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jayebug

jayebug

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  1. jayebug

    Praise the Automaton?

    I guess, since it's nurses week, I've been reflecting on my career choice, and regardless of whether or not anyone wants to be subjected to any of my revelations, I thought it was necessary to share them. Lately, I've been thinking about what it means to be a nurse. In nursing school, I had an instructor who stated that nursing, as a career choice, is "a calling rather than a profession." I think her words stuck with me because it really defined how I view nursing practice. To me, a nurse is an educated professional who incorporates their continuously acquired knowledge and skill into the action of providing care and guidance to each specific patient in order to assure a more desirable health outcome. Wordy, I know, but let's just say that it's difficult to touch on every facet of nursing in one sentence, so I'm trying to describe here, what I view are the most important aspects. These are : education, patient instruction, implementation of a finely tuned skill set, and overall planning and collaboration. I purposefully did not include the execution of tasks or documentation of events here so much because I honestly don't believe that these are MOST important parts of nursing practice. And I never will. Of course, this always seems to cause an uproar amongst my colleagues. I think mostly because they're missing my point. I won't say that task completion or documentation isn't important. It is. But I find that, in the course of any given shift, nurses are so inundated with tasks and documentation that, really, in an attempt to deliver excellent patient care, one must really prioritize their actions. I'll give you an example. I recently had a patient who was admitted to my unit around midnight on a night shift with a diagnosis of pnuemonia and pancreatits. If you think about all those nursing diagnosis you learned in school, then I'm sure you understand that inadequate oxygen exchange, pain control, and fluid and electrolyte imbalance (secondary to vomiting) were the priorities when developing a care plan for this particular patient. So, I got report from the ambulance crew, and, after I insured the patient was well oxygenated via nasal cannula, I brought the bedside computer (or WOW) into the patient's room and completed the admission. I drew and sent his labs, reviewed the doctor's orders, checking specifically for pain medications and antibiotics, prepared for him to be sent for various scans and tests, and, after verifying his name and date of birth via ID band administered the appropriate medications. The patient had come to the unit via the health system owned ambulance company from a subsidiary hospital. The ID band that he had on was from that hospital, unfortunately, in all the hustle and bustle of his admission, I forgot to apply a new ID band. OK, not good. I admit my mistake. The ID band he had on looked identical to the ones that were specific to the hospital where I was working, because it was the same health system, but it didn't have the correct institution written on it. Upon discovering this, the day shift nurse alerted, I think, every possible disciplinary figure she could think of and, subsequently I had to answer to my nurse manager who described this as "a very serious issue". The upside, however, to my meeting with the nurse manager was that she emphasized the importance of bedside hand off in order to review anything that has been missed by the previous shift. I firmly believe in bedside report, although, many times I get a lot of resistance because I think that the other nurse feels as though I'm looking for things to bring to the attention of management, but honestly, I'm thinking of the patient and providing a smooth continuum of care. I can tell you that in the course of my 11 yr career, I have only "written up" two people and that was when patient safety had been seriously threatened or compromised. This goes back to my statement of what I think the most important aspects of nursing practice are in that I cannot prioritize the disciplinary action of another nurse over delivering patient care unless their actions are serious enough to merit this and/or are further unresolved by simply speaking to that person. The importance of appropriately prioritizing patient care related tasks and documentation is something that I feel is missing in the nursing profession. I use the above example as an illustration of this. My point being that with the recent*increase in litigation that has been occuring over the years, it seems that nurses are forced to view every minute detail of our interaction with patients as being especially relevant to their overall care. In all of the what was going on in the specific scenario I just described, I can really see how I missed the ID band because it was really at the bottom of my list of prioritized tasks that I'm certain would have been completed in entirety should I have had the time. I know. It's the age old "24 hr job" thought. Am I negating it's importance? No. I'm just saying it wasn't AS important as some of the other tasks that I actually did complete during my provision of care to this particular patient. I'm also concerned by, what I have seen in many facilities and would describe as, an emphasis on overdocumentation. The truth is, many facilities are keenly aware of the legal ramifications of providing an inadquate timeline of services rendered to the patient. The initial introduction of the nursing flowsheet was one way of establishing a "blow by blow" record of patient care services, status of a patient's condition, and reaction to treatment. However, it seems that a lot of nurses fail to view it as such, placing their emphasis on the written narrative instead. This quote is from a recent article I was reading from the American Hospital Association that stated: "One strong advantage is that flow sheet design can incorporate clearly defined expectations for the type of patients cared for on each unit and in each care setting. A standardization of forms process within each facility allows caregivers to provide consistency in patient assessment and documentation. The CBE system still requires POMR documentation of significant or abnormal findings yet does not require narrative noting when expected outcomes are achieved by nursing interventions. Charting by exception can reduce the amount of time spent on documentation.Charting by exception has the potential to be a great asset to electronic medical records documentation. The use of quickly scored checklists that document routine matters complement at-the-bedside computerized data entry. By shifting the emphasis from descriptive, discursive narrative paragraphs for every routine and expected event, CBE uses minimal narrative notes for only unexpected or highly significant events. CBE may be the cutting edge of medical documentation (Stansfield, K., Yetman, L., & Renwick, C., 2009). " In short, I'm not a note writer. I never will be. I guess my question, here, is if we are being provided with technology that allows for us to spend more time at the bedside, then why are we not using it appropriately? I also completely agree with decreasing the nurse to patient ratio, but I disagree with the idea of spending the extra time that this allows for by excessively documenting on those 4-5 patients. The article I quoted before also stated: "If it wasn't Charted, it wasn't Done"*is inaccurate and misleading,according to Dan Small of the legal firm Holland & Knight and Launa Rutherford of the firm Grower, Ketcham, Rutherford, Bronsor, Eide & Telan.Good documentation is important, they continue, but documentation is not care. "Nothing in the law requires health professionals to document everything they do or say. That would be impossible."*Charting should be "a way of trying to record things that give a fuller picture of the care", along with specific key elements essential for documentation." I worked at a very prestigious facility recently where the manager of my unit boasted about adequate ratios and the recent introduction of a paperless EMR system, but I still found that the staff was placing priority on written notes even when nothing untoward had occured during their shift. They justified this by saying that "it only takes a few minutes to write a note", but, as I stated before, why are we allowing for this to become just as crucial as caring for the patient at the bedside? I was under the impression that one of the reasons EMRs are becoming so popular in facilities was, not only, to standardize documentation but to make it less time consuming to meet the required standards for describing what happens to a patient during any given shift. I think that viewing the EMR as means to increase the volume of progress notes in a patients' chart is sadly erroneous and it keeps nurses away from their patients. In conclusion, I just wanted to share some of my thoughts and concerns about our practice during nurses' week. I agree that my views may be seen as non traditional, but I believe nursing is a professional occupation that should be open to evidence based actions. I tend to disagree with a non reflective, "just stick the pill in the cup" modality that still seems to be so popular, even amongst new nurses. I really think it's okay to not be an automaton!
  2. jayebug

    Unemployed experienced nurses

    I'm a RN in the Phila area with 11 yrs of telemetry /stepdown experience at UPENN. I tried homecare for a while, because, as a single parent, I thought it would help me have a normal schedule. But I ended up working 60 hrs/week, and I was only being paid for 40. I tried to go back to the hospital but was turned down for jobs (and even invitation only job fairs) left and right (shortage....what shortage?). I'm now a traveler because I can't find work. It seems like I'm in the same boat as the new grads because the hospitals prefer nurses who have between 2-5 yrs experience. Am I losing my mind, or is this a correct assessment? Anyone else in the same predicament?
  3. Hey all, I have temporal lobe ADD (no hyperactivity) secondary to a polymorphism of dopamine beta hydroxylase defienciency. In other words, I have behavioral symptoms and autonomic nervous system defecits that effect my blood pressure, blood sugar, lactation, temperature control etc. I do have a lot of trouble sitting still, and often fidget or shift my position, although my doctor thinks this could also be because sitting causes my blood pressure to drop and I'm naturally compelled to move because of this. I've been a nurse for 10 yrs, but my symptoms have been getting worse as I get older, which is common with this disorder, and now that I'm in my 40s, I find it hard to keep up with acute care nursing. I have trouble focusing, which is one of my biggest symptoms. I could literally space out for hours on end, which is what my brain seems to be comfortable doing because forcing myself to focus for extended periods leads to mental exhaustion. I wish I could have a series of small 5 minute breaks througout the day (nothing excessive, just totalling like 30 minutes or so) just to sit and let my mind rest. I'm on a hypoglycemic diet, which means I eat small, constant, high protein snacks throughout the day instead of 3 large meals which maintains my blood sugar, but also combats any post prandial drop in blood pressure (food coma). I'm also very sensitive to dehydration, so I have to drink a lot of water, so I'm also running to the bathroom a lot. I have mood swings too, which are also effected by low blood sugar or the fatigue associated with my low blood pressure. I take medication. Actually, I take Adderall IR (the extended release didn't seem to work all that well) 3 times a day when I'm working, and twice a day when I'm off. I tried Vyvanse, but the D amphetamines make me agitated. I can't take the sympathommetics because they don't control the behavioral symptoms. Adderall controls all of my symptoms to a certain extent. It actually calms me, allows me to focus, while at the same time supports my blood pressure, fatigue, and hypoglycemia. Acute care nursing doesn't seem to allow me to take care of myself in the way I need to in order to be at the top of my game. I realize a desk job would be perfect for me, but with the job market being so tight lately, it's hard to change specialties without any experience. I probably shouldn't have gotten into acute care in the first place, but I was only properly diagnosed with this disorder 2 years ago, and like I said, my symptoms get worse with age, so I've really only been feeling this way recently. I realize I could ask for accomodations but I'm very wary of revealing my disorder to my superiors because nursing seems to be such a disability phobic profession, and I know they can really find something to fire you for if they are uncomfortable. Has anybody had these issues? Any tips or tricks, or ways to talk to management that I haven't thought of? I'd love some input, thanks
  4. jayebug

    Ashamed of Disability

    Maybe psychiatric nursing isn't such a bad idea. I know you don't want to be reminded of your illness, but there's another side to that-one that maybe you're not considering. With all the stigma against people with mental illness, wouldn't it be great if your patients could see you working and contributing to society? If we hide ourselves away from the public at large, we're only conceding to the idea that mental illness is something that should be cloaked in secrecy. That we should be ashamed of ourselves, and drastically removing the mentally ill from the rest of the population is what perpetuates the stigma. Yes, maybe our direct managers should be made aware of our limitations, but that goes for anyone who has a chronic illness. Would you be ashamed of having diabetes, or cancer, or MS? OK, so maybe acute care in your case is like trying to fit a square peg into a round hole. But who wants to feel sub par every day, which is what working in that enviroment might do to you. You might be a mediocre acute care nurse, but an excellent psych nurse. And don't ya just want to be that-an excellent nurse?
  5. jayebug

    Low/moderate stress nursing jobs???

    I'm also looking for a low stress nursing job, and although my co-workers and I have had many conversations about what type of speciality could provide such an enviornment, I honestly don't know where to start. My Mom was an RNAC for a long time in a long term care facility, and said that that job wasn't really stressful, but I don't know if that's the ticket because of the paperwork. Paperwork is one of the things about this job that stresses me out the most. I've been a nurse for almost six years now, and, although I started out in critical care, I have been working pretty much the whole time in med-surg acute care. Right now, I live in CA, but I got my education and worked for four years on the East Coast. I woked on a predominantly cardiac floor-like post caths and ablations and stuff, and I didn't realize how good I had it. Back there, I wasn't even doing half the hard labor I'm doing now working on a med surg/tele/renal floor. I'm not saying that it's really geography, as much as it is the types of patients you work with (renal pts I think are the most diffcult in the acute care setting because they usually have soooo many co-morbidities that they are rendered virtually helpless, and I used to think you were doomed when your had heart problems-oh no, it's your kidneys!!) But since I've been a travel nurse (that's how I got to Cali), I'm also realizing that your stress level also has a lot to do with co workers, and bosses, and the actual facility itself. It seems to me that no place is perfect, and it almost scares me into thinking that no matter where you go, or where you work, every job has it's drawbacks, so what's the point of trying new things? I know-really negative huh?! I got into this because I really wanted to help people, but I'm finding it difficult to help when I'm buried under mountains of paperwork, feeling pressure from mgmt to worry about a budget that I know nothing about, and dealing with patients who are mentally ill who, via external circumstances, do not have the resources or the education to help themselves so the hospital just becomes another institution with a revolving door. Aaaah!!! And I do have to say that all this stress makes us turn on one another to boot. There's always somebody in my bosses' office complaining about another co worker, and from what I see, these complaints rarely have anything to do with patient outcome, but are more about petty little things like how you turn your hospital corners, or whether or not the patient has had a bath on a daily basis. I kid you not-one of my co workers got written up for eating cookies that were left out and unlabeled in the break room. Another nurse who witnessed this alleged cookie incident was apparently appalled that someone would eat cookies that were not specifically designated as their own. (what the heck???) Honestly, I'm sooo busy I can't figure out where anyone would have the time to pay attention to things like cookies, let alone write a note to the boss about it. And it also makes wonder what's NOT being done for their patient while this person is perseverating about baked goods. I was thinking that maybe if I got my master's (I have my bachelor's now) things would get better, but I was a CNA for 7 years before I got my BSN, thinking that once I had a degree I would feel much happier and more fufilled. So do I want to incur more student loans just to find out that no matter what you do, it's all really stressful? I'm even starting to think that I'm not cut out for this, which makes me sort of sad because I realize that I do have a BSN which is helpful, and I received some really top notch training, so I do have a lot to contribute, plus I really enjoy science-A and P was my favorite class-I thought it was so cool. . I just think I'd be able to serve my patients better if I wasn't so stressed out. Even if it's boring, I would like a job that's 9-5 (or some variation of it) where I could clock in and clock out and feel like I've actually done something for someone, and that I'm not going to take my work home with me and worry about it until I have to return in the morning. Does that job exist-or is it just a pipe dream?