babs_rn

It concerns me that so many nurses need antianxiety or antidepressant medication just to get through what nursing demands of us. THAT should be the wakeup call to the employers...but it's not. Warm body, that's all they want. I don't have any advice for you, but I can tell you that I have been there too. More than once. And when all your off-time is spent recovering from your on-time, it becomes hard to find much worthwhile in life. I also left the clinical arena except for per-diem work and full time I work for an insurance company, and the flexibility is great, but the constant push for "productivity" by financial standards on top of clinical outcomes is quite something, and new to me. I've been an RN for 18 years. I have wanted to quit, and gone back to school periodically trying to get out of it, several times over the years. I find that focusing on the rewards, few as they may be, does help. But I know that I don't want to be a nurse at 50, which is why I'm going back to school again..this time, pre-med. Nursing is one of, if not THE, only degreed professions we have where the professional is treated like anything but.

As soon as they changed the "age of consent" law in this state from 15 to 16, aunt (and guardian) of soon-to-be-16 yr old (birthday in two weeks) brings the girl in, c/o "She had sex." Pressed statutory rape charges against the 19 yr old boyfriend, who now faced a felony sex offender charge and all that goes with that, including having to register as a sex offender for the rest of his life. Of course the place was crawling with (not too happy) police, an investigator, and DFCS. Not that I'm for 15 yr old girls having 19 yr old boyfriends, but I don't see having the boy go up for felony charges and using our ER to press it. I think it would be preferable to talk with the girl, rather than to mindlessly destroy her relationship with her.

Just my 2 cents' ... but I think it just has to do with the old phrase, "You can't teach an old dog new tricks." I'm not sure what's annoying about that...I've been around a good while myself...but always learned new tricks. I think if someone makes that self-assessment, it doesn't necessarily reflect on anyone else.

After 17 years in clinical nursing (including clinical management), I moved into case management a month ago. Working from home. Flexible hours. My body, mind, and soul are rapidly recovering from all those years of rotating shifts, extremely early mornings (2-3am in dialysis), having someone call my name every five seconds for 12-16 hours straight.....I have time and energy for my kids, the gym, to cook for myself instead of eating on the run....and a life. It has given me back my life, and pulling on those nearly two decades of clinical and people experience, puts me in a position to make a difference in people's lives - in a patient-first, provider-driven mindset. To get people what they need to keep them healthier and prevent unnecessary hospitalizations and disruptions in their lives. To be creative and resourceful in getting those needs met. To fill the cracks in the system. Do I love my job? Oh GOD yes.

I know it's a little late, been awhile since your post, but in the interest of discussion ... how long before this cbc was the stent placed? Acute Renal Failure might have something to do with it, in conjunction with the blood loss from her kidneys (which I hope has been investigated), plus any surgical procedures and/or inflammatory processes going on with her that would make her system resistant to even naturally produced erythropoeitin. All of this will cause a drop in hemoglobin. Typically we also investigate any possible GI bleeds, simple hemoccults, to rule out any further blood loss. Since it has been awhile, what was found and how is she doing now? Just out of curiosity....

No, I didn't think it would be the case with FMC. They HAVE to be competitive with everyone else at least. I have to wonder if Donnie has misunderstood the policy and just can't access the PTO time yet.

17 years as a nurse speaking here.... I moved away from Med/Surg very early on. Originally went for ACLS certification just so I could get off the floor and into the ER - which can be another hellhole often, but at least you don't see the same people for 12 hours straight and Hospital nursing is challenging and difficult and demanding and overwhelming. Nursing typically is. Floor nursing can also be very rife with criticism and shift feuds. It's good experience, and just the fact that you care enough to try to do the right thing and are overwhelmed by that speaks well of you and your patient care. Never let anyone tell you anything differently. Everyone makes mistakes, and I'd be willing to bet everyone has a crazy load - some nights more than others. I remember my nights as charge nurse on a 35-bed tele floor (only six months out of school). Charge and my own patient load (10 patients). And anytime a staff nurse got written up, the charge nurse got written up with her because of the Charge responsibility. It sucked. The previous response is correct - days are even more demanding (and generally paid less). You may have one or two fewer patients, but believe it or not, you have a lot more to do. A LOT more. Hang in there unless you get to the point where you can find nothing rewarding in what you do. Remember and cherish the times a patient says, "Thank You" or smiles at you or squeezes your hand. That means you've touched them in some way. That's important. That's what nursing is for. The rest is just tasking. Remember, too, that as you gain experience you will learn ways to organize your day and that there will be other options open to you for you to explore. In my years of nursing, I have worked in an OB/GYN office, ER (I still do per-diem), ICU (Good when the ER has burned you out on awake people) various med/surg floors, prisons, a nursing home (not good for me), and outpatient hemodialysis - most recently having left a position as manager of a large dialysis center and beginning a work from home case management position with an insurance company today. Remember that the world is your oyster. Never lose your principles, no matter how unpopular they may be sometimes with the powers-that-be. There are still a few nurse managers out there who believe in Nursing with a capital "N" and who will appreciate that in you. A suggestion to help you manage your day, taken from my own experience. At shift report, have a full size piece of paper and mark down each hour of the shift...7pm...8pm..9pm...etc. Use a pencil, because things change. Go through the Kardexes and for each patient, mark down under the appropriate hour when tasks are due: vitals, meds, dressing changes, etc. Keep in mind that you can sometimes combine them for the same patient ... stuff due at 7 and at 8 could be done at 7:30, for example, if you are in the room. Something due at 9 could be done at 9:30 if you are tied up with something else. Mark them off when complete. Add and subtract if orders change during the night. Realize that it's okay to say, "I'm tied up with a patient right now, but I'll be there as soon as I can." Be able to accept assistance, and to give assistance (makes folks more willing to help you) when you can. It really does make the night much more workable and easier to get through (not to mention go by faster!) Things that can be done at anytime during the night can then be planned for those hours that you have less stuff to do. It also cuts down on forgetting things because of being overwhelmed. Good luck to you, hun. We're rooting for ya. Barbara Good luck

A large corporation that doesn't offer PTO? That doesn't make any sense. Unless I'm mistaken, since Gambro's US operations were acquired by DaVita, that leaves only one major multinational dialysis company: FMC. DaVita had PTO and extended illness leave. I have never worked for FMC but I have worked around them and interviewed several of their nurses whose major complaint is pay, but I've never heard of no PTO. But since your company is a large corporation they should have HR available to you to ask these questions. I have to wonder if your administrator has maybe just cut it out temporarily due to low staffing or if your particular center is just giving y'all the shaft? Most companies do have a 90-day or so waiting period once you're hired before you can take advantage of time off benefits but I can't imagine one not having any available to any of their non-management staff at all, ever.

If you have a team that works together well and puts the patients' concerns first, then there's nothing about it TO hate. The early morning hours take some getting used to, and you might have to run late once in awhile if a patient has to have their access declotted and run afterward so you shouldn't plan anything on your workdays. But overall, it's a very, very rewarding job if the center is run like it should be. Give it a shot - hey - what do you have to lose? Make sure there is an adequate training program. You can get in over your head very easily if that is not in place. Good luck!

I just left my job as an administrator because I wanted it to be safe and I wanted it to be legal and right and I wanted the patients to be treated well - and I've been told that I made a huge difference - but the staff, oh the staff...if I never hear the words, "I don't care about everybody else. I'm just worried about me" ever again, it will still be too soon. And my response will be, "If that's your frame of mind, then you might want to reconsider your career direction because as a nurse and as a caregiver it's your JOB to be concerned about others besides yourself as well." I fired a nurse for sleeping in her car while on duty, and after doing so I had to keep an eye on the integrity of my tires because of the history of that staff (they like to slash their white managers' tires). On to case management. I am sorry about your experience. I would love to have had you come into my center. There's a major turnover going on there now, fresh blood coming in, and with the new acquisition by another company that I know well, all that stuff will finally stop - but it will be nasty for awhile. I simply had my fill. I started the change, and I am happy for my successor to finish it and see it through.

OnthegoRN, insurance companies do exactly that. There's telephonic case management and then field case management (where you work from home and visit clients who can't be managed telephonically).

Hi LabCat - I am surprised no one has answered you yet. I begin my new level in my nursing career as a case manager on Monday. I think your question can best be answered by the Case Management Practice page on the Clinical Case Management Certification website: http://www.ccmcertification.org/pages/13frame_set.html It gives the theory and description and lays it out pretty well. It's heavily based in the foundations of the Nursing Process, and as I stated to my interviewers, all nurses are case managers in one form or another. This is just doing it full time, away from the bedside. How much I enjoy my work and how much my hands will be tied will remain to be seen, but in theory at least, it seems to be based on what nursing should be to start with. Good luck!

Sorry all my ideas were already taken, I just didn't read all three pages first and now I can't seem to delete the whole post. Ah, well. Such is life.

Routine orders? No. Not with the K+. Your medical director might have developed a protocol but I haven't heard of it being a standard. In the osteodystrophy management the BMMs have been given more leeway in some areas in addressing the CA bath but not the K. Generally our docs will make changes based on the patients' K levels but if they're really high they need to run in the hospital anyhow. K, as we all know, directly affects the conductivity of the heart and a drastic change in that during a single treatment needs to be very closely monitored. As for smaller changes, it's simply not something I've heard of but then things change in healthcare (and particularly in dialysis) every day. Might be something to watch for.

That decub is another issue altogether. When contaminated with BM, that dressing has to come off and be replaced. Dialysis centers do not typically have that kind of wound dressing available and many companies have strict policies against changing or manipulating a wound dressing on the treatment floor (dialysis catheter dressings aside). And where else do you have to do all this? Maybe an exam room if you're lucky? Iso won't cut it because that's Hep B iso. And you might have patients running in there. Even if you don't at the moment, if you have an Iso patient who runs at all you can't use that. Yet you can't just leave a patient sitting in their own BM. Grey, grey, grey, grey, grey. It's challenging enough keeping patients turned and positioned in those chairs that are already so quick to contribute to a pressure ulcer in a compromised patient.

Good for the charge nurse for covering you! It could have potentially been very nasty for you. Absolutely the med nurse was in the wrong. The patient could have coded on her and what then? Would she have continued giving the Lomotil or Imodium or whatever NONEMERGENCY drug she was giving rather than take care of a crashing patient? Hey - just think. Soon you'll pass your boards and YOU can run and grab that hypertonic yourself. As for the documentation - you CYA'd. You didn't do it in an accusatory or unprofessional manner, you simply documented the situation. If something happened to the patient and you got pulled into court, you're covered. The med nurse is screwed. Nurses should cover for each other and help each other out, this is true - meaning simply that they shouldn't hang each other out to dry but NOT by falsifying anything. That med nurse left you - and the patient - out to dry. She apparently doesn't know how to prioritize care. I hope an incident report was written because that nurse needs to be dealt with either with a corrective action or with education or both. And it sounds like you have a great (thinking) charge nurse. That will carry you a long way.

You'd need to discuss that with the individual facilities. It's generally based on your experience, references, and the facility budget. It should be competitive. That's true in any company. There can't be much talk of specific salaries because they're in FTC negotiations finishing up the Gambro Healthcare acquisition so there's a lot that can't be said publicly. I know there are a number of positions in the LA area, however. I'm giving serious thought to travelling, myself (though NOT there - I'm a small town girl).

Are you in Florida? This sounds exactly like a patient we recently refused. Thank GOD. The nursing home they were going to send her to was uncomfortable with it, as the CD I was uncomfortable with it, and the doc's liason was uncomfortable with it. Bottom line (that we went with) was that if she needed constant or even just frequent suctioning there was no way she was going to get it en route between the center and the nursing home. Non-emergency transport can't do that, and EMS can't reliably deliver and pick up a patient on time because they have real emergencies - not to mention the act of Congress it takes to be able to get them reimbursed. So we refused on the basis of patient safety. I firmly hold to the belief that we are not set up for acute nor for custodial care. Patients like that need to be in a rehab hospital or - more mercifully - in hospice. But the families are what they are, and a little knowledge can be a dangerous thing. However, I do see a disturbing growth in what I call the "grey area" - patients who are too sick or incapable of caring for their basic needs and yet do not qualify for custodial care. We dialyze them to keep them breathing but quality of life is nil. It's a sad state we're in, and I firmly believe that just because you can do something doesn't always mean you should - but what can you do? Legal issues being what they are - look at the Schiavo case. It's a quagmire. I also firmly believe that as we have patients of higher acuities coming into the outpatient centers to dialyze eventually the dialysis companies are going to have to be forced to have facilities available TO bathe and change patients and may have to (one day) look at acuity-based staffing. There's a nightmare. The other option is to refuse these patients once CMS starts reimbursing based on outcome scoring because these are the ones who will bring your score down. Fun times ahead, I tell ya.

Personally I think "Marilyn" of the "Ask Marilyn" column should just keep her mouth shut about things she doesn't know anything about.

Well, it just might be one or the other. Two centers in our town are being sold (one Davita, one Gambro) and it was just announced today that FMC is buying RCG for 3.5 bill if the FTC approves it.

Yeh, here, too. All our Gambros are now Davitas. I'm a Gambro CD and it's not a done deal yet. Still waiting for the FTC approval. Meanwhile we're pretty much in the dark about what to expect, "business as usual". Though I do believe it's moving faster in the West than in the East. Not sure exactly why, except that DaVita's corporate offices are in CA/WA. I come from a DaVita background and am perfectly happy with the acquisition. Every company has its good points and its bad points, but I think good things will happen here (except that it gives staff and patients less of a choice).

I have to agree with you on that point. It is, more often than not, a matter of the individual center/clinic and the regional administration. I recently walked into a center that has had..mistakes made by staff due to lack of education, mistakes made in water treatment (also due to lack of sufficient understanding of the importance of the system), not to mention actual building/facility issues. In my 10 weeks here I have utilized the resources available, with the support of a fantastic RD, and have a heavy-duty training program going on, re-educating everyone from the basics on up. Those who are well familiar with the material can consider it a refresher, but everyone learns something (and once this is done no one can claim "I didnt' know")...building issues are being addressed though I pray for a new building when the acquisition is complete. I won't get into the differences between DaVita's and Gambro's computer systems. I will say I prefer DaVita's and look forward to working with it again. Just more user-friendly, but then it's newer, faster, and we're all entitled to our individual preferences. Staffing-wise, I work around a lot of Gambro CDs who are working the floor full time as charge nurses...and I know my day is coming there too. DaVita FAs have to do it too when there's a crunch, and in our state an RN has to have 6 months of dialysis experience in order to be able to charge. Six of one and half a dozen of the other on that end of things, we have 26 stations and often only one RN in house and with staff call-ins, she often winds up having to take a bay too. So that's not just a DaVita thing, that's an "available staffing" thing. For-profit companies are always going to be about the bottom line, period. The fact that they exist in healthcare is a topic for another forum.

Our various transplant centers will automatically disqualify a chronically noncompliant patient. No sense wasting a perfectly good kidney on someone who won't take care of it.

Yelling? no. Degradation? no. Making you feel stupid? Well, remember no one can make you feel stupid unless you let them. Your emotions are under no one's control but your own. But it makes you work harder, doesn't it? Or makes you quit. Separates the "men from the boys" so to speak. i think that's the purpose. May not be necessary for everyone, but it is necessary for some. It's still sink-or-swim out there. And yeah the students do work under the instructors' licenses so there's a lot at stake there. And if too many students flunk boards, the school loses its accreditation. So they only want to graduate students who will pass the boards and they will push the students to see what they're made of. Either they rise to the challenge or they quit. But it is as one instructor said once..."when I send you on your way, it means that I believe that you are safe enough to take care of my mother." And from what I hear, the schools here are about to lose their accreditation because of the kinds of nurses they're turning out. So see...its NOT just me.

Oh yeah. Had a doc who ordered Serum Porcelain Levels when a pt was a "crock" or FOS