rstewart

In my opinion this advice is 100% correct; Do yourself a tremendous favor and heed every single word.

At the risking of appearing argumentative, the decision/judgement to perform those actions before contacting a physician for a medical order may well illustrate one sort of autonomy; but without previously approved "standing" medical orders you would be practicing medicine without a licence and likely be terminated from employment for those same actions. And yet ironically doing things like ordering meds/labs etc. without an order may be illustrative of professional autonomy since doing so would no doubt raise the ire of the nursing board which regulates the profession. My point is there are different types of autonomy and in the workplace, particularly in the hospital setting, I believe that one could reasonably argue that staff nurse's have very limited autonomy, at least in the sense that the word is usually used and understood. In my opinion, the original question was not at all unreasonable. The existence of professional autonomy when severely restricted as it so often is by workplace conditions is of small comfort to the staff nurse. Indeed, even the lay public's "perceptions" are given precedence over the professional nurse's judgement. And in some institutions "scripting" of verbal responses is expected with each client/family interaction. In today's health care environment I would never advise an individual considering nursing that they might expect a high degree of autonomy. To do so I believe would be terribly misleading. Now that is certainly not to say nurses are not important----good nursing saves lives (among other things) no doubt about that. But they quite often practice under a repressive system with unrealistic demands placed upon them by other professions, institutions, the public, quality organizations etc etc.

Whether the nurse is 3 ft tall or 8ft tall there is no safe way to manually handle patients of that size. In my opinion, hospitals which refuse to provide appropriate beds, supplies and lifting/transfer equipment should lose government funding because there is no way to adequately care for bariatric patients particularly. Allowing a patient to lay in stool for an hour and a half is inhumane; neither should nurses be expected to perform tasks which are known to cause injury. Hospitals decry government regulations but this all too common scenerio is but one example of why no manual lifting laws, pt/nurse ration laws etc. are necessary.

I have seen this confusion with the terms "right to work" state and "employment at will" state numerous times on this site; They are not the same and they are only tangentally related. At will employment is a doctrine not a statute or law. The doctrine states that in the absence of a contract either party (employer or employee) can terminate the relationship for any reason or no reason at all. Over the years there has been some erosion of the doctrine. Public policy exceptions and exceptions related to race, gender etc discrimination are examples. Virtually every state is an at will employment state because only one or two have passed laws to the contrary, Montana being an example of that. So in 90% of the states unless you can show that you are covered under the very few exceptions to at will employment, the employer can fire you for no reason. BUT....if you reread my basic working definition of employment at will notice .....the doctrine holds true in the absence of a contract. And where do most contracts in nursing come from? They are negotiated by unions. So for example Florida is a right to work state, however, if a union member in Florida has a contract, they can not be fired at will---instead the contract applies. Right to work states in contrast have passed right to work laws or statutes. Basically they say that you can't make contracts that say union membership must be a condition of employment. Unions are generally weak in such states for obvious reasons...some employees can potentially reap the benefits/pay negotiated by the union without paying their share of the dues. They also don't participate in work actions (strikes). So right to work makes organizing more difficult---no organizing, no employment contract---and as noted above without such a contract in the vast majoity of cases your employer can fire you for any reason or no reason at all.

There is a relationship/commonality between these infectious diseases which may be the source of the confusion: Vancomycin. Vancomycin used to be the only drug which could handle most MRSA strains; And in general it became over prescribed to the point that many facilities were forced to develop institutional review processes to make sure Vancomycin was most appropriate for any given case. The concern was that high vanco use results in increasing vanco resistance. So the treatment for MRSA was Vanco. And the treatment for C-diff is stopping antibiotics and then starting Flagyl ....or Vanco. High Vanco use promotes increased resistance and there is a direct relationship to VRE as suggested by the name. Going full circle a major concern with VRE (besides that it can be life threatening in certain populations) is that in folks with VRE and MRSA a gene swapping can occur resulting in a vancomycin resistant staph aureas. That's significant because in general staph is regarded as relatively stronger/more serious than enterococcus.

I would be classified by most as an older, seasoned nurse. I maintain multiple national certifications and routinely complete numerous CEU activities. I am one of the nurses my peers choose to take care of their loved ones when they are admitted to our facility. Yet my most recent evaluation contained comments which suggested that I am resistant to change. To some degree that may be so-----but not without reason. First of all many changes these days are made for purely financial reasons, ethics and clinical considerations be damned. Younger nurses would be well advised to question why many of our larger health care providers have had multiple multimillion dollar fines for fraud, multiple name changes and bankruptcies. Nurses can not assume beneficence simply because their employer provides health services. Secondly, many proposed changes have been tried and failed before under another banner. We may have experienced the "new" initiatives at another facility, or at our current place of employment years ago, or even in a previous career field (many old dogs have chosen nursing as a second career). New nurses (and those new to their management roles) should take to heart the admonition that those who fail to study history are doomed to repeat it. Thirdly, many of the new "tricks" asked of the old dogs are so poorly thought out prior to implementation that even those ideas with some merit are destined to fail. Changes are "rolled out" without regard to available resources, individual institutional characteristics and without pilot projects solely in order to be first in the area to do so. Where pilot projects are used, negative feedback of any kind is ignored or punished because eventual implementation of the latest "favor of the month" is a foregone conclusion. Certainly there may be some old dogs who don't want to learn new tricks. However, one should not make the mistake of equating maturity and experience with inflexability. Rather they may be at a point in their careers where they can recognize a bad idea when they see it and will neither be praised nor threatened into stating otherwise.

I wouldn't be at all sorry for your opinion, Jayne. I think you exactly right. As an older worker it is sometimes difficult for me to internalize the complete disregard corporate America has for its workforce. There once was a time when a worker's sacrifices and loyalty were rewarded, but no more. One only needs to read the seemingly daily announcements of the massive layoffs and termination of promised benefits/pensions (even by financially healthy companies) to see that things have changed and not for the good. Over the years I have taken care of many dying patients; not one has ever told me that they regretted not working more when they had the chance. That is not to say that there won't be repercussions from taking a family first stand; there almost certainly will be. But years down the line I suspect that you will not regret your decision.

Ok, now I know there are strong feelings on all sides of the entry to practice issue ----but that said may I ask: Does anyone honestly believe that a nurse receiving a BSN after one year in nursing school (irrespective of previous educational preparation) will develop superior critical thinking skills, will experience increased respect from administration/physicians/general public, will be more likely to have the tools to better "rescue" patients resulting in improved complication and mortality outcomes, will be better prepared for being a charge nurse, will have equal or better psychomotor skills/knowledge of equipment use....than a diploma prepared nurse who spent 3 years on the floor? Or why is 2 years of intense training as a nurse (ie associate degree preparation) inadequate for the complex patients, technological advances blah blah blah of today, yet one year of intense nursing education is apparently sufficient if it results in a BSN?

Many years ago I was completing a degree in Music when I realized that I had enough Psychology hours for a double major. The problem was that the psychology degree would come from the College of Arts and Sciences and unlike the School of Music, there was a foreign language requirement, four semesters worth, in fact. Ahhhhhh but I was "fortunate". There was an experimental accelerated foreign language class (German) being offered. The class was 14 semester hours and it was strongly recommended that you enrolled for only that class. The hours of instruction were identical in number to those who took the classes in 4 consecutive semesters. But we had to memorize a week's worth of grammar and vocabulary about every day or two. Time outside of class was spent in the language lab or in nightly "cram" sessions/study groups. The tests and other requirements were identical to the traditional classes. But our students dropped like flies-----from 25-30 down to 5 of us at the end. And although I received an A and could read German fairly well, in less than one year I could barely remember anything but a blur. In no way is one year sufficient time to become a nurse---- BSN or otherwise. And please don't tell me that the joke nursing boards have become will provide a safety net for the public. Show me another profession where answering most of 75 questions correctly can qualify for a license and I will promise to be more receptive to that argument. These non-traditional programs are ridiculous; ever notice that no matter how they are condensed in time they always cost a small fortune? Now just why do you think that is?

(I think gay guys make better male nurses, but I don't want to say that too loudly because I'll get fried to a crisp. LOL) Hate to burst your bubble but I believe most men who are in nursing would strongly disagree with what you think-----as would their patients. Interesting how negative stereotypes are condemned with strong admonitions as to the irrelevance of sexual orientation/who sleeps with who etc; Yet positive traits, (though equally sterotypical) are socially and politically acceptable.

Open visitation has been in effect in my CCU for the past several months. In my opinion, it is a disaster. But then again nobody asked my opinion. The overall effect on our particular unit is an "anything goes" environment. Mind you on paper we still have rules but the reality is otherwise. We have more family members eating and sleeping in the tiny, equipment filled rooms. In fact, getting to the patient to assess or to perform care has become an obstacle course of bodies and stuff brought into the rooms. The noise level is noticably higher with the screeching of infants (we have no minimum age requirement for visitation) not at all uncommon. Cell phone ringing and usage are up. Families routinely disregard the 2 person limit and even those who are compliant frequently cause continual disruption as one group leaves to be replaced by the next. Privacy is a thing of the past. I have been interrupted on a frequent basis during conversations with physicians and with families of other patients, during report and while performing care. Security is non existent since people have a right to be in the building at all times. The repetitive questions and concerns are extremely time consuming and distracting. The effect on infection control although unstudied can not help but be a negative one for our fragile patient population. Resources to accomodate the increase in visitation were not addressed so there is no place to sit etc. Neither patients nor families can get uninterrupted sleep leaving them confused and irritable, not to mention the well known importance of sleep in the healing process. Etc Etc Etc Now certainly many of the problems could be minimized but that would involve in some form saying "No, Mr/Mrs. visiter you can't do exactly what you want when you want to do it," or cost money, or require support from management. And we certainly could not have that since the the primary reason for open visiting is increased patient satisfaction scores without financial expenditure. The ancillary effects of the policy can easily be ignored or dismissed. From the literature one would think that open visiting is totally without drawbacks. And "puff" pieces about the successful transitions to open visiting rule the day. Increasing the number of patients per nurse is NOT the only way to reduce actual care hours provided. Increased paperwork and policies like open visiting reduce both the quality and quantity of nursing care in a manner that is undetectable by the usual/traditional productivity measures. However, the powers that be do not want to know the possible truth, so these issues will remain unstudied.

Actually, I would probably find the vase even if requested in a less than polite manner. The problem I have with the "Hospital=Hotel/Resort" mentality of today's hospital administrations is the implicit assumption that all requests have relatively equal importance. Unlike other service workers, nurses must consider that some of his/her patients may be experiencing pain which they can relieve, some of their patients are incontinent and need cleaning and comfort, one or more their patient's medical condition has changed even become critical and are in need of immediate intervention and/or transfer etc etc..... It is ironic the Hospital Administrations often cite limited available resources when denying nursing requests for additional supplies, equipment or staffing yet they selectively can not understand that nurses can only be in one place at one time------that everything can not be done within five minutes of a request if any request is fair game. Fortunately, the vase request would not be an issue at my facility. Since vases can't be nailed down, they no doubt "disappeared" long ago.

You know, one thing I've noticed is that the nursing academic community has developed all manner of accelerated, online and otherwise nontraditional programs which result in BSN and higher degrees; But while they are quicker/more convenient to complete they invariably cost a small fortune.

As a manager I tried to use GPAs as a major factor in my hiring decisions for new grads-------our nurse recruiters had a fit and said that I couldn't. Nursing is a second career for me. Previously I was an accountant and I will tell you grade point averages and even the school from which you graduated determined whether or not there was even an interview granted, let alone a job offer. Now of course I realize that GPAs don't tell the whole story. Students who didn't have to work, for example had a huge advantage over those who did. And good grades do not necessarily translate to common sense. And then there are interpersonel skills. (lolol...Yes, even accountants needed those). But my argument remained: Absent an employment history, what is the best single indicator that the applicant learned the material/was serious about their studies and future career, etc etc.......my answer was good grades from a good program.

As a manager I tried to use GPAs as a major factor in my hiring decisions for new grads-------our nurse recruiters had a fit and said that I couldn't. Nursing is a second career for me. Previously I was an accountant and I will tell you grade point averages and even the school from which you graduated determined whether or not there was even an interview granted, let alone a job offer. Now of course I realize that GPAs don't tell the whole story. Students who didn't have to work, for example had a huge advantage over those who did. And good grades do not necessarily translate to common sense. And then there are interpersonel skills. (lolol...Yes, even accountants needed those). But my argument remained: Absent an employment history, what is the best single indicator that the applicant learned the material/was serious about their studies and future career, etc etc.......my answer was good grades from a good program.

I believe that widespread continous perioperative glucose monitoring is just around the corner----the technology already exists. The sad part is with the rush to move patients out of the intensive care units many times the patients are taken off their drips before the research suggests (the lower levels of care are not provided the resources, human and equipment to continue).-----the result being a bunch of checking/sticking without any improvement in outcomes. For DKA patients I think it would be hard to justify a-lines etc. simply for glucose sampling. They aren't cheap and they have risks of their own. Additionally, when you consider the necessary wastes, q half hour sampling can result in significant blood loss for some patients.

hmmmmm......Well the first step would be to determine whether your q wave is significant in width or depth. Although unspecified I'm going to assume that the 0.02 is in seconds since that is the norm for the horizintal axis. Generally that is not wide enough to be significant. The furnished depth confuses me. You state the depth as .08-.1mm. Since each small box is 1 mm, you are saying the depth of your q wave is only one tenth of a small box; since you say the wave appears "prominent" I doubt that is what you meant. And since the .1mV=only 1 small box, clearly you did not mean mV either although that is the normal unit of measure. I am going to guess that since you learned "1 small box = .04" horizontally, that the same can be said vertically. So I am going to guess that your strip had a q wave 2-2.5 small boxes deep. One common rule of thumb is to be significant it must be larger than 1/4 the height of the corresponding R wave. So in if your q wave is 2 small boxes and the corresponding R is less than 8 boxes it wouldn't be significant. And you would have to know which lead we are talking about because significant Q waves can normally occur in certain leads. So to answer your question: I dunno.

The powers that be have always behaved as though staff nurses can assume infinately more duties without impacting patient care. Nothing new there. But this latest delegation irks me particularly. As staff nurses we are responsible for patient care, of course, appropriate charting, noting orders, checking medical adminstration records nightly, doing 12 and 24 hour chart checks to insure orders have been noted etc. ---the usual stuff. But now the expectation is that we complete chart audit tools which take 15-30 minutes for each patient. Previously the audits were performed at the manager/clinical coordinator level; later they were delegated to the charge nurses. Now with the blessing of administration they have been "dumped" on the staff. Now I realize that an extra half hour a day for 2 critical care patients doesn't seem like much. However, these audits are just the latest in addtional duties/documentaion which are taking time away from patient care. And our productivity has consistantly exceeded 100% due to chronic understaffing. When things are slow/census low I don't think anyone would have a problem doing some audits. But I have never heard of making chart audits a staff nurse responsibility. And for good reason; nurses who are unable or unwilling to document properly will "fudge" on the audit tools as well. In fact that is what is happening; nurses are checking boxes without actually performing the audits. So when management audits the audits for blanks......well you get the picture. Those of us who refuse to document an audit was done properly when it wasn't because we had other priorities are regarded as the noncompliant, bad nurses deserving of "nastygrams". So my question to my fellow staff nurses: Do any of you perform chart audits in addition to a regular or even greater than budgeted patient load? I know we're the only ones in this city)

The NY State Education Department has an Office of Professions; The laws governing nursing practice (there are several) can be located under their website's Laws, Rules and Regulations listing.

Your state has an organization known as the Nursing Care Quality Assurance Commission; Visit their web site. There you will find that they list advisory opinions regarding various procedures (conscious sedation, botox injections etc.) Chest tube removal is not among them, therefore you must use the decision tree to determine whether or not you may pull chest tubes; there is also a form with which to request an advisory opinion by the the Commission. Finally, if it still appears that you may perform the procedure, make sure that your facility permits same as evidenced by a policy and procedure. Clear now?

Registered Nurses are licensed by the state. Your state's nursing practice act defines your scope of practice. If you practice outside of your scope of practice then your state's board of nursing can discipline that RN. This is true regardless of whether or not a physician or your hospital "gives permission" to exceed your scope through an order or a policy. Unfortunately, whether or not a specific procedure is outside the scope of nursing practice may not be entirely clear. Some states offer specific advisories/directives regarding certain procedures. However many do not, essentially pleading that to define all procedures as permissable (or not) would be overly cumbersome for the board and the nurse alike. Typically, they provide a decision tree to aid the nurse in determining whether a procedure is permitted under the act. Usually the decision tree requires that the procedure is not specifically prohibited by the board, that the facility's nurse executive has blessed the procedure, that a policy/procedure exists for its performance, that the individual has had the education/skills checked off to perform the procedure safely etc....... So be aware that even though a procedure may potentially be within the scope of nursing practice, if your facility has no relevent written policy/procedure, you are subject to be found practicing outside of your scope of practice should an adverse event occur. As mentioned above, the completion of a course in ACLS in and of itself does not bestow immunity from the above facts. But some RNs can and do perform intubation-----not because they have completed ACLS but rather because their employer has a policy permitting same, they have verified/documented the nurse's training and proficiency etc. My advice: If your facility does not have a policy regarding a procedure....don't perform it until one is formulated/approved. If you have any doubts regarding whether or not a procedure is within the scope of practice ask for a determination from the board; they might provide a straight answer to your inquiry or refer you to a prior determination they have made------or likely as not refer you to one of those damn decision trees.

I haven't been in school for over a decade and I don't plan on returning. But I couldn't help be struck with your comment that a 3.7 GPA is "not that great". Has grade inflation in nursing curriculums become so pronounced that a 3.7 is so-so?