Luv Nursing

Thank you so much for your insight. I felt like it was a "silly" question because to me, it's a no brainer for the reasons you pointed out in your post. There are Respiratory Nurses, you have home health nurses taking care of BIPAP, nurses manage vents in critical care settings, so obviously scope of practice is not the issue. However, a Resp. Manager is retalliating for another situation he was busted in, and is the kind of person who just makes stuff up....like the statement he made regarding the board of nursing telling him nurses could not do this. I hate it when people do stuff like that, especially when it's verifiable. I just was putting the question out there to find resources I can present to the Manager, but have actually found it to find anything really substantial to prove or disprove. Thank you for your comments!

I know this sounds silly, but I need to find out if RN's with demonstrated comepetencies, can set up BIPAP, or do they need a special cert? Having a dispute with RT and can't find specific info in Maryland Nurse Practice Act or in COMAR to support or disprove. Thank you!

I understand completely what you are saying. Document, document, document and do everything you can to protect yourself. Is it not crazy we have a mojor nursing shortage and yet EVERYWHERE, there is a hiring freeze going on. There have to be policies regarding staff safety, if nothing else....a grievance procedure. You should be protected by Whistle Blower Act...and if nothing else, the general public would a field day with firing a single mother being forced to put her physical being in regular jeporady versus working to feed her kids.

Thank you so much guys for your responses so far. In answer to your questions, the Pharmacist "doesn't have to work" meaning he is doing us a favor because he doesn't need the $...and Risk Management is a totally different issue. Our Risk manager is the CEO....and very non-confrontational....and is the person who brought the pharmacist on board here. In fact, the Risk Manager pretty much listens/does/believes what the pharmacist says. I'm the Unit Manager, Nurse Leadership has been dealing with this for a long time, and my boss, the DON is just as outspoken about it as I am, but again, its the only the CEO who can force any issue.....As for the tech....the tech was a CNA who has been given a false sense of security in "you can do that"...and truly isn't intelligent enough to research or understand the regs for scope of practice. They just go on "the pharmacist says...." So you can see how shaky/dangerous a situation this is. I'm just covering my bases to see if I'm interpreting Maryland's COMAR correctly so I can cover my own but. Looking forward to any other assistance/suggestions.

I'm dying to know how things turned out. As a Nurse Manager, my first thing would be to remind everyone "involved" that incident reports are not punitive, but a way to evaluate for possibly a system proccess flaw. (Of course, if you have one person repeating the same thing over and over and over...then you have an individual issue, still not punitive.) I also agree with the others. If you came to me with the facts as noted above...I would in no way have any issue with your actions. It sounds as you did exactly what you should have. If you don't mind, will you let us know how you made out? I hope well.

My God! You can't possibly stay there, forget your license, your physical being is obviously at risk! I cannot fathom any agency allowing their staff to be subjected to this. I would start looking at regulatory agencies for support, quick! Good luck and I hope you stay safe.

I'm a nurse in the state of Maryland. There's been an on-ging debate - situation regarding utilizing a pharmacy tech in the hospital. The pharmacy tech, who was grandfathered in by the pharmacist, has a key to the pharmacy, is physicially in the pharmacy when the pharmacist is not in the pharmacy, (sometimes in another building, sometimes not at the hospital at all), inventories/fills the pyxis with meds when again, the pharmacist is not there to verify the medications. My understanding of COMAR Regs state the tech cannot be in the pharmacy without the pharmacist being in there, nor can the tech dispense any medications without oversight from the pharmacist. These practices have been long and on going, and are obviously for pharmacist conveinence as we are such a small hospital you cannot justify needing a tech to assist. As a manager of an acute unit, I've tried many times to tactfully and then directly with both the tech and the pharmacist address these on going practices. Most recently we've had "saves" due to the vigilence of the nursing staff, when the the wrong med or doseage was placed in the pyxis by the tech. Most recent was this morning, when the tech came into put the correct medication in the bin....and the pharmacist is not even here. We have protocols in the event of an emergency as well as for persons entering the pharmacy. The problem is, the pharmacist has not only allowed but has encouraged the tech, giving the tech a false sense of security. This has gone up to the corporate compliance level, but I feel confident, I will have to lodge a formal complaint against the two of them with their licensing board before there will be any lasting change in behavior. Can anyone tell me if I am right/wrong, about my understanding of the regs and the scope of practice for a pharmacy tech? How are techs utilized in other facilites as far as scope of practice. Thank you!!!

I've posted before regarding needing something concrete, so I can see we are all in the same boat. I've develped some spreadsheets I use for personal uses, that all me to show a more clear picture as to what the staffing vs. census/acuity is. Of course, it means nothing to non-clinical persons who are controlling the situation (HR, CEO, etc) but it at least shows you are actively keeping an eye on things as well as those non-clinical persons who are giving you the grief don't have a CLUE of all the realities and possibilities. It may be timing consuming to enter your data, but if you'll send me your e-mail, I'll be happy to send it to you. The spreadsheet is in Excel just as a heads up. My e-mail is [email protected]

Dear Beachlover, You're not rambling, you're venting to keep your sanity so you can go face another day.....somehthing nurses everywhere understand. Here's another thought for you and for Melinurse, Come October...CMS guidelines will go into effect for many things....one being patient falls. Basically, it is expected no patient should ever receive and injury from a fall, or should even fall. This of course is crazy because unless you have a staff member attached to every patient's side, you can not control what they do, no matter how many protocols and processes you have in place. Starting October, anything that is related to a fall, diagnostics, extended stay in the hospital, tx, etc., will not be reimbursed for by Medicare....and the hospital will have to pay for it. That alone is a good argument for more reasonable ratios. Once the hospital is shelling out money regularly for these types of things.....compare the cost of staffing to that and it's no contest. As for "running your mouth about being united", you're doing the right thing. We have a group of managers where I work, who work our butts off. If there is a committe, chances are we are on it, not by choice. We do EVERYTHING you can imagine, include researching regulations and such that are really other emloyee's responsisbilities ( HR, HIM, etc) because we know they are looking us in the eye lying, or bending the policy to whatever suits them at the moment. While doing all this, we get continually slammed by these same people....and we all feel like flipping someone off and then running for the hills on a daily basis. While we feel this way, we've discovered the trick is We all have to have our "that's it, I'm outta here" days on a different day. That way we can vent and the other can remind us that yea, it really sucks and makes our lives totally difficult, but even though we feel like we're spinning our wheels, we KNOW we can't accomplish anything if we're not here. And as our awesome DON states, We are here for the patients and for our staff. Be really good at your job, be respectful when going against the powers that be, and never back down when it comes to your patients or your license. Good Luck!

Quick thought- I totally understand where you are coming from, and trust me, your department manager doesn't like nor much less agree with staffing from a budget perspective, but budgets do have to be taken into consideration. For instance, is there a process if the census is low, that people can be placed on call and reasonably compensated? Managers spend a great deal of time proving on paper why there are days that 5 patients are much worse than 12 or 15. The 1:6 ratio is in place because that is what I feel to be appropriate based on our drg's, acuity levels, etc. I am EXTREMELY FORTUNATE to have a DON who supports their department managers and who puts Patient care and safety First, Middle, and last, and would be fired before putting anyone in potential jepordy. Having said that, before you leave, talk to your dept. manager. If I were your manager, I would ask you to write a letter to me stating your concerns and your real thoughts of resigning; emphesizing it is not about money, but about the patient's care, safety as well as yours. Let your manager know you understand it is often out of their hands (many are in a position that if they don't do what the higher up's want, they'll be fired and someone else will be hired to do it.) but you feel the Executives need to know the seriousness of all the experienced nurses leaving and your nervousness as well. Then I would take that manager to next in my chain of command. A large departure of experienced nurses usually means one of two things... 1) A group of staff who has "run the floor" for a long time and has usually gotten away with everything (they are above the P&P's) are now being held accountable or 2) There is a real problem with patient care and safety as well as staff safety. Anyone and everyone has to ultimately protect themself...and if that many experienced nurses leave because they are worried for the patient or for their license...well someone will hopefully listen. I wish you the best of luck and remember.....there's teamwork, and then there is integrity. When you feel like you are having to truly compromise your integrity, it is time to move on.

Dear Talino, Outstanding and THANK YOU!!

I manage a Med Surg unit in name, but we are in reality a PCU as we keep cardiac drips and insulin infusions. Since taking over as the manager, I've instituted a 1 nurse to 6 patient ratio for both days and nights. I've done both shifts, as a floor nurse, and as the house supervisor on nights before this and do not buy in the "it's less busy on nights" theory. We do not have respiratory here at nights, so our nurses do all Nebs, CPT, I/S, etc. In addition, our ER has 1 doc, 1 tech and 1 nurse from 7p-7am and 1 7p-11p, so there is not really any additional help is the ER is busy and something happens. I also am of the strong mind that medicine chages daily and our patient care should as well. We are a small hospital ( 1 in-patient floor for the hospital) that can house 18 beds, surge to 22 if necessary. We have tele and the drips as I mention before. The bigger hospitals think we are a bunch of bumbling idots because we don't have all the capabilities they do...but countless times when a patient is beginning to crash, I've had to beg the patient to let us transfer them to the bigger hospital. I've actually said before," your heart rate can not keep beating at 200 beats a minute for much longer" (despite medication and cardiovert) " if you were my dad I would beg you to transfer. If you don't want to go, I need to know what do you want us to do when your heart stops beating..." These patients do not want to go because they DO NOT GET THE QUALITY OF CARE IN THE TIMELY MANNER they get here because of their larger ratios. Also, personal research has shown me that many med surg units are trying to get to a 1-5 or 1-6 ratio. I don't think it is unreasonable. However, no matter what, ratios must take acutiy and staffing ability/experience into account before any decision is made.

Pyxis are great! The pyxis is a large unit that houses anything you want it to- medications, narcotics, supplies, etc. The purpose of the pyxis is to provide a point of service billing for whatever is pulled out. When you pull an item out, it is done under the patients name, which then is automatically billed to that person's account number. To have access, you must have your entry system ( for us it is your initials and then your fingerprint via biometrics) and then pull want you need, enter the # your taking and then exit out. Asside from capturing a lot of otherwised missed charges, you can run reports based on a certain patient/staff/medication/etc. For example, we had a situation of a travel nurse who was stealing narcotics and ambien from patients. I was able to request a report for all narcotics and ambien pulled by that nurse and was able to discern this had been going on for much longer than we knew and was being pulled from patients assigned to other nurses as well. Additonaly, when narcotics are pulled, only the number you request is dispensed, so if you have 20 morphine cartridges in the pyxis and need 1, you won't have to count the whole 20 before taking any. This system has also allowed us to having to physically count narcotics every 24 hours vs every shift (we work 12 hour shifts). It takes a little time for staff to get used to when using it for supplies, but from the manager's stand point, it is very used to and the staff will get over it quickly. I highly reccomend them to everyone.

Thank you to everyone who's given me some great suggestions. Please keep them coming. I had already spoke to the Medical Director, the Medical Director had spoke to the Physician, and unfortunately, our Physicians are rarely (if ever) "forced" to do anything. The CEO takes an active "do not deal with it" approach with everything and everyone. The medical director is contacting our lawer regarding this (by the way, our CEO is our Risk Manager...how appropriate and effective is that?!) and I'm going to contact our local LTC's and see what they receive in the form of paperwork from patients discharged from other hospitals. Any more suggestions, I'm listening. And thank you again!!

Hey ya'll, I'm actually an acute unit manager but I'm having difficulty with a physician that involves LTC. This physcian refuses to write medication orders on the In-patient hospital physician discharge orders form. He writes next to the medications the word "Recommendations". His take is that by law, he can not write orders for a patient where he does not have privleges. This comes up every few months or so (and then he complies until he gets a bug up his bum). Each time he is told federal regs state LTC must have the discharge summary,(which we have always used the discharge orders) with the patient's medications or they can not take the patient. I've repeatedly tried (as the Medical Director has explained to him as well) that he is writing discharge orders from the hospital (as if he is going home) and not admission orders to the Nursing Home Facility. Today we went 10 minutes on the phone with him telling me literally that everyone else is wrong and he is interpreting the regs correctly. He asked me what it was the LTC facility wanted specifically, and I told him the word "recommendations" could not be on the form. I told him regardless of his feelings and even if we are all wrong, the patient has not left the floor and will not go to a nursing home as his physician discharge orders stand. Can anyone help me out? Any specific regs regarding this, better way to explain this? I'm dreading tomorrow morning because if he doesn't round on the patient he knows is here, we'll have another issue to contend with. Appreciate your help greatly! Also, due to renovation, we have Rehab patients on our floor now so we have Acute hospital regs and LTC regs (which we know nothing about and have had little inservice to help us) to contend with as well. If anyone has some good links or info I could look for LTC help with I'd appreciate it even more!