Gardengal

Ever since I took my first "blood bath" at work I have kept a full set of scrubs as spare at work. It has nothing to do with the weather, although when the weather gets rough-it's not uncommon for me to bring in an additional set and extra underwear and socks. I've been stuck at work before, and if I have my own stuff it's not too bad.

It's been 7 years since I was there, but there are 3 key hospitals in Lexington. Central Baptist Hospital, University of Ky, and St Joes. I worked at Central Baptist and liked it. The worst hospital at that time was Humana and wasn't really thought well of by nurses-it was changed to Columbia and I don't know what happened at that point. As I said-it's old info.

This thread concerns me from a legal and safety standpoint. Propofol is only indicated for intubated patients as an infusion. Bolus dosing may only be given with anesthesia. I do not as a nurse want to risk loss of respirations and an airway because I gave propofol to a non intubated patient-and will not do so despite pressure from some physicians who want to do a procedure. They'll say so and so- does it all the time and why can't i be like that nurse? My response is always -because I only work under my nurse practice act and do not choose to violate that-I then offer to call anesthesia to see when we can get the procedure scheduled appropriately. MDs back down. I then follow up with anyone the MD named and make sure that they understand the safety and legal ramifications of actions if what the MD is saying is true. Intubated patients having a procedure typically are not considered concious sedation since they have a protected airway. In these patient I still do not bolus with propofo because these are anesthesia doses and not covered under my licensure and nurse practice act. Be careful.

I don't know that there is a standard answer to your question. There are many areas in nursing where the frequency of exposure to gross stuff is less, but typically ou have to get some experience first. In general I would say that as a staff nurse there are some days that are grosser than others. Although I know that the bloodborne diseases require caution, I always felt better dealing with blood that vomit or feces because the smell didn't make me gag. I learned to keep Halls mentholyptis cough drops in my pocket. I could overcome any smell and gag response with the strong menthol smell-although several of my coworkers would ask if I was ever going to get over my cold. It kind of depends on the support of nursing assistants as to how many excrements you deal with. I spent many days on med surg and telemetry when my patients were all continent and just required assistance to the BR. I also have worked with many nursing assistants who have cleaned up my incontinent patients unaided. In ICU as a staff nurse I deal with something gross a few times a day. Even now, as a manager I still deal with it every few days. If I see something happening I'm there to help out so...it could be gross. My husband questioned if he could deal with the gross stuff when he started nursing school and clinical. The first day he said he didn't think he could handle it. Then, the dog got sick at home and he cleaned diarrhea stool several times. He told me about it when I got home and said it was really gross, but he felt bad because the dog looked so sick and ashamed. He said he focused more on worry about the dog and less about the task and realized that nursing couldn't be worse. A year later he tells me-the gross stuff isn't so bad after all and it really isn't constant all day. Maybe a cuple times a day or not at all on some days. If you are thinking of PA don't go to nursing school. I would only do that for nurse practitioner. By the way-when I was in nursing school I got sick every day at my part time job-working at McDonalds. The stale smell of old grease when we sloped the floor at closing and cleaning the milkshake machine was gross. I'd rather be a nurse.

We maintain a full census all year in our ICU except for maybe 1-2 weeks/year. We're usually looking for more staff instead of hoping not to be called off. Most of the staff would love an additional surprize day off. Years ago I worked staff in a facility where we had a big drop in summer census. When people started to get sick of being downstaffed, I volunteered to be farmed out elsewher for weeks at a time and we all won out. I gained a few new skills, learned more flexibiity, saved my vacation time. The other departments got the help they needed and my peers protectedtheir benefit time and paid hours. It was fun.

Like glassam, as a manager I deal with tardiness when it is an issue. I did terminate a nurse because of chronic tardiness, and it was upheld in grievance and when she fought it through unemployment. She was chronically late, and did not respond to questions regarding reasons, and efforts to assist her if needed. She would say, I just can't seem to get here on time....There was a 7 minute window to start times, so tardy didn't even count until after that time. I honestly didn't note her tardiness until If felt the rumbles in the unit and followed up. I learned at that point that instead of just accepting the total of 8 hours or 12 hours noted on the time sheet I needed to actually look at every minute. This nurse improved for about 1-2 weeks after I spoke with her then reverted right back to her disrespectful late ways. After almost a year of talking, counselling, trying to rearrange shifts, verbal warnings, written discipline, final written, suspension.. I had no choice but to go to termination. The funny thing about it was that she too was a really good nurse when she was there, but her late behavior caused a poor working environment and anger within her peer group. Her peers were not exactly happy to see her gone, because we all liked her, but everyone was relieved when we all respected each other's time. She would always say," but I have to get my children to school. " My response was typically that I understood that, but since several others in her area, in the same school district with the same time constraints could do it then I didn't see why she was any different. As we went further through our process I actually would tell ehr about other job opportunities which started 1/2 hour later...she'd say but I need to get home earlier than that, I can't get home late. I tried offering her 4 hour shifts, that wasn't aceptable either because she needed less work days. When we finally got to the end of the discipline trail she knew what was coming, but still thought that her priorities took precedence over her peers and those of the organization. After this learning experience I look at every minute on time sheets. When I begin to notice the beginnings of a problem I bring it up. My staff know that I do this and accept this. They also know that I will never tell them if I am disciplining someone, and would never tell anyonethat they are being disciplined. So...if I have someone who appears to be having an issue of any sort and they are angry about it they know that I am dealing with it, but they will never know the details.

Xtreme1, Your screen name says it all...this sure is an extreme one. You are absolutely right. She is obviously wrong.Obviously administration is viewing the severity of the situation to call her in. I do question their confidentiality however by you knowing that she refused to come in. For her confidentiality as an employee-they should not have revealed that and should instead have said that they are "arranging for her to come in and discuss it" The other real issue here though is the hostile and threatening environment that is resulting. There are whistleblower laws which should protect you, and if there is any witness to the call that in itself should be grounds for dismissal. Obviously what she did was also wrong and also grounds for dismissal and a board reportable offense. You did the correct thing, and I'm sure it is an enormously painful process. I recall the initial fallout I received from an accused individual and coworkers when I brought to light false narcotic documentation several years back. It led to an investigation and the nurse, choosing not to admit a problem , lost her job. I felt guilty for a while until I remembered that although the discharged nurse was gone because of my observations and complaint, she was the one who did wrong....to patients and the organization. Try to feel good about what you did, correctly in the protection of your patients. We are patient advocates and need to act in this way. Stick to your guns and try to ride it out. If it gets increasingly messy, insist on time off with pay while th eorganiztion deals with the issue. I would also recommend an unlisted phone number so you don't have to deal with harassing phone calls if you get any calls at home. I admire your integrity.Hang in there!

Have you ever been to the NTI? Did you enjoy it? I loved this past week at the NTI. I just had to share my enthusiasm for our profession, (and I think my husband is tired of the topic now that I've been home for a few hours). I just got back from the AACN (American Association of Critical Care Nurses) NTI (National Teaching Institute) annual critical care convention and can't contain my renewed energy and excitement for our profession. This year's conference had 6000 nurses attending and it was an awesome experience. The conference was in San Antonio Texas. The conference was great and the city was incredible. Anyone with any doubts about customer service programs should go to San Antonio. Every person I encountered was welcoming and warm and makes me want to return there. The conference as a whole was really good. Many vendors with info and freebies, many professional nurses with ideas to share, and a lot of fun. The conference is an almost week long annual event. It will be in Orlando FL next May. I hope to see many of you there. This was my 5th NTI. I think the best thing about the conference is the fun and friendship. It is such a joy to be able to talk to so many others who love nursing and go to this conference to get information and furtherpromote nursing. I am re-energized from my experience.

Night Owl: I agree with you with the exception of the JCAHO surprise visit. I sure wouldn't want the fall out institutionally for that. I'd deal with it internally and if inefective quit this unsafe situation...then report to the state after telling them I was doing so. I quit a management job because of my inability to make a discipline stick for sleeping on the job and poor care by an employee. (Not supported by human resources because how could I prove that the nurse was sleeping at the nurses station?-I had a written complaint of a coworker,(but only 1 of 5-no one else would document for fear of repercussions) vitals documented in the medical record which did not correlate with the bedside monitor in the ICU for the time frame , the employee when confronted who said that 'might have dozed off for a minute', and a patient who had a femoral IV line discovered by another nurse lying in the bed, blood dripping to the floor and the site already clotted. The other nurse entered the room because an IV pump was beeping. I couldn't see a question. The patient died a few hours later. I can't say it was directly related to the event, but it sure was contributory-exanguination is never really healthy. The RN in question had returned from a sleep break of at least 1 hour less than an hour previously according to the coworker. NO ONE should sleep while on the job. Lives depend on it. I do agree though that when on break anyone can nap(out of sight in the break room), as long as they wake themselves up and report back to work on time. It should not be a coworker's responsibility to come find you if you oversleep. That is taking them out of care giving while getting you. If you work with a staff who routinely naps on break everyone can quickly get acclimated to needing to wake up the previous co-worker. This is only OK if someone else is getting report from you as you leave to go on break, and a different person is giving report to the person coming back from break-otherwise you can have too many people gone at the same time and emergencies always happen when least expected. Having lived thorugh this, as an unsupported manager I agree with you wholeheartedly. Employee handbook says no sleeping or immediate dismissal. I have found that this is difficult because of permissive human resource practices which don't match policy and takes successive occurrences and much documentation to enforce. There is always a fear by an institution that things will be overturned because everyone is not following the same rule the same way. Vicious circle.

I would ask the coordinator of your trip. A physician at our hospital takes our expired stuff every year to India to clinics in poor areas when he goes home to visit. We give him all sorts of stuff. When I asked him about things do to expire soon he told me that as long as packages are intact so that we would not question sterility-he'd love to take it. When I questioned him about expiration dates he said "when I look at no supplies or supplies that are just not guaranteed perfect anymore, I'll take the not guaranteed. He looked at it as supplies that he could use there, which he would not have otherwise. NSS should not degrade so i wouldn't think it would be a problem of stability.

I think the tube system is a real timesaver. At my current place of employment it's a little limited though because it couldn't go into some areas without a lot of reconstuction so they chose not to include some areas. In a new hospital though it should be pretty straightforward. The tube system at my hospital was installed after I started there in th epast few years and has really improved our deliveries. If you can't sell the idea on decreased labor costs because of transport of items, maybe you can convince them with increased speed and efficacy of treatment: Lab tests run quicker because specimen goes straight to the lab instead of traveling in a basket while a phlebotomist draws more blood before returning to the lab. Blood transfusions can be given quicker because you don't have run for the blood. Documentation is more accurate because you get your addressograph plate sooner-so your chart has better identification. Forgotten meds with transfers can be tubed-so doses don't get missed. Pharmacy copies of orders can be tubed to pharmacy-speeding up order verification and then delivery. Old charts from medical records come sooner-better care and MD satisfaction Better transport times for patients to get to tests because escorts, and aides don't have to do the other trips. Remind them that salary costs are perpetual, and they would speed up delivery and decrease labor costs so the sytem would eventually pay for itself if your hospital is large enough.

zuchRN I love that idea. It sounds like fun and rewarding. How are the funds obtained though. Is there a budget for it? Are donations sought?

I look forward to learning from the publications cited by Edward, IL. It's a topic of great interest to me, but it looks like it will be a while until I can get it all read and digested.

Deespoohbear- I see you did what I did today, assessed what you did and thought about what could be billed. Ifind myself thinking that I belittle the nursing profession though by trying to state the tasks. For example, taken from your list: Started 2 IVs and discontinued an IV. I believe that your task was more than a task. You probably either had bad IVs or needed additional lines based on your knowledge of incompatability of meds and need for further. You started a new IV-I bet you probably taught the patient about what you were doing, allayed anxiety, gathered supplies, performed the procedure, assessed tolerance of the procedure and then used the new line for whatever reason you started it for - and then assessed tolerance for that. You then had to document this. The 3 prns you gave-You assessed your patients, decided they needed the meds, administered the meds, documented them, assessed efficacy and then documented more. For each of your interventions I see that we would underestimate our worth, if we can't spell it all out. I agree that it doesn't seem right to bill to the lower acuity patient the same as another which requires more care. Should we try to bill based on tasks though? Or more for the level of care which most hospitals seem to average out by billing for a type of bed and assigning a cost. ie regular nursing floor, telemetry, step down or ICU. I see why you would have been tired after your 12 hour shift, but I see it because I am attributing each task with an assumption about your patients needs.......it sounds like telemetry since you put a telemetry pack on one....... I don't know. I agree that we should be able to bill for nursing, but until we as a profession in general can assign an average cost to a standardized acuity level it sounds like just more work added to our plates. .......too many questions for my tired old mind today....

I think that one of the reasons charges are higher for some of the items we use when we do bill for them is because it costs to use them-ie foley charges, ng, etc. -cost to hospital is way different than to the patient. I can't think how we could bill for the critical thinking which is what differentiates nurses from techs. One of our biggest frustrations is that we spin our wheels coordinating all sorts of activities all at the same time. Kind of tough to bill that to one individual. Easier to group it as a charge in toto. Perhaps we could differentiate nursing charges based on where a patient fits into an acuity scale, but I still see a data entry work increase...is it worth it? a couple of other points-I don't think it's a male female thing. Our pharmacy, pt and xray departments are led by women. Also, I recall reading a book years ago about paternalism with hospitals and vaguely recall this topic (probably the same book referred to by Edward)-I believe our health care environment has changed quite a bit since the publishing date of 1975. Afterall DRGs came out in the mid 80s-and finances have gone down since then.