Roland

That is a very good queston because they have the so called "eICU". I can only surmise that chest tube vacuum integrity is not a parameter that is closely monitored by the folks "in the sky".

The problem with that is about 50% of the posts that I place have the same sort of "attacks on my personal sincerity or integrity" The net effect of closing all such posts is to place a "de facto" ban on my ability to post. Why cannot those who commit such "attacks" simply be told to stick to the issue at hand (whatever that may be) or to not reply?

I had one post where I referenced writing a book about why nurses lose their license. I did that even BEFORE my wife experienced her present situation precisely because I believed then that many, many nurses and nursing students are punished for capricious, bogus reasons that have little to do with their clinical conduct. . However, I realize that is not an acceptable explanation, and that more complex socio/psychological dynamics must be at play to explain what otherwise seems unexplanable. I would still like to get a handle on why it is that some nurses lose their licenses or get fired for mistakes that are no greater (or even smaller) than other nurses who don't even get written up. Part of me feels like that if I could study hundreds, or even thousands of such cases (by pouring over State Board of nursing records, talking to witnesses ect) that maybe I could eventually elucidate some kind of pattern, or tendencies which makes this happen to some people and not others. Someone above just suggested that my wife was actually more to blaim for not noticing that suction was turned off than the nurse who intentionally did the act! I honestly cannot understand how anyone could sincerely have that reaction. I will be completely honest my first reaction upon learning how my wife was treated and all of the cirucumstances involved was to want to drive to her hospital and to cause grave physical damage to the primary people involved. However, that would obviously solve nothing and in fact make things much worse. Instead, I sought to bring some sort of meaning, and clarity on what had occured with the hopes that such discussion might help me to better deal with our circumstances. During my tenure at Allnurses I have explored issues ranging from "twenty four hour childcare for nurses" to "what would you change if you could build a hospital from the ground up for nurses" God only knows how much I love this place. In nursing school I was practically known as "Mr. Allnurses" because I brought this site up to allmost all of my fellow classmates and instructors. To me this site was allmost like a religion or philisophical ideology because of the worth that I believed it to hold. I would even go so far as to post threads on subjects discussed in class and then send emails with the links to some of my instructors. I even would point out the threads where I was critical of the university (such as posts where I complained about our having to be totally nude in assessment class and palpate for inguinal lymph nodes on our partners). In the last five years I have mentioned this website to literally hundreds of people because of my sincere, and profound belief that it has the power to transform nursing for the betterment of nurses and nursing because knowledge is power and no where will you find more knowledge about nursing than here. Nurses are often in my opinion subject to the whim of powerful forces like Dr's, hospital's, HMO's ect. and it is my belief that a site such as Allnurses has almost in and of itself the power to greatly diminish such disparities in power and that this will be a good thing not only for nurses, but also for the patients whom they serve. Frankly, I am proud of my contributions here, and I doubt that few have covered greater thematic ground than have I. At no point have I ever knowingly spoken untruthfully. Indeed, when I have gone so far as to give more precise details (because of the criticism that I can't possibly be sincere) I am then criticised for being too specific! For the past five years (ever since we decided to go back to school to become nurses) nursing has been my passion. I made it my goal to become absolutely as knowledgable as possible on the subject, and to bring my "manic tendencies" into useful focus. If I sound dramatic its because for me these are very importent issues that have consumed a high percentage of my waking hours. I am perplexed as to why I seem to be the only person around here where it seems to be okay to break the TOS of Allnurses and attack my integrity, or sincerity personally? And don't say that it's because I always discuss my wife a while back I started a thread titled something like "what are the easiest nursing errors to make that could seriously harm someone". It produced a good deal of useful information and many, many replies, but it wasn't long until people were posting "why is he asking that he's not even a nurse" . I don't know maybe because I was a terrified nursing student who had heard many horror stories about mistakes hurting patients, and I was doing my best to make sure I didn't make such an error (and also because I am a big believer that "processes" rather than persons often drive errors, in theory this is at the root of evidence based practice analysis). The point is no matter what issue I raise I seem to draw those sorts of attacks. When my wife actually comes on to give her own version of events and to update her other post on the subject at https://allnurses.com/forums/f8/icu-should-i-stay-go-132141-2.html and it seems like if anything the attacks simply increased! Frankly, I often seem to see the same attitude here as I believe exists on her unit which generated the impetus for the thread being created in the first place. Why can't you just respond (or not) to the question at hand? In my entire life I've never questioned the motives of someone who asked me a question instead I either answered the question or didn't (IMHO even if the events didn't occur as stated which they DID, it would still be a valid learning scenario that might prove either useful to epanding general knowledge about the subject or to helping educate nurses on how they should handle similiar situations if they ever encountered them). Part of me wants to give you our names, phone numbers, where we work ect. just to prove that this occurred as stated. Indeed, I have considered printing this entire thread off (and the one Oahu RN started seperately) and hand delivering it to not only my wife's unit manager, but also to senior management at the hospital. Of course in the end I won't because doing so would mean the end of my marriage in all probability. The bottom line is that talking and discussion are always better than violence, however when someone comes in with a sincere problem that is really driving them to the edge and seeks assistance here, and you dismiss them (not that all of you have in fact the majority have not) you may be pushing them towards the negative end of that spectrum. I wonder if Robert Alvarez didn't experience something like that at the University of Arizona before he went over the edge and used violence in an attempt to solve his problems. I wonder if he had come here and attempted to "discuss his problem instead" if he might not have been met with the same sort of "black hole of skepticism and indifference" that I felt these past few days. The next time that you react to someone like that you may very well contribute to the circumstances that produces a headline in a paper somewhere. CaroleladyBell, I know that we have had our differences, but I would like to thank you and Susanne who offered some good insights in my wife's thread (same thing) for your sincere replies it really means alot. You didn't agree with me in fact you took me (or more accurately my position) to task for reasons that you felt were justified, but you did respond with sincerity and even more importantly you were responsive to the issues asked in the OP. That may not seem like much, but it makes all the difference in the world.

The original thread in question is here https://allnurses.com/forums/f8/is-legal-ethical-preceptor-sabotage-student-133692.html . Note this is an issue that we will be following up in one manner or another either in the media, within the corporate ladder at the hospital in question, or before the State Board of Nursing (or possibly not at all). I would think that almost everyone in nursing would be concerned that something like this can happen, and have a unit manager say "well the preceptor felt bad for sabotaging", but then fire the student, and make the preceptor face absolutely no repercussions.

Sorry that should read "Should". The nurse in question (referenced in the now closed post" is sabotaging a student ethical/legal") actually admitted the incident on my wife's weekly evaluation. The manager of the unit said that my wife's preceptor felt bad about the incident, and that's why she didn't tell my wife until several days later. Never the less the unit manager will be terminating my wife's employment on the unit in large part due to my wife not catching the disconnected chest tube suction (although probably not the hospital, or hospital system in other words she can switch back to a med/surg unit). The question now is do we just "take this as a lesson learned" or complain up the corporate ladder or even file a complaint with the State Board of Nursing? Again she admitted to this on paper on my wife's weekly evaluation ( which we will be getting a copy this week hopefully). I have even considered letting them know that we will be writing all of the local media since I'm sure that many people would be interested in knowing that nurses at one of their local hospitals are taking actions that could be harmful to patients just to test other nurses. I know that if I was going in for a heart bypass I sure would want this information.

The problem with the rad tech sites is that you have maybe a 1,000 members rather than 100,000. With a 100,000 people there's a good chance that there is an expert or two out there in Allnurse land who could tell me the ins an outs of building a ham radio let alone an allied health profession. Many of you have contact with people in these fields on a daily basis. As I have stated many times I wish that there were a sort of Allnurses for every field from firemen, and policemen, to waitresses and postmen. Indeed, if I had the cash I would take the Allnurse concept and try to do just that. It's fascinating to get a "behind the scenes perspective" on fields that we interact with in our daily lives.

I know that the governmental publications say that it's "above average", but those are often not all that accurate. I also know that it is no where near as good as it is for nursing (just look at any Sunday newspaper). However, that is my current "plan B" after withdrawing from nursing classes as previously stated (also it will only be 30 minute commute each way instead of two hours). I also have the opportunity to do either nuclear, medicine technology or radiation therapy would either of these be better? My primary goal is to be in a position to support my family while my wife goes to grad school. Any "real world" street insights would be greatly appreciated.

In reply consider the following: 1. My wife posted her own post on her issues with this ICU and they can be read with a simple search on the name OahuRN (I think she only has a couple of posts so it shouldn't be too hard). 2. I am as certain as I can be that you have the whole story with regard to the chest tube incident. As I stated above she called me as soon as the preceptor confessed. In adddition, she has read the above posts and corrected me where I made a factual error. 3. I respect your opinion that she should have reported the incident immediately, but am not certain that I agree (nor am I certain that I disagree). She has probably witnessed no less than twenty incidents that could have conceivably have caused the various nurses involved to lose their licenses or at least faced disiplinary action. It is not possible to report "every" such incident without being labeled "a snitch", and to quickly become unemployable in my opinion. In the real world of nursing such "errors" or deliberate acts of questionable ethics occur on a daily basis. Indeed, on those occassions in the past that she has gone forward with those types of concerns (not on this unit) she has been politely told to "mind her own business." With that said sometimes action must be taken and one has to choose which battles to fight and which hills to die upon. Perhaps this is such a hill and perhaps not. I am not knowledgeable enough to assess what if any risk the patient was exposed to (how important was the chest tube in this patient and did removing the suction for two hours place the client at any risk?). Keep in mind that the opinion that this preceptor relates to the manager tommorow at that meeting will effectively determine if my wife has continued employment at this facility as well as the conditions of that employment (it will also in part guide the nature of the reference available for any other conceivable employment). Again, two paychecks without pay, and our entire family would be on the verge of losing our home and automobile (which since we live ten miles out of town would be like losing almost everything). 4. No where in my limited (two and a half semesters) of BSN nursing courses did we discuss this situation. The closest we came was "patient abuse" or "M.D's giving patients placebos" and I'm not certain that this qualifies which is one reason that I asked. Furthermore, I do not believe my wife was even told exactly WHEN the preceptor removed suction (not what date and not what patient), and her only evidence is the preceptors unwitnessed confession. Had she "turned her in" on the spot (not really possible since it was night shift, and the preceptor in question had many years experience/seniority on the charge nurse who probably fears her nearly as much as my wife) who would they believe if the preceptor simply changed her story and denied the confession? My wife who is new and struggling or the nurse with over twenty years experience on the unit? 5. I have never stated anything on these boards that I did not believe to be true nor have I ever attacked anyone personally. I take exception to the comment that there "must be more to the story" based upon my history. Futhermore, I believe that such a statement may be in violation of forum rules against personal attacks. You may disagree with my opinions, but they are thatly that, my usually well thought out personal opinions. Also, as previously stated my wife has indicated that she will be writing her own response to this entire thread tommorow evening (however, I fear that it the thread keeps moving in this direction that it will be locked by that time). Thanks to all who have expressed their opinions and insights. Those who have expressed support are appreciated more than they will ever know and those who have expressed criticisms will have their thoughts considered and reflected upon to a much greater extent than they might expect.

In reply consider the following: 1. My wife posted her own post on her issues with this ICU and they can be read with a simple search on the name OahuRN (I think she only has a couple of posts so it shouldn't be too hard). 2. I am as certain as I can be that you have the whole story with regard to the chest tube incident. As I stated above she called me as soon as the preceptor confessed. In adddition, she has read the above posts and corrected me where I made a factual error. 3. I respect your opinon that she should have reported the incident immediately, but am not certain that I agree (nor am I certain that I disagree). She has probably witnessed no less than twenty incidents that could have conceivably have caused the various nurses involved to lose their licenses or at least faced disiplinary action. It is not possible to report "every" such incident without being labeled "a snitch", and to quickly become unemployable in my opinion. In the real world of nursing such "errors" or deliberate acts of questionable ethics occur on a daily basis. Indeed, on those occassions in the past that she has gone forward with those types of concerns (not on this unit) she has been politely told to "mind her own business." With that said sometimes action must be taken and one has to choose which battles to fight and which hills to die upon. Perhaps this is such a hill and perhaps not. I am not knowledgeable enough to assess what if any risk the patient was exposed to (how important was the chest tube in this patient and did removing the suction for two hours place the client at any risk?). Keep in mind that the opinion that this preceptor relates to the manager tommorow at that meeting will effectively determine if my wife has continued employment at this facility as well as the conditions of that employment (it will also in part guide the nature of the reference available for any other conceivable employment). Again, two paychecks without pay, and our entire family would be on the verge of losing our home and automobile (which since we live ten miles out of town would be like losing almost everything). 4. No where in my limited (two and a half semesters) of BSN nursing courses did we discuss this situation. The closest we came was "patient abuse" or "M.D's giving patients placebos" and I'm not certain that this qualifies which is one reason that I asked. Furthermore, I do not believe my wife was even told exactly WHEN the preceptor removed suction (not what date and not what patient), and her only evidence is the preceptors unwitnessed confession. Had she "turned her in" on the spot (not really possible since it was night shift, and the preceptor in question had many years experience/seniority on the charge nurse who probably fears her nearly as much as my wife) who would they believe if the preceptor simply changed her story and denied the confession? My wife who is new and struggling or the nurse with over twenty years experience on the unit? 5. I have never stated anything on these boards that I did not believe nor have I ever attacked anyone personally. I take exception to the comment that there "must be more to the story" based upon my history. Futhermore, I believe that such a statement may be in violation of forum rules against personal attacks. You may disagree with my opinions, but they are thatly that, my usually well thought out personal opinions.

Why is "eating their young" used so frequently (espcially around here) to water down the reality with should be stated as acting like an aXX. The reality (IMHO) is that many nurses (it especially seems like the older, more experienced ones especially on specialty units) act like aXX's especially towards younger, newer nurses. Few other professions would tolerate (medicine perhaps excepted) such behavior for more than a day. Even within this thread I saw evidence of this attitude when someone above made a post about how standards have been revised downward. Really? What is your evidence of this? I know that in my nursing class of 60 over 200 applicants applied and that the LOWEST accepted GPA was around 3.4. In addition, we were required to take 40 hours of tough science prerequisites before we could even apply. Even after all that we had an attrition rate approaching 40% only halfway through the program. Personally, I think these people are nothing less than petty and indeed Evil. If there in any justice in the universe they will pay for their behavior either in this life or the next.

Jessica, my wife read all of the replies except for yours (she had to get ready for work) and she promises to write her own response tommorow night (she has a meeting in the morning with her manager, preceptor, and unit educator about her progress/future). She said that I had one thing factually incorrect. Specifically, her preceptor admitted only to disconnecting the vacuum on the chest tube for two hours not for four. I am sorry for that error. You make a good point about health, but money is part of that equation as well. My wife, son and I have all been suffering from a cold that turned into bronchitis since early November. She has gone through three rounds of antibiotics and is much better (although she still has a slight intermittent cough) however, mine has grown progressively worse to the point where it feels like I have fluid in my lungs and in my ears (compounded with recent onset hypertension and daily nosebleeds). The difference of course is that she has health insurance and I don't so while they (my son and wife) take antibiotics, I take goldenseal, echinacia, tea and occassional garlic (not much because she says it makes me stink). The money that she had to give up to meet their schedule demands (because it meant working during the week, and giving up the weekend shift differential that she made for week end work in her old Med/Surg job) would more than pay for me to have health insurance. As to why her preceptor thinks that she was using an "acceptable" teaching method (assuming she was telling my wife the truth and not subjecting her to some sort of moral test as some here have suggested). I can only suppose that she doesn't believe that disconnecting a chest tube for a couple of hours places the patient in any sort of significant risk ( or that any risk is outweighted by the information that she believes it gives her about my wife's competence to care for patients in the ICU). My wife is actually dealing with the situation much better psychologically than she was even a few weeks ago. It used to be that I knew that every shift would be a battle just to keep her from telling them that she was quitting. Now, she seems to have somehow created some sort of "psychological space" where she goes in with the attitude that she's just going to do her best and "let God sort out the details". I really admire her and consider her to be a role model for myself in how she has dealt with this situation ( I didn't even mention that her mother who had been living with us for many years and helping with child care in exchange for living rent free, returned to her abusive husband this semester who also abused my wife as a child. So that is one more thing she has had to deal with in addition to going to school full time, having bronchitis, and providing much of the care for our son and her brother's infant daughter whom the parents have pretty much abandoned). She has also had to deal with a husband who after going into debt almost $40,000 in student loans drops out of nursing school (for reasons previously discussed) and has all of the earning power of a Wall Mart worker to show for his efforts (I do plan to go back and become a rad tech to support her through CRNA school, but even that will be difficult for the same reasons previously mentioned). Honestly, I think that many people would have cracked and either left in a fugue state or ended up in an asylum if subjected to the same stresses she has faced. I can't speak for her, but this experience has made me appreciate just how spectactular a person she is even more. I just want to see her standup for herself, speak the truth and let "the chips" fall where they will.

The Mrs. is still asleep, but I will try and get her to do a quick reply (or at least read the above posts) when she awakes, but before going back to work. First, let me clarify the chest tube suction was removed, but not the chest tube itself sorry for the confusion on that issue. Second, yes it appears my wife did "drop the ball" by missing this fact (assuming the theory about the preceptor lying to test my wife is not accurate). I have not asked her "how she could miss that" because I know that she is very busy often with two CRITICAL patients on many shifts (they have hourly glucose stablizers, many times 15 minutes vitals, lots of titration decisions et). Either because she is new or hasn't been taught she wasn't particularly "attuned" to that little ball and how important it is. Also, I know that some of her chest tube patients have had very low output, which would make disconnected suction less noticeable. However, at the end of the day it is also HER error for not catching the disconnect of suction and she takes responsibility for the error (and knowing my wife all it takes it one error and she almost never makes it again she is also "anal retentive" and will no doubt be checking suction on chest tubes a billion times per day for the rest of her life, like I said she is a perfectionist my exact opposite). My wife is an excellent nurse many of her nursing school instructors and her former Med/Surg manager commented that she had among the BEST clinical skills that they had witnessed in a student or newer nurse. Have there been other possible "deliberate acts" well the preceptor said so, but didn't say what they were. It is my opinion that the preceptor is not the type of person to make this up as somesort of "morality test", but I could be wrong. As to why she has had so many preceptors? Well they started her on days (even though she was hired to work weekend nights) and on days she had two or three different preceptors. Originally, they tried to accomodate her schedule for her one night a week class, and my nursing school schedule (because obviously she has to work on the same nights as her preceptor, and I had to leave for nursing classes at 0500 due to the two hour commute). This meant by necessity that she have different preceptors. Then in late Oct. they told her that they would no longer accomodate her schedule (which is when I withdrew from nursing school classes despite having the highest grade in my class of 60). She has had the same preceptor for approximately the last month. This particular preceptor is considered to be a good, experienced nurse, BUT also very anal retentive and something of a "busy body" (because she will often go all over the floor pointing out various charting errors, and ways that she would do a particular procedure better to other nurses). It is my impression that if my wife challenged her on this that the preceptor would take the attitude "so you want to play that game do you" and then "find" a million issues to get my wife in further trouble. Note also that she called me on a payphone shortly after her preceptor had confessed to doing this. I had warned her that this was a possibility, but frankly she considers me a "paranoid conspiracy theorist" (there is a saying that I like "just because you are paranoid doesn't mean that someone is NOT out to get you"). In addition, I didn't mean to imply that Med/Surg nursing was a "step back" in terms of professinalism or knowledge. However, it is a "step back" in terms of our CRNA school/ life plans. It would also be a shame in my opinion if the last four months of hard work and critical care classes go into some sort of "black hole" that cannot even be mentioned on her resume (because no one would consider it a plus to work for four months in an ICU internship only to have to leave again for Med/Surg). The current "master plan" calls for her applying to CRNA school with three years of ICU experience, her CCRN, a GPA of around 3.75 and GRE's which will probably like her SAT's be in the top 5% of all those who take the exam (note this will put her well above the minimum for most schools). Thus, if she has to do an extra year in Med Surg it will take a year longer to get that three years of ICU experience. My other point was that $50,000 per year or more in extra income that she could earn as a CRNA is "gone forever" if she loses a year. I also pointed out that $50,000 invested at 7% interest is worth more than 200K after twenty years so it is ALOT of money (more than many retire with). Is this over ambitious? Well, she graduated first in her highschool class, had 1500+ SAT's and wanted to be an M.D., but her father a fundamentalist minister didn't believe in women being alllowed to go to college let alone be Dr's. Also being in our mid 30's "time is of the essence" since right now we are no more than a couple paychecks from being homeless. Thus, even starting a retirement fund cannot come until she graduates from CRNA school. We also have about $60,000 in student loans ($38,000 of which is mine) so income is not a minor point (ideally as most of you know you should start saving for retirement no later than your late 20's). However, I also realize that it is ultimately in God's hands and that man's will (or women's) and plans will not overcome a destiny that he has in mine. Maybe that it part of the problem/answer in that I'm not sure that we have prayed about this issue the way that we should have(or at all for that matter).

Well since I wasn't there personally I cannot be absolutely sure it is the WHOLE story. Furthermore, the nurse stated exactly what she did (remove the chest tube to test my wife). In addition, I know my wife and she doesn't lie. She's not perfect, but she is a perfectionist by nature (she got all A+'s this semester despite working 50+ a week, orientating in a job that is virtually driving her to suicide, and taking care of her brother's out of wedlock eight month old child). The nurse in question has 25 years experience, and more importantly the "ear" of the manager. What's more she rarely takes patients since she usually has an orientee and also acts as unit secretary (and she has the orientee's take two patients from almost day one). She indicated to my wife that she had done several things (to see if my wife would pick up on them and that my wife had missed several). However, the only one that she specifically admitted to was the chest tube. Here's reality folks, if my wife makes an issue of this she will probably be "toast" at the hosipal. She might "win" the issue, but my instincts tell me that there would be payback in one manner or another (you don't take a nurse down with 25 years experience and who is friends with the unit manager without repercussions, it just doesn't happen). It's a good unit, considered one of the top in the city if not the region (at least by reputation). My question was simple is there anything in terms of laws or ethics that would make disconnecting a chest tube to "test" a nurse prima facia "over the line"? I could see how she might make a case for "testing" my wife, but to let the error continue for several hours (even though my wife should have caught the error) seems clearly over the line to the point of being a license issue. She has been "under a mircroscope" for about four weeks now (ironically ever sense she got this latest preceptor her sixth or seventh), but it's one thing to be "under a microscope" and something else entirely to be "set up for failure". She fears (my wife) that they may well place her in a position to not only lose her ICU job, but maybe her entire job with the hospital or even her license. On the flip side she worked very hard to get this opportunity (and has worked very, very, hard to keep it) so I hate to see her have to take a "step back" to Med surg. (which would be likely since she still doesn't have a full year as an RN, and it would probably be hard to get another ICU job having just failed at one). Indeed, a major reason why I withdrew from nursing school was to accomadate their schedule (her ICU's) which was entirely different from what they had promised. I will try to have her follow up this post, but it won't be until Friday since she is working tonight and has to go back in tommorow afternoon. One thing that she often says to me is that "I like the job, but despise being under the power of those whom I feel have at best indifferent, and at worst malicious intent." She actually told me that she sometimes wishes she would be involved in a car wreck just to spare her the agony of facing "that place" for another shift. I'm partially to blaime, in that I point out that quitting would probably mean "at least" another year before she can become a CRNA, and that probably means at least $50,000 in lost income (which when amortized over a 20 year investment period at an anticipated interest rate of 7% is more like $200,000 in lost income). We even discussed taking this post along with the one that she posted herself to her next evaluation next week where the nurse in question, and her unit manager will be present (along with all relevent replies). Just to demonstrate fully (to her manager) how frustrated that she was with the situation (and then if things go poorly to make sure the entire managment chain gets the same information). Of course I can't imagine that having a "pretty" outcome either.

My wife recently posted about the difficulties she has faced in a new ICU job. She is recluctent to leave because it was tough to find the position that she now has. However, just the other day when her preceptor asked her how she thought she was doing and my wife answered "fine" the preceptor basically said "well I've laid some traps for you that you haven't caught." For example (and this was the only specific that she admitted to) the preceptor said that she had disconnected one of client's chest tubes for four hours and that my wife had not caught the error. My response would have been "so you let a patient go without benefit of a chest tube for four hours due to a deliberate act?" . However, my wife simply smiled, said she would try harder, and learned to focus on the "floating ball" that indicates suction. My question is doing stuff like this (introducing errors to test whether the nurse will catch them and then letting those errors be implemented into patient care) ethical and legal?

What would be some of your criticism of the author's methodology? I am doing a review of this article for a statistics class and am looking for some fresh perspectives. Educational Levels of Hospital Nurses and Surgical Patient Mortality Linda H. Aiken, PhD, RN; Sean P. Clarke, PhD, RN; Robyn B. Cheung, PhD, RN; Douglas M. Sloane, PhD; Jeffrey H. Silber, MD, PhD JAMA. 2003;290:1617-1623. Context Growing evidence suggests that nurse staffing affects the quality of care in hospitals, but little is known about whether the educational composition of registered nurses (RNs) in hospitals is related to patient outcomes. Objective To examine whether the proportion of hospital RNs educated at the baccalaureate level or higher is associated with risk-adjusted mortality and failure to rescue (deaths in surgical patients with serious complications). Design, Setting, and Population Cross-sectional analyses of outcomes data for 232 342 general, orthopedic, and vascular surgery patients discharged from 168 nonfederal adult general Pennsylvania hospitals between April 1, 1998, and November 30, 1999, linked to administrative and survey data providing information on educational composition, staffing, and other characteristics. Main Outcome Measures Risk-adjusted patient mortality and failure to rescue within 30 days of admission associated with nurse educational level. Results The proportion of hospital RNs holding a bachelor's degree or higher ranged from 0% to 77% across the hospitals. After adjusting for patient characteristics and hospital structural characteristics (size, teaching status, level of technology), as well as for nurse staffing, nurse experience, and whether the patient's surgeon was board certified, a 10% increase in the proportion of nurses holding a bachelor's degree was associated with a 5% decrease in both the likelihood of patients dying within 30 days of admission and the odds of failure to rescue (odds ratio, 0.95; 95% confidence interval, 0.91-0.99 in both cases). Conclusion In hospitals with higher proportions of nurses educated at the baccalaureate level or higher, surgical patients experienced lower mortality and failure-to-rescue rates. Author Affiliations: Center for Health Outcomes and Policy Research, School of Nursing (Drs Aiken, Clarke, Cheung, and Sloane), Leonard Davis Institute of Health Economics (Drs Aiken, Clarke, and Silber), Department of Sociology (Dr Aiken), Population Studies Center (Drs Aiken, Clarke, and Sloane), and Departments of Pediatrics and Anesthesia, School of Medicine (Dr Silber), University of Pennsylvania, Philadelphia; and Center for Outcomes Research, Children's Hospital of Philadelphia (Dr Silber).

The thing is that Davis does include a section on "off label" uses however, in the case of Viagra none were referenced. My take is that if drugs are being used it is important for nurses to understand why whether or not the drug is FDA approved or being used in a nontraditional manner. Now if we can agree that it is important for nurses to understand even off label uses then most would probably also agree that there should be a standard reference which contains this information (understanding of course that off label uses are continually evolving and therefore no reference will ever be complete).

Thanks, your information also raises another question. Why is it that Davis (and I'm going to go out out a limb and assume that Lippencott, Mosby et al are the same) don't mention the off label uses for Viagra? Is there a text (or website) that extensively covers the off label uses of various drugs? Also, I just did a Google search and found this article that discussed Viagra after a CABG to reduce the chance of graft blockage http://www.chestjournal.org/cgi/content/full/128/4/3065

A client that my wife cared for in an ICU environment had Viagra prescribed BID. This was a post-op CABG scenario. Is there an off label use for the drug not in Davis where this would be appropriate?

Thanks for all of the advice it will be relayed along with some other suggestions. For me it is too late as I dropped out of nursing school this semester (I withdrew in November with a W). I was getting one of the highest grades in class, but struggling with getting my care plans complete by 0700 of my clinical day (our care plans had to be handwritten and averaged about 25 pages with drugs, ND's, interventions, patho, assessments, labs ect). This combined with my four hour commute (and the fact that I probably took longer than average to do my care plans) meant that I was literally not sleeping at all the night before clinicals. My program had approximately a 40% attrition rate by the thrid semester of a five semester program (and Spring semester would have been even harder since I would have had to do hand written care plans on two clients due the morning of clinicals). In any case, I will be attempting a radiographic technician program which will take approximately 14 months starting next June. On the plus side this will at least allow me to better support my family and will only involve a 30 minute commute. On the other hand I really did enjoy nursing even though I struggled with many of the skills (plus I will be graduating with 190 hours of college credit and only an Associates degree to show for it!!!).

The following email was sent to me by someone that I know asking for input. All of the names, and key identifying details of both the instructors, student, and locations have also been altered to protect the person's privacy. Honestly, I don't know what to say to this person because my wife comes home almost everynight in tears (she recently started an ICU position, I know many of you have objected in the past to my referencing her issues, but her experience in many ways mirrors this person's, which if nothing else proves that it's not just a male/female issue). I don't know how to change the hearts of people who seem to be inclined not to like you. What would you say to this person? So, the title may be a little misleading. I am not thinking about quitting Nursing school. However, I am already thinking of what else I can do with a nursing degree other than a floor nurse. We are currently on the 3rd floor, which is a neuro and orthopedic unit. The patient care is not overwhelming and I have learned a great deal from this particular unit. However, the nurses are extremely abrasive and they have that "Mrs X, Mrs. Y" (these are two instructors that we had together who were considered abrasive and unsympathetic by many students) attitude. During our clinical prep work we "discovered" that someone was going to receive an unsat day from the week prior (as you know we only get two before being required to drop the course). Everyone was on pins and needles during prep work and no one slept well. During clinicals the following morning Mrs T. (my clinical instructor) informed us that a nurse telephoned the Dept. Chair. Dr. Big the day after our previous clinical and informed her that (student nurse A) used the incorrect tape while doing a dressing change. Dr. Big immediately ordered Mrs T (my clinical instructor) to render an unsat day. Here is the kicker. 1.) Mrs. T assisted student nurse A in the dressing change 2.) The patient was not allergic to the tape student nurse A used 3.) Nothing negative occured because "the wrong" tape was used. For whatever reason, the nurse was upset that student nurse A did not use the type of tape she normally uses. My question is, why is something so minor so blown out of proportion? Call me crazy, call me paranoid but I adamantly believe I have encountered two particular nurses who do not like me soley because I am male. One nurse in particular goes straight to Dr. Big if I "did not do something correctly." For instance, this man hater approached me at 9:30 am on Thursday and stated, "I need you to discontinue your patients PCA pump." I replied, "ok, I will get my instructor to watch me." Keep in mind, there are 10 people in my clinical and aside from giving oral meds and making assessments we HAVE to have Mrs. T approve or assist us. As you already know, the PCA is full of morphine. Obviously, a student is prohibited from disassembling the machine and wasting the morphine. I alerted Mrs. T. to my scheduled task and she replied, "OK, we will do it later." In the meantime, I continue with patient care on BOTH of my patients (yes we now have to prep for two patients and do total patient care for both). At a little before 11am my nurse informed Mrs. T that she has already d/c the pump and that I was no where to be found. Oddly enough I was in my patients room giving him a bed bath. Mrs. T comes in and begins lecturing me. Insisting that I was not working with my nurse, etc... About an hour later the nurse then goes up to Mrs. T not me and informs her that I did not chart my neurovascular checks on one of my patients. I admit, I did indeed forget to chart that particular assessment but why couldn't the nurse approach me about it? Sure enough I got another grand lecture from Mrs. Cooper in front of everyone. Needless to say I was not happy. Roland, I have no clue what to do. I only have one semester left, so switching majors is not an option. But at the same time, I just don't see myself being a floor nurse. The attitudes are almost unbarable. Whenever I am around these nurses I remain silent and avoid them as much as possible. Infact, I think I am starting to become a little bitter and jaded, which is something that I do not want. Again, I like working with the patients and am compatible with the role of a nurse but am not compatible with "nurses." I have to get into a position of management, research or something. Any ideas, any suggestions? Even though doctors have a reputation for being condescending, I would much rather be around a Dr. than a nurse. While addressing student nurse A's clinical unsat day Mrs T said, "I don't know why but women love to talk and love to tattle tale. For some reason it's part of who we are." SENDING OUT AN SOS ...---...---...---...---...---...---...---...---...---...---...---...---...---...---...---...---...---

What do you think about my "reapplication hypothesis". Namely, that you will have a better chance reapplying to ten schools where you did not get accepted (I pick ten because it's a nice round number) than to ten new schools the following year (again the actual number could be three or five). Basically, I believe that the schools which rejected you the first time are likely (at least some of them) to give you a bit of a bump for tenacity. Ceteris Paribus obviously applies here we are assuming that the ten schools are not particularly unsuited to your profile (as compared to the other alternative where you might apply). I wonder if there might not be a thread over at student docotor.net or elsewhere where this approach has been discussed relative to medical schools (given that so many more students apply to medical schools each year than CRNA school there is likely to be more data on this approach).

Yes, you learned them because you are probably a bright, attentive nursing student with exceptional focus and attention to detail. I'm looking for things that will help the "mentally challenged" like myself who struggle to remember to put the cap back on the toothpaste and to not leave the electric burners on the stove on when they leave the house (okay perhaps I am beyond help, but others who are more borderline might not be).

Well that's good to know I still cannot imagine asking someone for a reference. Heck, I was too shy to ask people to even sign my year books in school. As to the school that had 240 applicants that is precisely why schools should have more of a "looking glass" policy when it comes to their admission standards. For example if I knew that the schools I were interested in only accepted 22 out of 240, I would be much more inclined to apply to more schools than if I thought they would be getting say 40 for those spots. Keep in mind that most of our cogitations apply to the "borderline" applicant. Those with high GPA's, years of CC experience, and good GRE scores will tend to get in even with a small number of applications. It's no great challenge to find a date for Tom Cruise or Tom Hanks that goes well. However, setting Danny Devito (without his money or fame) up on a date with a model that ends in a marriage is much more of a challenge and requires far more deliberation, cunning, and calculation. I've stated before and firmly believe that some schools tend to have higher average GPA's and lower applicant to accepted applicant ratios than do others. For example, I would wager that the schools in Penn, and Tenn as a whole receive fewer applicants per slot than say the schools in California. Also, I bet that the classes that start in the Winter/Spring receive fewer applicants than those which start in the fall (since more people will tend to graduate in the Spring, and thus hit their one to two years CC experience level in the Spring). I would also suppose that schools which have a 24 month program tend to get more applicants than those which require say 30 months to graduate. Also, those schools which require less Chemistry, and don't require Physics, and or the GRE probably get a few, fewer applicants per open slot (keep in mind for example that there are those with high GPA's who don't do well on standardized tests for whatever reason). All of these factors (and probably many others) can be considered and potentially utilized to give "Danny Devito" a better chance of finding love.

Okay, here's a couple more example's (I think) of the sorts of issues that could be easily missed or overlooked by newer nurses: 1. Never giving K via IV push (maybe I shouldn't say never since maybe you would to counteract some sort of acute hypokalemic situation that I cannot imagine right now). 2. Remembering to use an airtight seal for a chest tube that comes lose (such as petrolium jelly), but using a vent bandage (three sides sealed with one side loose) for a penetrating, open pneumothorax type injury. 3. Confusing mls, with units on insulin injections (I think I read a post here or somewhere where that occured). Okay, I'm looking for about a hundred more things just like this.

My main problem with the "shotgun" approach would be references. It will be hard enough for me to find three or four people who don't think I'm half crazy let alone thirty six! On the other hand given that I will go into my interviews with profound in your face honesty (Mr. Roland what is the most important reason that you want to be a CRNA. Me: well for the money of course let me explain.... as I go into a thirty minute diatribe of neo/conservative/libertarian rhetoric) it would probably take at least ten interviews for me to even have a shot. With that said the better applicant you are the less applications you will probably need to send. Furthermore, for some (myself included) the reality of finances and time mean that applying to more than about five schools is probably out of the question.