Turk182

I always smile when I see a post with someone who works in a "small rural hospital" and the bed capacity is 30 or plus. I also work at a small rural hospital, but we have one in patient floor with the capacity for 16 -18 beds. A while ago we implemented the Rapid Intervention Team (RIT), the same concept as the Rapid Response Team hype that's all the buzz now. We do not have Respiratory in house 24 hours (and they don't intubate, only the physicians do) but the basic set up goes like this: A person requiring activation of the RIT, has been defined as a rapidly detiorating person/patient, or one that may require the use of emergency equipment. To activate the team, where ever the situation has occurred, the page is made overhead (by the department/person, etc.) as "RIT" and then the location. To help differeniate (sp?) the deteriorating / unconcious person, from the the true Code Blue, overhead page would be made as "RIT Code Blue" and again the location. We have a standard team set up that is the same for days and nights. The team consist of : 2 ER staff ( preferably the ER physician and nurse, but it may be the nurse and tech, the doc and tech, depending on what is happening in the ER, but all must be ACLS certified including the tech) 1 ACLS certified nurse from the Med Surg unit ( our in- patient unit ) 1 BLS certified CNA from the Med Surg unit 1 Respiratory staff (if they are there at that time. Otherwise, they would be called in if necessary). On our night shift, we have 1 ER doc, 1 ER tech, 1 ER nurse, so should a RIT be called, the ER nurse (who is also the night shift supervisor) may designate another appropriate person to go in his/her place if necessary, and would call the on call ER nurse in to cover the ER during this time. Daily RIT assignments are made and posted on each department's monthly schedule. In addition to that, I have them posted on the daily staffing / patient assignment sheet as well. There have been challanges and I've only shared the bare bones of it, but I'm more than happy to provide a copy of our policy to anyone or answer any questions you might have with starting a team up. Hope this helps!

As the manager of a Med Surg floor, I have read and fully appreciated every posted comment relating to this subject. I think everyone has hit on a valid point of some aspect or another, and for the record, I know how hard you work! I'm not so sure Med Surg nursing itself has the bad rap, but more like the working conditions and expectactions that are asked of you each shift. Add to that a changing census every few hours, the co-morbidities for each patient, and the endless change and ever more difficult to meet regulatory agency requirements, ....well you take all that and then be the lowest paying hospital in your "region", (or lower paid nurse because it's not perceived as difficult as ER/ICU) I can see why the new grads are hesitant to sign on. Med Surg doesn't have that "glamor" of the drama and trauma that is perceived with ER or ICU nursing. But it can, if we promote it. You know all the hype now about "Rapid Response Teams" ? Well who did that before they came on the scene? The Medical Surgical Nurse, who sensed that "something wasn't right" or just felt like " if this one crashes, it'll be fast." The Med Surg nurse "saved their life" then and continues to be the first in line to do so now. Pull a new nurse in on a "bad" patient as soon as the opprotunity comes up, let them place a second IV line, or document. But get them involved and they'll get the same Adreneline rush the ER nurse does with a priority one patient. A quick after thought, I was in the ER for several years, and LOVED it, becasue I loved the drama and trauma.... the having to think quick on my feet. Since transferring to a Med Surg Managers position, I've found the same number of opprotunities of turning around a bad situation. And while I certainly do not want to encourage "speciality nursing bickering", do you know an un-recognized difference between and ER nurse and a Med Surg Nurse ? The ER nurse knows their patient is there for a finite amount of time and will be going somewhere before their shift is over (usually)... the Med Surg Nurse will continue to have a case load for 12 hours, with ER admissions, direct admits, discharges, transfers, etc....because if the patient load isn't there for them to care for, guess who gets placed on call? Not the ER Nurse. I applaud your dedication, and hope we can all work to promote the "coolness" of this specialty nurisng. Thank you from all the Med Surg Managers out there who are really trying to do right by the staff and the patients!

Another thing to consider, who placing the IV/heplock? In my experience, many times the ER tech, not the nurse will place the site. Often they want to be assured of a "sure" thing and not feel like other's are judging their skill if they don't get a site. I was the night nurse in the ER for 5 years and then moved to Med Surg as a mangaer so I've seen both sides of the coin. We resolved this by talking with the ER manager who passed it along to her techs and it got better. There are always obvious reasons why the site went into the AC in the first place, but if the tech understands you really need to save that spot for a true emergent situation, and that its not a critique of their skill, their much more likely to leave the AC alone. Besides, how will you ever get better if you always go for the easy one?

Bravo to all of us who keep plugging along! If you've read my first post from when I took over as the manager of a Med-Surg unit at a small rural hospital, you'll know how frustrated I was with many of the things that have been posted recently. I still go nuts over the lazy worker, or the one who calls in all the time - but I go even more nuts with the system that allows them to stay and prohibits me to let them go. "At will employee/employer" is a joke. I would never approach HR about letting somebody go if I didn't feel like I had the documentation/proof to support it, but it never seems to be enough. I do feel like I am spending more time than I should be spending on telling employees they need to come to work. It seems like I can't get ahead, ever.....because I'm dealing with an issue that shouldn't be an issue in the first place or I'm having to clean up a mess that wasn't created by my staff. My biggest pet peeve, as well as lack of work ethic? Why can't anyone say " I was wrong/ I forgot/ I didn't know" If people put 1/4 the effort of just stepping up to the plate, half of the problems wouldn't be a problem at all. Today was horrible for me and I came home early. I was mad, frustrated, and thinking why even bother? But, after a 45 minute "nap", I sit here and realize that I bother because I do care. I care what happens to nursing as a profession and the perception people have of a nurse. I care about the hospital I work at and the good things I've seen. I care about the good people who work there and work hard. I care that I do a good job, and that I make positive changes. I realize that I have made positive changes. - And then I realize that it was just a really bad day, because of a bad situation, and that if I don't continue "to bother", the next person who comes along may not care as much. There are so many things I can't control ( the computers we desperately need, the new tele we need, the staffing we need, the $ they deserve to get, staff in other departments who are never held accountable for whatever reason) if I focus on those things, I will never accomplish what I want to do. And I am sooooo glad there is a place like this where I can see that I am not the only one. And that is just as important to me as anything else. So raise a glass to yourself ( mine is filled with rum after this day) and all of the other manager's who keep doing the very best they can, whatever the circumstance! We do make a difference!!!

Mr. "RNPATL", Dude, you're awesome. I can't count how many postings I've read from you that were soooo helpful. There was absolutely no orientation to my management postition when I started 1 1/2 year ago as the manager had quit months before and the Nurse director was filling in while doing her job. Thank you for all your advice, and for god's sake, please keep reading and posting. You are a tremendous help in explaining the basics!!

Before leaving for work, I sat down to find some help with what is evident to be a monumental problem everywhere. I've been a manager for almost 1 1/2 year now, and feel like I'm not making any headway either. We are a small hospital, one floor, and we take everything we possibly can. Often we have patients who qualify for a CCU step down unit, along with post/ops, internal med and those "social" admissions because the doc knows the family and won't say "no" to the uneccessary admission. Our census fluctates so crazily there is no way to predict. We will literally have 8 patients one day, and discharge 6 of them home, only to admit 8 that night and by the day after we are at 13 or 14. I know that sounds like nothing to the bigger hospitals, but the nurse's at our hospital are the lowest paid in our "competative region", have the oldest and least amount of equipment to do their job. They are pulled regularly to the attached nursing home when our census drops. This makes them angry (understandibly so since the nursing home staff finds out what our census is and then calls out sick) and then they start calling out sick as well. I'm researching ways to put together a proposal to show the CEO and board of directors ( who get this, the President used to be the manager of our direct competition.... and now we are being forced to "partner up" with them...although they seem to reap all of the benefits and we've seen not one thus far) . How do we show them that nursing is a profession, just as much as the physicians and just as important? My floor knows that I'm consistent and that I do deal with employee problems like fake sick days, unsafe employees and they appreciate that, but that only goes so far. They feel like the "step child" of the hospital since I'm not allowed to pay a nurse to be on call to come for those days we are hit with a lot of admissions or discharges,etc. I can honestly say I don't know of a clinical manager in our hospital who doesn't regulary works the floor. The best part of everything... I've just been told that I have to be able to present to JCAHO ( who comes in 3 months or so) a "back up plan" for just this sort of thing. How do you come up with a plan when you are down 2 night nurses, have only enough day nurses to cover the shifts ( hope no one gets sick or wants to take a vacation)? I let my mouth get the best of me when I responded to this "request" for a back up plan and said I'd just let JCAHO know they could ask the CEO and board since they won't give the $ the nurses rightfully deserve ( we are well behind market value ). Hell, a Perdiem nurse makes exactly 1.00 dollar less than I do. Seriously, any ideas?

I'm the manager of what is termed a Med-Surg unit, however, our case mix regularly includes ICU candiates as well as Cardiac Care Step down patients for various reasons. We are more of a "fly by the seat of your pants" orginization. Administration really has no idea what it takes to provide the excellent care my nurses provide. I'm looking for a realistic formula to assign patient acuity. The one we have is a) not used, and b) so vague it really doesn't help. If anyone knows of a resource (that won't cost me a couple of hundred bucks out of my own pocket) I would sure appreciate your insight. Thanks!

That's great! Question: Do ya'll obtain and run them or just run them and give it to lab? What type of training did you get before hand and did you do a competency check as well? Thanks for your time!

Thank goodness for this forum!!!! I can't tell you how much the comments regarding "all nurse managers are not the same" theme has made me feel a bit more positive. "Zashagalka" : I don't understand the hostility in your postings. I understand completely the frustration in feeling like managers just want to tell you what to do, don't care what it costs you personally or emotionally, even the perception that they are just "pencil pushers". But that is what it is, your perception, and though valid (as those are your feelings) not always accurate. You blasted me earlier saying that I was angry because the staff wouldn't "do my job", and something to the effect that I wanted to be a manager, so deal with it. Again, that was your perception. What you don't know is why I wanted to be a manager. I left a very secure position in the Emergency room that I LOVED, thrived on. and was very good at- to go to a unit that was left without a manager, was barely hanging on, but had the potential to explode with greatness... because I cared. I knew the strength and talent that was being wasted due to lack of leadership and the willingness to deal with the "problem people". When you have staff who bring the whole unit down, with their attitude, bad behavior, whatever, it doesn't matter if they are the greatest nurse in the world- the unit suffers and ultimately the patient suffers. If you don't want to be on a committe, CQI, fine don't. Just have the integrity to follow the policy and procedures that are in place, or implemented. If you want change to happen you have to be willing to help. Most managers do 3/4 more behind the scene, on their own time and at an out of pocket expense. You won't hear them fighting for you against the higher powers that be, because you shouldn't. Just like you shouldn't know what happens when someone is counseled, you shouldn't hear what's going on between upper management and me. But that doesn't mean we're not doing everything within our power to make your environment and your time/pay etc. better. Please do not think that nurse managers are people who have little or no clinical experience, don't care, and who want to hide in their office. The staff nurse answers only to their manager. The manager answers to more people and agencies than you realize. We just need a place and a moment to vent like everybody else, and we deserve the same respect for accepting the challange ( for whatever the reason ) in managing a department...that you do working in difficult conditions. It shouldn't be a "you" or "I", we are all nurses first and foremost, we should be working together, for the patient and then for our profession.

Nothing brings the morale of the unit down then watching some people get away with murder, over and over and over. Most people will tell you they would rather work harder because they are short then have someone they see who does everything wrong/call in all the time/is unsafe/whatever sit next to them...especially when they don't have the power to do anything about it. A lot of my people would probably describe me as a b**** for a manager because I am hard, when the time calls for it. But I throw in with them anytime they are crazy on the floor, I stay later than them sometimes, I get rid of the staff who need to go for valid reasons, and I'm fair. They also see me fight for them when upper management is only seeing $ and cents, and when they have genuine difficulties going on elsewhere in their life. I just lost a CNA who really was in a crisis. I spent 3/4 of the day trying to figure out a way to help her so she wouldn't have to ( she didn't want to quit) go. When she left, she told my boss " I never thought I'd be hugging (me) ". Then I stayed 2 hours late to do what I had to do, and took the rest of it home. Be fair, be consistent, let them know how you appreciate and see how hard they are working. Let them know its not personal, it is professional. Explain the bigger picture to them and then fight for them with the bigger picture (ie upper management) But most importantly..... you HAVE to have a DON who WILL back you up. I've seen it too many times in my short time as a manager, a DON who does not back you, will destroy your credibility and make your job impossible. Take it as a challange and go for it!

Dear Skay, I know you posted this last month, and don't know if there has been any change, but as cheesey as it sounds I swear I wish I could give you a big hug. Sometimes management does really suck... sometimes it sucks a lot! But I'm sure you've had some rewarding moments no matter how small. If you go to the "Calling all directors/managers" post by "Patrick", you can read my post (Turk 182). I totally relate with some of your issues. I have an LPN who has been on my unit, since the day she started, which was Sept 1961 ( I was born in 69). She is on personal social terms with all of the doctors (except for 2, which are American, the rest Indian), and is even going to India with them in a year. She is the stereo-typical does what she wants, how she wants, when she wants... and she doesn't want to do a whole lot. She has the "tell it like it is" personality with no regard to how it sounds or may be perceived, especially with patients. She starts everything with " How come" " Why is it," " Why should we", etc.; I think you get the picture. She should be able to run the unit for as long as she has been there, but I still have to tell her to piggy back her solumedrol,lasix, what not when it is crazy busy instead of bugging the charge nurse every time she turns around to push it for her. She routinely used to say real loud (when she didn't like what she was made to do or told) " 543 days until I retire. I hope I can make it." I used to get so mad at the disrespectfulness of it and ignore it, then I started countering with " 543? You said 443 the other day. Don't tease me like that." A thorn in my side would be putting it mildly. BUT, when she hurt her back at home and got a doctors note saying she couldn't stand or sit for more than 15 minutes at a time, no lifting, etc. that was it. I spoke with HR and since she couldn't do her job in any sort of way, she was forced to take vacation and she was ticked. Now she doesn't push me as hard, she comes to my office to complain, she isn't anywhere near as disrespectful as she was before. When I did her evaluation about 6 months ago, she was hot! That was because she rated "satisfactory" for the first time ever. The previous managers gave her "excellent" and she thought she was. If you spoke to the other employees they would agree with me, but didn't want to tell her. I knew this was going to cause great drama with her so I ran it by my boss and HR first. They agreed as well. My point is, regardless of how anyone feels, you have to be honest and you have to do what is right for the unit. Sometimes I feel like I'm just getting rid of people because I have fired 3 people and I've not been the manager for quite a year yet, but they had to go for the good of the patients and the staff, and the staff are glad, appreciate it (but would never say so publicly). The other LPN who has been there one year less than the first, she can run circles around any RN, can run the unit and is a GODSEND!! I make sure I'm fair, that I jump in anytime it is crazy on the floor, and that I do as I enforce them to do. My suggestion: deal with this thorn in your side. Document every conversation you have regarding what the expectations are and what the unacceptable behavior is. I have found that when you ask HR to "sit in" on a counseling, people tend to take it much more seriously. Be honest on the evaluation. I look at everything with the "This is professional not personal" attitude. It'll be 1 year this March 29th, that I've been there a year. The unit is running more efficiently, less wasted cost, Overtime way way down. We have our bad times ( right now I'm down 2 CNA's who were also ward clerks, one had to go for extenuiating circumstances, the other.... she refuses to take her nails off..... after multiple warnings, over the last 4 years it turns out.) But for me personally and for the morale of the unit, its better to be frustrated because we are short staffed than because poeple will not do their jobs and nobody takes care of the issue. You've been a manager for 7 years, so you must be doing something right and there has to be something positive in it for you. Focus on that and get rid of the walking negativity(ies), those who buck you just for the sake of a pissing contest! Hope this helps, or at least lets you know you are not alone. Good Luck!

THANK YOU!.....To everyone who has replied so far. I really appreciate your suggestions and if have any more that come to mind, please let me know. We're a level 3 hospital, and I figure if you don't technically have to have a physician in house for the ER (they just have to be readily available but could legally sleep in their own bed if they lived close by) I don't imagine we have to have an in house RT. But I am checking into the legalities of it all. What would you suggest for training? When you did a vent (as a RN) did you feel comfortable after your training to do them? One of the full time RT's is an LPN from a long time ago, who has kept her liscense active, so I thought that would be a great help as well. If this came to be, only a select few nurses would be certified to do it,(my clinically strongest and reliable) and a pay adjustment would go with it as well. I will be doing it as well. Ya'll have been very helpful!

Does anyone work in a hospital that does not have a very efficient Respiratory dept? There is a possibility that ours will be eliminated and Nursing will do the ABG's and such. I'd like to talk to anyone who has experienced this, how the staff bought into it, the training, etc. Our Resp. dept closes at 4 pm and afterwards the nurses take care of resp. treatments and such. Resp. is on call for ABG's presently and once in a blue moon for a ventilator. They don't intubate, so I'm really pondering the pros and cons of this if it were to happen. Thank You

Thank You Tulip, I appreciate the response. For all of us managers out there, your frustration is a good reminder of what we need to remember and try to accomplish.

Wow- I sense some seriously built up resentment there. Let me clarify please..... Anything anyone has come in for, I have paid for their time. When only one person shows for the staff meetings, I pay them 2 hours per federal law ( I required them to be there and sent them home. ) As I stated previously, I have tried multiple attempts to time staff meetings to accomodate everyone, despite the fact it does not accomodate my time. Incentives, rewards, etc were offered on my behalf at my cost. Never before did any of these staff members receive gifts or lunches during nurse/cna week, until I arrived. I went to all the physicians and asked for money, donated myself and made these weeks a big deal for them. So yes, I do expect that the staff will show up to a staff meeting every now and then. I absolutely expect staff to show up when it is made mandatory ( and isn't sad it has to go that direction? ) or that someone will let me know why they can't be there before hand. Are you a manager? I'm just wondering. If you are, then you know that your staff expect you to do their payroll sheets correctly, give them a fair work schedule, work on their behalf with issues they can't directly control and to work right next to them when all hell is breaking loose on the floor and not hide in your office and shut the door. If you are not a manger, you might consider that a manager's job is no walk in the park. A staff member only reports to their manager generally. A manager reports to their Director of nursing, the CEO, answers to JCAHO and anyone else who has the authority or power to change something on your unit. It isn't easy to try to appease both ends of the spectrum who often have different ideas as to what is important. Sometimes staff meetings are absolutely neccessary. You can't hold somebody accountable if you don't know for sure they got the message. Nor can you ensure everyone receives the same chance for opprotunites if you don't know for sure if everyone is aware of those opprotunities. You absolutely deserve your personal time - and the manager deserves respect enough for staff to show up for a meeting when they are taking time away from their personal time to have one. By the way, I wouldn't require you to be there on your birthday.