sunflrz321

My biggest frustration with the "evaluation" process is that management everywhere seems to now be required to divide their staff up into "high performers" and "low performers," and then each group is treated VERY differently. Sometimes staff are divided into these categories based on evaluation results, and other times they are divided this way based on manager preference. Then management is now ENCOURAGED to show favoritism towards the high performers. I really don't know exactly where this practice derives from- I think it might be from some six sigma business principle that was not designed in hospitals. I get the sense that management is *supposed* to invest in the low performers and improve their overall performance. But a great nurse manager is a rare gem these days, and even the good nurse managers are usually too busy to have much time to invest in any of their staff and really help their performance. As a result I have seen nurse managers deal with their low performers in a wide variety of ways, from making up infractions and pushing them out one by one, to only giving the high performers the opportunities they need to succeed and advance on their evaluations (thus ensuring the lower performers remain low performers no matter how hard they try or what work they do), to giving special favors such as flexibility with scheduling to high performers and not to low performers. Does anyone else out there have experience with this high-performer/low-performer conundrum, or have further insight into the issue?

Like many of the commenters, when I first read your description, I thought this baby was going through drug withdrawals. I know a few years ago I worked at a hospital that had just started to get babies with opiate withdrawals, so they really didn't know what to do with them yet, or even how to identify the symptoms very well. They tried to treat the babies withdrawing from opiates the same way they have always treated the babies withdrawing from cocaine, and it didn't work. (This was a community hospital that is not magnet and was quite behind the times regarding Evidenced Based Practice). Make sure you know the differences between opiate versus cocaine withdrawals in neonates- study up on this if you aren't already familiar with it. I agree with one of the other posters too that it sounds like the baby is in pain. So here I would start thinking about your consults and precautions. I would put a call in to your child life department- see if they can send some volunteers to hold the baby, or if they have developmental toys that might help. This baby is likely not gaining weight very well because he or she is spending so many more calories crying and moving and fussing than normal, so a nutrition consult could recommend a better formula - perhaps a soy formula or a formula with a different lipid base- and the baby will probably need a higher calorie formula also to compensate for the increased calorie spend. If the baby isn't on reflux precautions I would see if you can get an order for that. I would also make sure social work is heavily involved on this case- this child is going to require parents with extraordinary patience, coping skills, and a REALLY good support system. And as far as getting flustered, a baby like this will make even the most experienced nurse flustered over time. Don't take it personally when you get flustered. Also, don't be afraid to ask for help from the consults listed above, and also from your peers and charge nurse.

Many years ago I started out in peds ICU, and I LOVED it and it worked out great. It is, certainly, trial by fire. You have to commit to studying on your off days, and bringing your absolute A-game to every.single.shift. You have to basically become an expert in each category of pediatric complications- you have to know the worst of what can happen and what to do about it for neuro, cardiac, respiratory, metabolic, endocrine, etc problems. BUT- you will become an INCREDIBLY good nurse in the course of your first year. You will learn to calculate and titrate drips like nobody's business, you will develop incredibly fine-tuned assessment skills, and you will learn the art of one of the most in-depth forms of nursing. If you meet up with your fellow graduates one year from now, you will probably have stronger clinical skills than most of your peers. When your classmates hired onto med-surg or ortho call a rapid response or any other type of alert, they will be calling for your team and your ability to respond quickly on your feet and your critical thinking skills. Your first year as a nurse is like the real final year of your schooling in many ways, because there is SO much learning that happens in that year. You will be taught by some of the most nit-picking nurses in the field, and they will challenge you every day, but they will teach you a TON. They are like the hardest teacher you ever had in nursing school- the one who taught you more than you ever wanted to know but whom you can only dream of knowing that much one day too. That will be most if not all of your coworkers and preceptors. Just remember ICU experience is HIGHLY sought after, so if you can learn to swim in the ICU over the next year, you can survive anything in your career. Starting as a new grad in ICU is not for the faint of heart, and it also isn't for the nurse with a ton of other distracting family and personal commitments that can get in the way. But if you really put your all into it, you will be the better for it.

Working at a high end day camp years ago there were lots of great names... Siblings Paris and Jet Siblings Porsche and Ferrari Working at the hospital, a girl named her baby Baebie Here's some food for thought on the subject: Republicans and Democrats can’t even agree on baby names

I once got a pretty monogrammed name badge holder embroidered with my first initial (along with a very sweet note) that was a great nursing gift. There are a lot of things like this on Etsy for $6-10, though I'm sure you can find them elsewhere as well. I like it because it is something that I used every day in the hospital. Many hospitals have Starbucks in the lobby, so a Starbucks gift card or reusable Starbucks cup or mug is always nice. A pretty reusable water cup or water bottle is nice too since many nurses aren't too great at staying hydrated. Vera Bradley has some cute ones- both on sale and at normal price here: Tumbler | Vera Bradley, and Camelback water bottles (available at Target) are great too. I hope this helps!

Like others on here, I run a low baseline temp- around 96.4-96.8. By the time my temp hits 99, I usually have chills, body aches, burning sensation behind my eyes (I don't know why, but every time I have a fever I feel that) - but I have all of the other symptoms of fever, even if my temp never actually goes over 100. I take this with a grain of salt in myself and my patients. Does a higher-than-normal-for-the-patient temp mean they are probably fighting an infection- quite possibly. Does this mean the patient is septic? Usually not, unless they have other clinical signs indicating sepsis. Many patients who have experienced hypoxic brain injuries (especially those patients who are trach/vent, like the one mentioned on the first page of comments) will have lower core body temps, because they hypoxic brain injury affected their hypothalamus which regulates the body temperature. It is important to adjust your expectations for these patients as well. The most important thing is to know your patient, and what is normal for them, and also to look at fever as one piece of your thorough clinical exam. Once when I worked PICU I was caring for a stable vented patient with a stable temp in the 97's, she spiked to 99.5, but when I touched her she was just burning up, even though she only had a light sheet on her. Her cap refill was delayed, and she looked a little mottled- this was a drastic change from my last assessment just an hour earlier. I called the doc in, got an order for blood cx even though her temp hadn't reached 100. I wasn't going to wait until it got to 100 to treat her, I could see where this was going. The patient crashed that night, almost didn't make it, but she pulled through. Perhaps she pulled through because we caught her just in time, or perhaps God was just really looking out for her that night. Either way, you have to consider the temperature in relation to the rest of your clinical exam, rather than focusing too much on the numbers/ vitals.

University of Wisconsin Green Bay RN to BSN program looked great on paper, but they really don't care about their existing students much at all. They have massive problems securing clinicals for students, and they don't inform students of these problems until the semester has already started and they have already paid tuition for said clinicals...such a scam. It seems like most of the teachers are barely paid anything, because almost all of them have other full time jobs, and many of the teachers frequently go days at a time without responding to student questions because they are busy picking up shifts at their other jobs. Even worse, the teachers just seem burnt out, and they don't seem to enjoy teaching or respect students at all. There are a couple of exceptions, those who are great teachers, but for the most part the teachers have NO interest in teaching. The teachers are mostly just facilitators, they don't even design the class they will be teaching, and they can't even change the content if it is messed up. You don't know who your teacher will be when you enroll in a class, and there are only a few nursing classes offered each semester, so there isn't really any way to avoid the bad teachers either. I have friends that have had much better experiences at Purdue's BSN program, and I would encourage people to look at that program first.

Yes, I want to clarify as well. I wasn't suggesting you should intentionally delay discharges to avoid getting new patients. That would not be ethical. Like Jessie, I was just talking about prioritization- addressing a potentially higher acuity situation very briefly before the lower acuity situation of a discharge. I did say that eyeballing the patient and taking a quick set of vitals should take 2-3 minutes, 5 minutes max. 5 minutes to ensure a patient's general safety and cover one's own tail as a nurse is not going to delay anyone's discharge, or create any problems in "moving the meat."

I agree, always at least put eyes on the new patient first, just to CYA. After all, how do you know the patient is stable if you haven't even looked at him or her? The triage vitals and assessment that may have been taken two (or more) hours ago don't telling you how the patient is doing now. You don't have to do a full assessment at that time. Just go in, do a very quick set of vitals, put them on monitors if need be, look for any apparent distress (pallor, diaphoresis, altered mental status, alertness and posture, clear speech, guarding/ grimacing in pain, tachypnea, dyspnea, or retractions etc- all of these are pretty easily apparent in a 2 min conversation w/ the patient without a more thorough assessment, and they are much of what constitute the experienced nurse's "spidey sense") and quickly check the cap refill to confirm good perfusion or catch sepsis early. Introduce yourself and let them know what to expect (that you & the doc will both do assessments and histories, etc), tell them not to eat anything until doc gives the okay, etc. All told this should take 2-3 minutes, 5 minutes max. Don't ask too many questions here, they will suck up your time. Then go do your discharge, and come back to this patient for the full assessment and interventions when the discharge is done. I agree with the poster above that if you discharge first, you will immediately get another patient in that place that might be less stable and might keep you from the first admit. Also, if something should start to happen to the first admit (e.g. desat, HR goes tachy, etc), if they are at least on monitors then it will be apparent to everyone at the nurses' station, even if you aren't there to catch it. I think your instinct to do at least some assessment/eyeballing of the patient is spot on, so don't be afraid to follow those instincts. When making decisions like this in the future, you can always weigh the risks and benefits of each scenario. The risks of seeing the discharge first without even putting eyes on the admit are that the new patient could deteriorate and you wouldn't know it and that you could also get two back-to-back new patients at almost the same time, which can be tricky. The benefit is that you can "move the meat" faster. These decisions are all about weighing risks and benefits of multiple situations, and deciding which risks you feel comfortable with and which you are not. You will be making risk-benefit decisions like these throughout your entire nursing career.

I think what is lost here is that HIPAA exists to protect health information privacy- not any and all information pertaining to the individual. If you pulled up in a van that said ABC home health agency, DEF respiratory supplies, or XYZ DME company, would this patient's neighbors know any more than they do now when you fill out the form as you are currently doing? I would encourage you to further research the difference between PHI (Protected Health Information) and SPI (Sensitive Personal Information). SPI includes information such as date of birth, SSN#, etc- information we certainly don't want to share. Generally, only PHI is covered under HIPAA. SPI is typically protected under separate organizational policies. According to the Department of Health and Human Services (http://www.hhs.gov/ocr/privacy/hipaa/understanding/summary/index.html), information that cannot be shared due to HIPAA regulation must include one of the following: "the individual's past, present or future physical or mental health or condition, the provision of health care to the individual, or the past, present, or future payment for the provision of health care to the individual" Most importantly, I would encourage you to always provide the "minimum necessary" information to security. Remember, just because they ask on the form why you are there and what company you are there from doesn't mean you have to answer those questions. Family and friends likely visit these patients too, and they don't have to fill out those boxes to see the patient, so you likely don't have to either. If security does need further information, handing the security staff a business card should likely suffice- then they get the information that you are an RN from ABC home health agency, but that is not connected to the patient and listed on the same form as the patient's name. If you remain concerned, talk with your supervisor, to get his or her take on the matter.

I have not heard of ER nurses actually floating in either of the hospitals where I have worked. In both of the hospitals where I have worked, the ER nurses have been known to help out the IV therapy team and serve as their back-up when they have the time. IV therapy often has a back-log of IV's to draw and labs to start and central lines to place first thing in the morning, so it helps to have the extra hands for the first couple hours of IV therapy service, without requiring them to hire an extra IV therapist- and by doing IV's, you are usually free to go at a moment's notice. I worked in a small but intense PICU with a drastically fluctuating census.We would often start the PM shift nearly empty, and by the end of the night, every bed would be full with a very critical child. In order to address this, the small community hospital did put a few measures in place. 1) PICU (and NICU, because they never knew when a critical baby would be born) had the "right to call back" their nurses from a float. This meant that if PICU got an admission or critical patient, they had the right to call their extra floated nurse back from the assignment, and the nurse had to be back to the home unit within 30 minutes MAX. In order to accomplish this, there were strict limits placed on the acuity and quantity of patients that we could be assigned when we floated, and the nurse that would be the backup and take our patients if we suddenly had to return to our unit had to listen to report with the floating nurse, to make the handoff quick and seamless. However these strict requirements made the other units not want to use the floats with right to call back, so then the PICU and NICU nurses would be placed on call, and they would have to come in within 30-45 min if an admit happened. 2) The ER developed some alternative shifts that addressed the census fluctuations hour by hour. They kept a few nurses on the standard shifts of 8's (7-3, 3-11, & 11-7) or 12's (7a-7p & 7p-7a), and then they added several 11a-11:30p shifts, to address the peak census times in the ER.

The toxic negative nurses-eat-their-young culture. Basically the way we treat one another (that often stems from the way we have been treated since day 1 as a nurse, or even day 1 in nursing school for some). The way our hospitals will so often blame a nurse and throw her under the bus rather than take responsibility for a systemic problem. Call it what you want, bullying, lateral violence, etc, it is rampant. Everybody has their theories on why this happens: too much estrogen in the field, too many people promoted to management who have great clinical skills but no managerial or people skills, not enough clinical hours/experience in nursing school, lack of a unified nursing voice, the fact that we tolerate it, etc. I think there's a bit of truth to all of those things. What I can tell you is that when I made the jump from bedside care to case management for a managed care corporation, I didn't do it because I was tired of the pace, the patients, the families, the intensity of the work, etc. I did it because I needed a break from the culture, and the people who perpetuated that culture. And sure enough, you don't find that same toxic culture in a workplace with a good mix of both genders, where people are promoted for their management skills, and where staff know what to expect from their schedules, and don't have to fight between themselves to get days off. So far, the grass IS greener on the other side (out of the hospital).

I was a mental health counselor before I became a nurse. They still had us narrative charting, to leave room for all of the great quotes in the documentation. There are also some crazy quotes that I have to document from parents now, when we have child neglect or abuse cases. I tend to stick with the old standbys of "Pt stated..." or "Pt's mother verbalized...."

I've never smelled death persay myself, but I would guess that experiencing the smell with the event would have to happen enough times to make the connection in your mind. I have been fortunate that I haven't had enough experiences to make such a connection. I can identify the smell of someone in liver failure, renal failure, with pseudamonas, c-diff, and more. However I am fortunate to work in pediatrics, so we tend to children in acute organ failure, rather than chronic organ failure (which I associate with certain smells). I would not be surprised if it was related to the liver failure (which makes for a very pungent smell) and/or renal failure (which alters the chemical composition of both urine and sweat, since we can sweat off what we don't excrete through urine or stool). As far as the stories about animals identifying such a smell, I would guess that dying animals probably make similar smells when they are in organ failure. Given that cats and dogs have much stronger senses of smell than we do, it is not surprising that they can smell death/organ failure/ etc earlier.

A few years ago I graduated from a large ADN program at my local community college. I would guess that out of everyone who started, about 50-60% of us did graduate as scheduled. We also had LPN students join our class in the 2nd year, and we would also have students join who had failed that class the year before (so they didn't have to re-do the entire program, just start back at the class they failed out of and move forward from there). One thing that program did was watch what things statistically predicted failing out of the program. It turned out that the number one thing that predicted students' grades was how much they worked outside of school. As a result, they developed a policy that you could not work more than 20 hours/week while you are in the program. And I found this to be true as well- I had several friends who started out doing very well in nursing school, and then thought they could start a new job and do just as well- and every single one of them either did fail out or came extremely close to failing out before they learned their lesson. Quite honestly, when I am a patient in the hospital and my life is in a nurse's hands, I want it to be a nurse who knows her stuff, not a nurse who just tries her best but was too busy working to have time to learn everything she needed to learn in nursing school. I'm not very sympathetic to people who say they have to work 20+ hours/week for the money, and that is their excuse for being too busy to learn the material. If you need the money, take out a student loan, or check out the grants and financial aid programs at your school. Too many people think all you have to do to become a nurse is pass a series of classes, and if the classes are too hard for you to pass, then something is wrong with them. Nursing is making life-or-death choices, and if the schools are too easy, then they are graduating people who are not capable of making these choices. I have friends in medical school & PA school, and their programs do not allow them to work whatsoever, and they are literally at the library until midnight every night - 7 days a week. One more thing I want to say- being a nurse is the most grueling and difficult job I've ever seen or done. It interferes with your ability to eat and sleep at normal times, and usually you are lucky if you get to use the bathroom more than once in a shift. And that's not even counting all the weekends and holidays you spend away from your family, and the fact that even when you are home, you are so exhausted from working that you don't have the energy to really enjoy the time you do have with your family. I love this profession, and it can be very rewarding, but it is NOT for the faint of heart. My hardest days and weeks in nursing school were a breeze compared to even a week of working as a nurse now. Nursing school is a piece of cake compared to being a nurse, so if people can't cut it in nursing school, I strongly question if they would be able to cut it as a nurse.