TrafalgarRN

First and foremost i don't know how long you have been doing this to understand the union perspective. Let me give you a story....a long time ago , i worked in an Oncology floor and i had 6-8 patients on a night; 2 would be getting blood transfusions, 2 would be having platelets, 2 antibiotics e.t.c ...if this was not unsafe then tell me what unsafe is....management never cared and they simply stated that if you couldn't handle it then you might as well quit. I left that floor and went to the ER where on a regular day i would have 10 patients spread all over the department; you would have an MI, PE, GI Bleed under you care plus 7 other patients. Through an union, we united and were able to pass the ratios law in California. Since then life looks easy and it amazes me when the new generation of nurses can't even handle 4 patients and whine that the assignment is hard. Money...never unionized for money...it simply fell along with the demands for better working conditions. And yes i do this for the love...wouldn't do it for charity and its a stupid idea to suggest that since we love this we provide free services. I do it for the love and also appreciate the pay check. I unionize to prevent unfair practices e.g closing down floors, emergency rooms and other medical services in areas that are deemed " poor"...those are some of the reasons...so next time you see nurses marching they are probably mad that families will have to travel 60 miles away since the pediatrics floor has been closed so that the Big Man can make money. I stated that unionizing is hard and i don't recall demanding people to pay into it...but as a rule you have to join the union if you work in an unionized place. Its okay to be non-union.....> works for some. And then you wonder how the gap between the rich and poor has spread plus why the middle class is under assault.

Its amazing when i see people say we don't need any union and yet they come crying to AA when the Sh*t hits the fan. I see people cry about having 10 ER patients, 7 Medsurg Patients or even 4 ICU patients . I see people cry how they got laid off without reason since their boss hates them or even fired without any investigation. So many complains and yet when offered a chance to unionize they claim they are better off...so for those who don't want to unionize and have an opportunity i say tough luck. Back to the topic: 1. Union forever ; i would never cross a picket line. 2. Yes they are scabs...the money is good..there were rumors about people making almost $1500 for working a 12 hour shift + Transportation, accommodation... 3. We don't unionize for money...we unionize for better working conditions, patient safety, better treatment of workers....that's why i gladly pay my union dues and i see them work. 5 % increases a year, Patient ratios enforced; Clear guidelines on clinical ladder advancement, no mandatory overtime, no work place harassment , unfair firing practices e.t.c....> that's what a union is for. My union has fought for 3 successive contracts where i get free medical, dental and vision coverage....corporate attempted to take it once but we held six 1 day strikes and they got the message..yet they earned billions and claimed to be non-profit. Its not easy to be unionized; sacrifices have to be made. Its ridiculous when people buy management's position that unions will create loss of jobs ...blah...blah...> Yet same management withhold opportunities, wages,pay the CEO and other executives millions , benefits e.t.c ...but when it comes to nursing they downsize departments, don't hire enough staff and don't even pay them reasonable wages. Wake up people...smell the coffee

Hate to say this but it really gets better. The only problem is that many hospitals are rushing to implement the system lacking better implementation. I don't know what the rush is but i think its related to the new Health Legislation. I work for the biggest Healthcare in California and we use an Epic Based system tailored for the organization and have been Live for the last 3 years and loving it. But to get there the system was implemented in 2 phases. Phase I started in 2005-2008. In Phase the system was used to store medical information such as labs, imaging, EKG's and provider notes on ER and PCP visits. Nurses still had to chart on paper we used paper MAR's. MD's could do some charting but all orders were done on Paper. Phase II started in Mid 2008 where everything now was done on computer ; orders, labs, MAR and the cool part was scanning medications to ensure safety. By this time we were used to the system plus it took them 5 months of classes and test runs before we could go Live.And when we went live they had EPIC certified staff + IT work with us on the floor for another 2 months for support. Of course there were issues when we went live due to change but as of today we love the system and don't we hate it when there is a scheduled maintenance/update(which happens on nights) and we have to pull out the paper charts. Back to your case...i have a per-diem in a rural hospital ER which just implemented the system a month ago to an EPIC system. They were using IBEX. Everybody is frustrated since they only scheduled nurses for 3 days(18 hrs) of training one month before implementation and they only had EPIC staff + IT staff for only 2 weeks and they were gone. As an experienced Epic user i am getting afraid of the situation where orders are missed or people don't know where to find orders. We are unable to scan medications and in many instances people over ride medications. The purpose of EHR is to encourage efficiency and safety. And the worst part is that they have not uploaded old records into the new system. So i understand your frustration. As a Super User i have some tricks of dealing with bugs: - Have a white board or a book where people can write their concerns and problems with the system. - Have processes created for the common tasks e.g administering medications, I & O's, Lines, Vitals, e.t.c - Have a policy on what support personnel are supposed to chart in the system. For example the ED techs are able to chart vitals, make a note that an EKG was done and also enter the time, write a note about a splint placement e.t.c. Support staff should be discouraged from writing too much. - Every bug encountered should be logged and forwarded to system support staff in the IT dep't/ Help Desk. - Have weekly meetings between staff, management and super users to see if previous issues have been resolved. And after that it should be easy. Once you know where to find what you want it becomes easy and there is increased efficiency and flow. Pros of EHR's - Increased efficiency and Safety. - Better consolidation of information. Its easy for me to know more about patient condition and previous visits to department, mulch-disciplinary noted, easy access and compare data e.g labs(old and new) , visits, print old EKGS's, MD's can compare imaging, allergies all at one click where information has been verified and less easy to make a mistake. - Centralization of care. Everyone involved in the care can access the charts and care continues; hated it those days everybody wanted the chart and there were delays. Cons - Makes critical thinking seem redundant; there are order sets to be followed and some department policies are overtaken. 3 years ago i could order Tylenol for a baby with fever in Triage , draw labs based on systems, could administer a nebulizer to someone wheezing or even order an X-ray for someone with ankle pain. Today i can't and have to wait for the MD to see them. I can do some stuff without waiting for an MD e.g EKG, SL with blood draw when its definite we need them but i will have to wait for the MD to order the labs plus i will have to ensure that he/she enters the orders. Of course the MD expects that you did all this but they have to ensure the entries are done. - Nurses concentrate too much on the computer at the expense of the computers. MY argument is that you can always back chart what you have done. Just like they taught you in nursing school; first look at the patient. Sorry about the long rant but i hope this helps and trust me it will get better

Always put your foot down...i will be stern and tell them that if they can't be polite then i can't help them and they can get another nurse to take care of them or they can sign out and go home and follow up with their doctor. I am polite but if you want to be nasty i will treat you the same. And i will involve my charge nurse who will inform you of the same....and in my hospital we are allowed to write up such patients. I have had people scream and i leave them and tell them when they are ready to be polite and respectful then we can have a meaningful conversation as to how i can help them with their problem. And i will not hesitate to AMA. No grown up should be allowed to abuse you unless they have dementia or are psych. My managers are also for the same and wish all managers would be supportive of their staff. Always document and have witnesses since there are your best friends against accusations.

Did you say you guys tube blood through the pneumatic system? Are there no checks between the blood bank tech and the person picking up the blood? As to who was right; i would say whoever was following the written policy and procedure. As for tubing the blood ; i have never heard about such a system and as part of a Quality council i would be against that...blood needs hand over from one human to another.

1. When you are a frequent flyer and you are in my department to score a round of Narcotics. Hey its your life...if the provider orders its and your blood pressure and rest of the vitals are normal...i will gladly give it. Hey i love my job. 2. When you get those pain medications and can't get a ride to take you home. No i will not get a taxi voucher for you and if i see you drive off just imagine your surprise when you find the PD in your parking lot waiting to take you to jail for driving under the influence. 3. When provider orders don't care harm to my patients. I may have some suggestions for the provider and 99.5% of the time we work as a team and always have plan of care on what we shall do for the patient. 4. When you are a nurse from another department and want to tell me and the provider what we should do for you patient. Yes your family was involved in an MVA and he walked to the ambulance and didn't come on a backboard. Yes he has facial abrasions but that's not a worrying concern. And yes he waited for 1 hr because we were having 2 intubations back to back. Yes he has muscle aches but that doesn't warrant an EKG, Cardiac panels, MRI e.t.c. Yes he will get a Head CT and Facial CT at you insistence but we just gave the poor bastard radiation that he didn't need. Yes i know you are a nurse and i respect that but pedi and ED nursing don't mix. I took something called TNCC when i worked in a trauma center and this is not a trauma..wait till you see one. 5. When you come to the ER for you condition and you have not been taking care of yourself at home...Dang you have not taken your oral hypoglycemics for 1 year and you are worried your sugar is high...what made you wake up at 0300 and come to the ER? It seems you don't care about yourself....why should I? Yes you a 4'11 but dang...you shouldn't be weighing 400lbs...I'm not being mean but you need to take better care of yourself. 6. When i go above and beyond to provide learning information and yet you meet me 1 week later with the same symptoms...why the heck did you eat all that greasy food yet you have gallstone issues...i was your nurse last week for the same thing....remember all the diet handouts i gave you and tool an extra 15 minutes to go over them with both you and your significant other? What a water of time...i should have used that to go sit down and have a snack. You can continue....

Exactly...who cares who writes the orders..if you want you own orders then be a provider. There is always a reason for maintenance fluids....why would a sane person maintain a 500 ml/hr infusion rate on maintenance fluids? Dosage is based on age, weight and clinical condition. They don't need to have CHF to get a slow infusion rate...they might have hyponatremia e.t.c Then we have what we call neurotic...they need some IV fluids because they feel dehydrated and IV fluids makes them heal and "feel better". Just start then damn fluids at 125ml/hr and in 2 hrs the workup is complete and they are ready to go home... Phew And yet the patient may weigh 300 lbs and receive 0.5mg of Dilaudid...there is a reason for that. An a nurse you have the right to question orders that may compromise patient safety but don't complain just because the orders don't fit your convenience...Jeez!!!

Something i read somewhere and would love to share: You Might be an ER Nurse if: You consider a tongue depressor an eating utensil. You have ever tried to identify what a patient ate last by examining the barf on your shoes. You're at the grocery store, look down and notice you have at least 2 body fluids on you shoes and it doesn't bother you. You've ever rolled your eyes when the 14 year-old says, "No, I've never had sex"? You've ever told a confused patient your name was that of your co-worker and to HOLLER if they need help? You've ever passed on the green stuff at the buffet because you are certain you suctioned it from a patient earlier? You know it's a full moon without having to look at the sky. You've developed a crease between your brows from trying NOT to inhale the various human secretions you've encountered over the years. Eating microwave popcorn out of a clean bedpan is perfectly natural. You've been exposed to so many x-rays that you consider it a form of birth control. Your bladder can expand to the same size as a Winnebago's water tank. You believe Tylenol, Advil, or Excedrin provides a large part of your daily calorie intake requirements. You don't ask "frequent flyers" their history, you know it by heart. You can keep a straight face when a patient responds, "Just two beers." Your idea of a meal break is finishing your coffee before it gets cold You've ever bet on someone's blood alcohol level Discussing dismemberment over a meal seems perfectly normal You believe in the aerial spraying of Prozac You have encouraged obnoxious patients to sign out AMA so you don't have to deal with them any longer You believe the government should require a permit to reproduce You believe unspeakable evils will befall you if the word 'quiet' is uttered You have used the phrase 'health care reform' to terrify your co-workers You have witnessed the charge nurse muttering down the hallway, "Who's in charge of this mess anyway?" 25....Lets keep the list populating

Hey...if they called me to be a sitter i would go running :)...and it would be the most easy but boring 8 hrs of my life. But to your question...i have never worked in a place where they float ER nurses and from a legal point its a risk issue when you float to other floors where you are not trained. I would not have any idea what happened in the ICU, NICU, PACU, OR, Pedi e.t.c. I would fit in Telemetry and Med-Surg but i would still be apprehensive since i don't know what are their processes. The question is what units are being offered when you float? Is there any training offered? What happens if you say no? For the Research Paper...I would checking your state BON on Floating and then Google Scholar will help you piece the article...good luck:) PS: Some Link on the Issue from the Texas Board. http://www.bon.texas.gov/practice/faq-floating.html

Silence Kills ; Patient Safety Comes First; I never overlook when co-workers endanger patients through shortcuts. My family use the ED where I work and I want to be comfortable knowing that the right steps are being followed by in providing care. That goes for them and their families too. To the OP: 1. How come that the other Nurses never Reviewed the Chart? Was this nurse working straight 24 hours? I thought nurses were supposed to review their charts every shift? When i worked in a place with paper charts, i used to review the orders placed in a chart for the last 24 hours and ensure they were implemented despite getting report from the previous shift. 2. Stat Labs were ordered; the next shift got report that labs were ordered/ drawn ...or lets say they were not informed. Then it goes back to point 2 where i stated how come charts were not reviewed ? A LTC is a 24 hour care facility and things don't stop after 8 hrs...there are 2 more shifts. If the other shifts got report that labs were ordered/ drawn how come no one followed up and if they noticed no labs drawn why were they not ordered and had to wait for 4 days? Incompetency? 3. How come a blood thinner was administered for 6 days in a row...was it just the one nurse who initialed it for those days? And if he did it, what systems do you guys have for discontinuing medications. I have seen LTC nurses yellow it out and write in red ink " DISCONTUNUED". Did some previous shift forget to do it? And back to my main question...why were the charts not reviewed? 4. Procrit initialed as given but never given...did he borrow it from another patient? Did he get it from stock? Did he initial it as given for 4 days? Again Chart and MAR review for any every nurse who works in that unit. 5. Your work place seems to be lacking some efficiency and responsibility of care. There are no good process flows and the nursing management needs to implement effective processes. If you are the MDS who seems to have extra responsibilities in reviewing charts then i guess your next task will be to review charts that have new orders and ensure the nurses implement them effectively...that's an extra task but you seem to enjoy it. If labs are ordered then there needs to be a lab log....signed and dated that labs were drawn and sent to lab e.t.c.' 6. BON is creating a mountain out of a mole hole. Let management handle it for now and if you feel they are lax then call the State. The BON will investigate but its a life time process. I know nurses in California who are still practicing 5 years after complaints have been filed with the BON...their crimes include diversion, patient abuse...e.t.c. I think your state DPH would be the next course of action. 7. Last but not least there seems to be a Vendetta against this nurse. Whats there between the 2 of you? Your investigations are not impartial since you are not investigating what role other nurses played had plus you are not even trying to think of what solutions can be implemented to prevent this from happening. I would love to hear the whole story and the role others played. Thanks

@Kyprn...wish to defer for a minute....A New MD is certainly different from a New NP...Those rotations in med school are thousands of hours for clinicals....in residency you eat, live, shower, play in the hospital. Definitely the NP approach is different from the floor nurse but to get to that point you need continuous bedside clinical experience and not some 600 hours in the program clinicals. NP schools should enforce a 3 year minimum bedside experience before consideration. Back to the OP....thanks for hammering the point...its ridiculous that a BSN can graduated in January and then by August they have enrolled in an NP program. I would rather treat myself than see one of this for my care...and trust me they are out there flooding the healthcare system. I have experienced excellent NP's out there who are competent and know what they are doing but when you talk and listen to them, you realize that they honed their skills before becoming advanced practitioners. Ruby is expressing a genuine concern that needs to be looked into. Nurses follow provider orders but at the same time a clever nurse has to determine the rationale of those orders or question when in doubt. Otherwise it will end up being a lawsuit and the loss of that license you worked hard for.

Your location please

The patient has some serious psych issues because no normal person would have behaved like that. Manipulation, attention seeking are psych symptoms in my little world. But at the same time i agree that this guy should have been in jail or close Psych Unit and no ER or floor. I have only seen such characters at the jail psych unit where they are locked up 24-7 and when they refuse medications court orders are given to forcibly medicate. As psych nurse there is no way in hell i would try take care of such a patient. And yes the security guard should have been allowed to file charges; exposure to bodily fluids is no laughing matter. And last but not least as someone said....for hostile patients always go for Geodon...it works wonders. If not get an IV, put them on monitor + oxygen and then Ativan IV, Benadryl IV and Haldom IM if your facility allows it and patient is at risk for injury to self and the surroundings . ALWAYS BE SAFE.

Hello and sorry about you frustration but i have some basic rules to avoid poor reports. We have an electronic health system and when assignments are done i will take at least 5 minutes to review the records of the patients i am getting. We have a max of 4 patients in the ED but most times we have 3 except on those rare bad nights. I always have a blank piece of paper and will glance chief complaints; orders given and done; orders pending; labs, medications given and vitals and jot them down. I also quickly glance at the MD's notes to see what the plan of care since i'm one who gets really irritated when the nurse has no idea what we are planning to do for the patient. With such information I'm ready to receive report from the nurse and get extra information that i missed and it takes less than 15 minutes. In those 15 minutes i believe i have enough information. Then as a general rule we walk to the bedside together and at least the patient knows there is a change of shift plus if you left that urinal on the counter or your room looks like a tornado zone then you can clean up:)....your mama doesn't work here.That way there are less complaints and you can voice your concerns before the previous shift goes home. I learned it the hard way where i was being given subjective data but the objective was different. I don't care if the patient is cute and nice when for the last 4 hours you have done zilch.. If you are on a time constraint for report i would advise that you get to the floor at least 15 minutes early; review the charts and by report time you are up to date. And last not least bedside reports in critical/complex patients is a must..If i have an ICU patient i like being by the bedside as i get report. Hopefully this helps.

Mhhh....never heard of such method of administering Morphine or any other narcotics intravenously but as someone stated you are always covered by following the hospitals policy.I have seen many ways people administer IV narcotics but as a rule its prudent to push IV narcotics for 2-3 minutes.All my IV narcotics are diluted with 10 ml NS and pushed slowly. Some people don't dilute and will use a Carpuject and push the med and then flush. . So when you hang a 50ml bag whats the infusion rate? And is it safe to leave the patient with the bag infusing while you do other things before reassessment? Personally i would rather wait for those 3 minutes than hang a bag.