NPH insulin is variable in its effect from person to person, as well as variable in its effect on a person based on their activity levels. I'd normally give straight NPH insulin based on the patient's history and eating patterns. Believe it or not, you can usually trust a seasoned diabetic to tell you how they react to an insulin. I've had patients that would crash on me (BG of 50 or so) at 3 am the morning after a 430 pm dose of NPH. Best part: patient was like 340 at 2100. I held the bedtime coverage based on the patient waking up that AM at 48-55 past two mornings. Patients that are relatively slow absorbers of the NPH insulin will sometimes surprise you like that. Also, some sites are less effective at absorbing the NPH. I know a patient that injected NPH into his thigh one day and got no effect from it; although when injected into the abdomen it had fairly consistent effect. So the right answer is to give long and intermediate acting insulin as ordered, but report patterns such as borderline lows occurring the same time each day. Short acting insulin should be given very closely to a meal and I would consider a patient that did not eat breakfast to be at risk if given either a short acting or a combination like 70/30. Those merit immediate physician calls. Come to think of it, if in doubt, call the physician anyway. They don't want the patient crashing either and refusing to eat meals is something that in itself should be noted, especially if its a repeated pattern.

Students, being non-essential to patient care shouldn't be forced to come in. When this happened to me in nursing school, any day where the campus closed also was a day they canceled clinicals. We did have one day where the drive (for me) was just fine, but classes were canceled and I got the day off. Of course there was a make up day

When it comes to being a health care worker, I've always favored death -- my own -- as the only real reason to call out. My only exception to that was the time I was down in the cardiac unit -- it was only pneumonia, but they wouldn't let me out for my shift, even though I promised to come back. I've just been through this, as we got two feet of snow last week. My boss sent her husband out in a 4 wheel drive vehicle to round up stragglers. Some folks did stay in the building a few days. Others came in hours early and camped as well. Since the patients CANT be flexible, we need to be. Now it IS my opinion that when you get there, you're on the clock and should be paid for the time that you're available to work. But what do I know?

Oh she's an INTERN. She doesn't have permission to either speak to nurses or raise her eyes from the floor unless her R3 is present! Seriously, the comments about involving them in care and open communications are very valid. I get this a lot. Sometimes my patient load has included families members such as nurses and even an ER doc that I knew from my EMS days. If you are confident, know your skills and can articulate your intentions clearly, that defuses a lot of the testing. Sometimes I will ask what they would do differently. (Sidenote: yep, we're all busy and in a hurry but ten minutes up front is worth preventing days of hostility and CYA charting). I ask for research references supporting their ideas -- some of which are actually valid -- and share what I can with them. I also like to help the "medication loggers" get the right pills written down. If for any reason I have to bring an unwrapped pill into the room, I'm ready to explain exactly what it is, and why it doesn't look like what their pharmacist gives them at home. Let's face it, sometimes its all in the presentation. I tend to milk my "old flatus" status. When they assume I am a doctor, I correct that immediately. When I'm the charge nurse on rounds, their assigned nurse is the best one in the building, and I let them know that I have confidence in that nurse. Sometimes it's salesmanship. Remember, the puff up is almost always because the person doing the puffing is fearful and feels powerless. It takes time and patience to build the rapport and get beyond the fears. Most importantly, it takes the ability to manage your own emotions. In two years, I've only refused to care for one patient, and that was due to a family member that was really hell bent on litigation. I embrace the patients with the the co-morbidity of "crankypants". Someday it will be you in that bed!

Aren't they adorable when they're young? First of all, the doc-in-the-box type clinics are usually placed in the higher volume pharmacies. I think its unlikely to impossible to manage both the pharmacist role for a 10K script a week pharmacy, AND try to carry a decent patient load that would make such a split feasible. I've been a tech in a pharmacy that was doing half that volume and the PharmD in charge had no slack time. None. Seeing patients as part of the day would have been impossible. I'm also willing to wager strongly that you would not be compensated adequately for taking on multiple roles. You'd reasonably be expected to pro-rate salaries. Due to legal liability issues alone, I'd expect that you'd be expected to block your time so that you only did one job or the other. And anyway, most of these clinics are separate corporate entities anyway, so you'd be on two payrolls. Of course, one would be remiss in not mentioning the loss of safety coming from one person fulfilling both roles. I don't need to tell you how vital the pharmacist is to the protection of patient safety. If you write an order for a patient then fill that order, you don't bring fresh eyes to the patient's profile and health history. Some might raise ethical questions, but I don't think that they would be any different for a separate NP and PharmD. The AMA is unhappy with the idea of in-store clinics funneling prescriptions to the parent pharmacy. Where I would see a person with your willingness to keep up in two very different professions at the same time would be in rural health. Even there, the loss of objectivity is an issue. But in a town with one pharmacy and maybe a handful of practitioners, your skill-set combination might be a strongly positive difference in an area where the economics of adequate care are not working. After all, they may only be able to afford half a NP and you can earn your keep at the pharmacy. Obviously in disasters, all bets are off and you'd be welcome to wear both hats, and push a broom while you're at it. Another, big-city solution is the obvious one. In-hospital clinical pharmacy. Pharmacists that work the floor are amazingly helpful and how hospitals did without them is a mystery to me. Nice side benefit: no FNP necessary. By the way, if you're looking at doubling up as a way to make the economics of being a pharmacist work for you, I might humbly submit that you need to look at someplace other than the chain that owns the doc-in-the-box you mention. Costco, for example, pays well enough that you shouldn't need two jobs, and definitely a lot more than most chains. Best wishes to you.