swmn

I have noticed in elderly patients onset times are delayed compared to younger patients. I don't have any firm rules yet about when to switch from doses at 2 minute intervals to 3 or even 5 minute intervals, but I do have some guidelines. Anyone over 80 yo, 3 minute intervals is as fast as I will push. 3 minutes goes for lots of folks in their 70s too. 60s is kind of borderline, I guess mostly I am guessing how much longer this patient is going to be coming in for elective procedures. I have noticed redheads tend to have delayed onset times earlier than brunettes, so redheads over 70 I treat like brunettes over 80. Seems to work OK. There are a couple other groups I take my time with. I don't see very many, but every once in a while I get to sedate a Basque. I am not going to say they have "funny" names, just unfamiliar combinations of letters in their family names, and it seems to take a little longer for whatever dose I give them to reach peak. Really nice people too, usually. Another one is patients over 100 years old. The few I have seen coming in for elective procedures usually look better than my dad, and he is only 58. Centurions generally tolerate meds pretty well, but I conciously use 5 minute intervals when sedating them just because they have come so far I wouldn't want to be "the one".

I draw up 5 and 100 when I am using Versed and Demerol, 10 and 250 when I am using Valium and Fentanyl. Drope comes in 5mg ampules, so that is a no brainer too. When it is my turn, I want fentanyl and versed. On integrated units where recovery is handled by other endo procedure nurses I would say 50 of demerol and 3-5 of versed is pretty typical with gentle docs and healthy outpatients. Females who have had lots of babies might need 75 or even 100 of D, but all these folks will recover and walk out pretty quickly. Anyone on maintenance opiods or benzos for pain/panic etc is going to be a little tougher to sedate. Anyone taking about 30mg morphine or 10mg diazepam PO at a single dose is going to make my short list for droperidol, along with everyone who drinks alcohol everyday or is currently using marijuana, cocaine or crystal meth. The "seekers" asking about vicodin for the post procedure pain they haven't even felt yet frequently make my drope list too. If there are some pulmonary issues to consider I'll go heavier on the versed and layoff the D. Patients on maintenance valium I lean away from the versed and push the D a little harder (if I can't talk the doc into using fentanyl). Those little lines on the 5cc syringe of versed are 0.2mg each Frankly I dilute my Demerol to 10mg:1cc in a 10cc syringe and will go with 2mg incremental doses if it is indicated. My smallest dose on an ancient inpatient was 0.6 of valium and 12mg of Demerol for a very long colonoscopy. Sometimes I can time 5 of versed, 100 of demerol _and_ 5 of drope to all peak at the same time and still have to talk the patient through an EGD. For obese patients without respiratory compromise I am more than happy to start with 2&50, and then run the versed up in more or less a hurry. Don't forget to use Starling's Law to advantage when you sedate without fluids hanging. Starling is my friend. Still have to find my calipers to comply with the latest safety warning about droperidol, went up on fda.gov on 12-05. Gosh I want to be inserviced on propofol.

LBurns, I got just one wuestion for you. Are you a "better" nurse now because of your BSN program, because of the fulltime clinical experience you got in your day job, or is it becuase you were able to to apply the stuff you covered in class last night to your clinical challenge on the floor today? Just wondering.

LBurns, I got just one wuestion for you. Are you a "better" nurse now because of your BSN program, because of the fulltime clinical experience you got in your day job, or is it becuase you were able to to apply the stuff you covered in class last night to your clinical challenge on the floor today? Just wondering.

Jill, Thanks for your impression of your endoscopy sedation. Like I had said before, I have never acutally had any of the stuff, I got a PO Valium once when I was getting some stitches in the ER. I have spoken with a couple folks who got Demerol only for Dental work, that is where I came up with the "aware of pain but unable to respond" impression. Yet in your post it seems maybe Demerol alone is good for something. I do think some folks get both good sedation and good pain relief from Demerol and Versed, but I think from standing at the bedside lots lots more folks get good or excellent pain relief with Fentanyl. Also, I think if a patient is experiencing pain the pain should be treated, whether the patient is going to remember the pain or not does not matter to me. In my procedure room, if you are in pain, or appear to be, and have a reasonable blood pressure and are breathing OK I _will_ give you more. Scott

Jill, Thanks for your impression of your endoscopy sedation. Like I had said before, I have never acutally had any of the stuff, I got a PO Valium once when I was getting some stitches in the ER. I have spoken with a couple folks who got Demerol only for Dental work, that is where I came up with the "aware of pain but unable to respond" impression. Yet in your post it seems maybe Demerol alone is good for something. I do think some folks get both good sedation and good pain relief from Demerol and Versed, but I think from standing at the bedside lots lots more folks get good or excellent pain relief with Fentanyl. Also, I think if a patient is experiencing pain the pain should be treated, whether the patient is going to remember the pain or not does not matter to me. In my procedure room, if you are in pain, or appear to be, and have a reasonable blood pressure and are breathing OK I _will_ give you more. Scott

Several possible issues here, maybe some will apply to your situation. One is working for salary instead of hourly, and one I would urge you to consider carefully before accepting a management slot. If you can not come up with staff, guess who gets to work that shift for free, while still being held responsible for all that paperwork and the performance of whatever staff you do have? That would be you. Nurse Manager is one of a very few professions that get less pay and more responsibility than floor nurses. No more OT. No more shift diff. Lots more headaches. Another thing to consider is the managment culture of the facility. A new DON can have a huge impact on management culture, the way things get done, by deciding who gets what, and which other somebody is paying for it. Frequently DONs are changed because management culture or structure does need to change. Sometimes new DONs...well nevermind. A third item is the boatload of new requirements coming down the pike in the last few months. Two years ago everyone had to know where the fire alarm pull was, come up with something reasonable if a JCAHO inspector asked about "R-A-C-E" and demonstrate reasonable competence applying universal precautions universally. Now we proabably all are looking at new documentation with a space for that "new" fifth vital sign, plus we got the ergonomics inservice to get through annually. On top of that, the defense lawyers clearly had some big top secret national convention somewhere, 'cause CYA charting is tripling everywhere I have been or heard about lately. The real shame of all the new paperwork and computer screens is I have yet to see a new blank on a form or "required field" in a computer screen that is doing anything but wasting the precious little time I have. I would be a lot happier in my job if I could charge triple time for all the times I write "N/A" or "see nurse's note", even just one day a week. This comes back to frustrated management because the nurse managers can't just add a box to the assessment form for "pain assessment." They got to go to meetings, lots of them, with lots of different departments to get that one little box put on the form. The bigger the instituition or corporation is, the more committees and risk managers there are to put their two cents in. True story, I was on an Endo unit at a big teaching hospital, the nurse manager went to meetings for a soild month and a half to get the "pain assessment" block onto the unit flowsheet. Finally, nursing steeering, risk management and executive management all three signed off on the new form and she sent it over to the hospital printer so we could start using it. Five days later, still no form, she calls the printer to see what's up with the form and she gets the run around for three more days. Finally the printer calls back, and says the risk manager of the printing department says the text describing the numeric, thermometer and faces scale in the new pain assessment block is "too small" and poses a liability to the facility because some nurses might not be able to read it, and therefore might misuse it, exposing the hospital to potentially expensive litigation and therefore they are not going to print it, but are instead forwarding it to legal, not risk management this time, but legal, for a second opinion. In the meantime, no we could not have any more copies of the old form even if we were out, because the old flowsheet form did not have a pain assessment block on it, and even the printer's secretary knows assessment forms have to have a space to chart pain assessment. It was a total circus. Not even the medical director of the unit could get actual preprinted forms from printing. We finally called the Chief Medical Officer of the University Health System and left him a voice mail to the effect that we were going to start Xeroxing our last copy of the old form until we got the new form in, and wouldn't those look great to a jury. If this sounds like something fun for you to do all day every day, by all means consider management.

Several possible issues here, maybe some will apply to your situation. One is working for salary instead of hourly, and one I would urge you to consider carefully before accepting a management slot. If you can not come up with staff, guess who gets to work that shift for free, while still being held responsible for all that paperwork and the performance of whatever staff you do have? That would be you. Nurse Manager is one of a very few professions that get less pay and more responsibility than floor nurses. No more OT. No more shift diff. Lots more headaches. Another thing to consider is the managment culture of the facility. A new DON can have a huge impact on management culture, the way things get done, by deciding who gets what, and which other somebody is paying for it. Frequently DONs are changed because management culture or structure does need to change. Sometimes new DONs...well nevermind. A third item is the boatload of new requirements coming down the pike in the last few months. Two years ago everyone had to know where the fire alarm pull was, come up with something reasonable if a JCAHO inspector asked about "R-A-C-E" and demonstrate reasonable competence applying universal precautions universally. Now we proabably all are looking at new documentation with a space for that "new" fifth vital sign, plus we got the ergonomics inservice to get through annually. On top of that, the defense lawyers clearly had some big top secret national convention somewhere, 'cause CYA charting is tripling everywhere I have been or heard about lately. The real shame of all the new paperwork and computer screens is I have yet to see a new blank on a form or "required field" in a computer screen that is doing anything but wasting the precious little time I have. I would be a lot happier in my job if I could charge triple time for all the times I write "N/A" or "see nurse's note", even just one day a week. This comes back to frustrated management because the nurse managers can't just add a box to the assessment form for "pain assessment." They got to go to meetings, lots of them, with lots of different departments to get that one little box put on the form. The bigger the instituition or corporation is, the more committees and risk managers there are to put their two cents in. True story, I was on an Endo unit at a big teaching hospital, the nurse manager went to meetings for a soild month and a half to get the "pain assessment" block onto the unit flowsheet. Finally, nursing steeering, risk management and executive management all three signed off on the new form and she sent it over to the hospital printer so we could start using it. Five days later, still no form, she calls the printer to see what's up with the form and she gets the run around for three more days. Finally the printer calls back, and says the risk manager of the printing department says the text describing the numeric, thermometer and faces scale in the new pain assessment block is "too small" and poses a liability to the facility because some nurses might not be able to read it, and therefore might misuse it, exposing the hospital to potentially expensive litigation and therefore they are not going to print it, but are instead forwarding it to legal, not risk management this time, but legal, for a second opinion. In the meantime, no we could not have any more copies of the old form even if we were out, because the old flowsheet form did not have a pain assessment block on it, and even the printer's secretary knows assessment forms have to have a space to chart pain assessment. It was a total circus. Not even the medical director of the unit could get actual preprinted forms from printing. We finally called the Chief Medical Officer of the University Health System and left him a voice mail to the effect that we were going to start Xeroxing our last copy of the old form until we got the new form in, and wouldn't those look great to a jury. If this sounds like something fun for you to do all day every day, by all means consider management.

Excellent, a worthy subject for a change. Before I get started, I have never personally taken Demerol or Fentanyl (or even percocet really), but I have sedated a lot of patients for endoscopic procedures. I despise Demerol. I hear repeatedly from folks that have had it that they still "feel" pain, they are just powerless to do anything about the pain they are experiencing. The only thing I know of Demerol has going for it is that it is relatively cheap. In combination with Versed, concious sedation is relatively easy, but lets see, the patient is still feeling pain and can't do anything about it, but because of the Versed they can not remember later they were in pain. To me that sounds like "pain control" maybe, but definitely not "controlled pain." I do like sedating with IV Fentanyl just fine. It seems to me it is a lot smoother induction (takes a little longer than Demerol), and a smoother recovery too. Intra-procedure, once I got a good handle on dosing and onset timing, my patients seem, to me, to be more relaxed during their procedures. The folowing is anecdotal, but I think I see fewer EKG changes too. When it is my turn for a colonoscopy, I am going some place that uses Fentanyl.

Excellent, a worthy subject for a change. Before I get started, I have never personally taken Demerol or Fentanyl (or even percocet really), but I have sedated a lot of patients for endoscopic procedures. I despise Demerol. I hear repeatedly from folks that have had it that they still "feel" pain, they are just powerless to do anything about the pain they are experiencing. The only thing I know of Demerol has going for it is that it is relatively cheap. In combination with Versed, concious sedation is relatively easy, but lets see, the patient is still feeling pain and can't do anything about it, but because of the Versed they can not remember later they were in pain. To me that sounds like "pain control" maybe, but definitely not "controlled pain." I do like sedating with IV Fentanyl just fine. It seems to me it is a lot smoother induction (takes a little longer than Demerol), and a smoother recovery too. Intra-procedure, once I got a good handle on dosing and onset timing, my patients seem, to me, to be more relaxed during their procedures. The folowing is anecdotal, but I think I see fewer EKG changes too. When it is my turn for a colonoscopy, I am going some place that uses Fentanyl.

I would really appreciate it if my nurse managers would not confuse "nurse manager" with "charge nurse". (DANG IT!!) A "charge nurse" is on the floor throughout the shift and is responsible - to the nurse manager to be sure- but is nonetheless responsible minute to minute for just what the heck is going on. "I'm sorry, our nurse manager is in charge here Mr. patient's disgruntled family member, only our nurse manager is also at a meeting with the big wigs to learn how to provide better care to disgruntled family members, why just like you. Now you hold that thought, you hear? And have a seat in this chair right here for, oh, about four hours or so...." I agree we are all "in charge" of our own patients, and I am sure this varies from unit to unit too; but by golly you can not be "in charge" and off the floor for half the day at whatever meetings it is you have to go to. Name a team leader and go to your darn meetings. For me to continue to provide good care, I need food, as in calories, about halfway through, and 30 seconds quality time with a candy bar while I am waiting on you to get back on the floor and start relieving people for lunch ain't it. End of rant. Scott

I would really appreciate it if my nurse managers would not confuse "nurse manager" with "charge nurse". (DANG IT!!) A "charge nurse" is on the floor throughout the shift and is responsible - to the nurse manager to be sure- but is nonetheless responsible minute to minute for just what the heck is going on. "I'm sorry, our nurse manager is in charge here Mr. patient's disgruntled family member, only our nurse manager is also at a meeting with the big wigs to learn how to provide better care to disgruntled family members, why just like you. Now you hold that thought, you hear? And have a seat in this chair right here for, oh, about four hours or so...." I agree we are all "in charge" of our own patients, and I am sure this varies from unit to unit too; but by golly you can not be "in charge" and off the floor for half the day at whatever meetings it is you have to go to. Name a team leader and go to your darn meetings. For me to continue to provide good care, I need food, as in calories, about halfway through, and 30 seconds quality time with a candy bar while I am waiting on you to get back on the floor and start relieving people for lunch ain't it. End of rant. Scott

Excellent question. My mom had a colonoscopy on my unit while I was still in orientation on my first endo job. I did not actually participate in the case, but I saw her both before and after. I know what she is "like" in real life, seeing how tired and dehydrated she looked before the case was a big clue to how "draining" a colon prep can be. She did not look much better after the case, until she was awake enough to take some fluids. She really enjoyed a simple glass of 7-up, even commented weeks later what a relief it was. Getting PO fluids to patients in recovery has been one of my highest priorities ever since.

Two things. 1. Who is the unit clerk? Is this going to be someone you can get along with, or someone who is going to make your life miserable? In my experience the unit clerk/ unit secretary is a key postion that the nurse manager delegates much responsibility too. If I instantly dilike the person, the job is going ot be hell. 2. Who is really in charge here? It is almost never actually the nurse manager. It may be another nurse middle manager a step or three above the person you are talking too, frequently it will be a staff MD, could be almost anyone, but it is usually not the person doing the interview. Neither of these are questions you can come right out and ask. I have found both pieces of information are key to doing my job well.

Reading these threads and evaluating my OTJ frustrations, I wonder what we really think we deserve. Quantitatively the big issues seem to be pay, patient load and hours worked every week. Qualitatively patient acuity and respect seem to be the big intangible frustrations. Qualitatively I require enough free time to unwind from work _and_ have some fun as just a plain old human. I don't think I am super-nurse, but to clock in and really throw myself into doing the best job I can, there has got to be some time for me to relax. Mandatory overtime ain't it. On the respect issue I think we really need to put out own house in order before we look to outside sources for support. There is no reason for anyone in the general public to have any more respect for us than we have for each other. Read some of the random invective on this site, imagine we were all plumbers, and try to imagine hiring one of the posters here to fix the pipes in your basement. While we are failing to respect nurses, no one else is going to respect nurses. I thought my pay as a new grad was pretty good until my student loans came out of deferment. I held on for six desperate months for my first annual review (hahahaha), and had to leave the field for a little while to go make some money. With five years in the field I think I am worth about double what I am making now. That is assuming I don't go into a higher tax bracket because of the big raise. The warm fuzzies I get from helping other people make up for some of the difference; but at the end of the day all the warm fuzzies from helping other people and all the respect I get from participating in an honorable profession don't pay the phone bill. I can't imagine anything happening in the US that is going to change rising acuity. The only way I see that we could actually do that would be to demolish the entire healthcare system, and rebuild from the ground up as a social rather than capitalist system. I am not holding my breath for that one. Americans don't want to lead healthy lifestyles. They want to eat greasy food, drink too much beer, smoke cigarettes, and then be "fixed" during a ten minute appointment with an MD as an outpatient so they can go out and drink more beer, eat more greasy food and smoke more cigarettes while complaining the MD was ten minutes late for the appointment. What is a caring sharing underpaid professional to do? The only solution I see, the only solution the system in place can provide is money. The big money invested in healthcare is capital invested with the reasonable expectation of financial return on the investment. In a nutshell, that is the state of healthcare in the US. When the root is evil, it does not matter how good the grafts are, the vine will be afflicted. I am oficially infected. I don't expect less acute patients, I've given up on getting respect from the public, nursing hours are always going to suck. Pay me what I am worth or have your colonoscopy with no sedation. I really hate having come to this place, but my ideals have met the real world and the real world won. It was no contest. If someone knows of a profession where I can have more responsibility while getting less respect and make even less money, I would like to know what it is. How much do you think you are worth, what would it take on your paycheck for you to go back to work tommorrow doing the same job you did today, only going going in glad to be there? As a percent I mean, 50% raise in takehome, double? Half the patients you had today and 50%? Keep it general like that please, the cost of living does vary dramatically in places. How long have you been in practice? Thanks, Scott

Overall it sounds like a snake pit job you are better off without. Been there, done that. I am not going to pass judgement on your decision to pass the HumulinN. I was not ther to asses the patient, you were. I do have some rhetorical sorts of questions for you. How low is "LO" as in low les than 40 or lo less than 65? What were typical AM FBS's for your little firecracker here, and did you call (and document having called) the MD? Did you include this on report? I often wonder how awake the 7-3 shift nurses are already when I am giving report to get off 11-7, there has been more than once I have entered a chart ntoe to the effect that I had paged MD so and so, had not heard from him, passed report re: the LO and the N and the pt eating breakfast etc. to the oncoming nurse, sort of end of shift summary. If all you charted was LO, 8uN, and OJ, I can already hear some of the snakes I have worked ith, "I never heard that in report." Sounds like you will be better off elsewhere anyway. Scott

Congratulations Karen! Nothing like starting out on a hot topic. As an R.N. I am acutely sensitive to CNA's and LPN's among my co-workers being refered to as "nurses." It happens all the time. To the public it seems like anybody who fluffs a patient pillow must be a nurse. When asked what or whom I am I say not "I am a nurse" but "I am an R.N." sometimes I have to add "Registered Nurse", but Joe Public does seem to still understand among "nurses" I am the ace of spades. I do still get a little uncomfortable when my patients refer to a CNA as "my other nurse," but I am getting over it. To me it is not a battle worth fighting. I know they are not nurses, says right on the label "nursing assistant." Still, if the CNA was not available I would be the one giving bed baths and answering call bells. CNAs unmistakably work within my scope of practice, and they are going to be referred to as "nurses" by patients who do not know any better. I have too many other teaching responsibilites to lose sleep over that. Is an LPN or LVN a "nurse", sure. But you are a "medical assistant" with an associates degree. I have never worked with one of those. It sounds to me like you have been educated to work in a physician practice, sort of the first hire to get everything rolling. I imagine you probably have some basic triage skills, and know way more about ICD-9 codes than I ever will care to hear about. I don't really know, MA is a new one on me today. As long as you work within your scope of practice, and ask for help when you are over your head, I'll get along with you fine. As far as I am concerned there are three kinds of people in healthcare right now. There are hands on caregivers like nurses and MDs. There are administrative people who help me see more patients and do more hands on patient care, and there are no account paper pushers who ought to be taken out and shot. I get along fine with everyone in group one and everyone in group two. Please try to avoid joining group three. Scott

Prepared, yes, ready no. I will try to explain. I graduated from a hospital based diploma program in 1996. I continued working in the computer field through school, my only experiences in patient care before my first shift were from nursing school clinicals. I went into nursing because my computer customers were more interesting than their computer problems. I walked into my first shift knowing I _could_ do everything I was going to require of my CNAs, and my LPN; and was confident in my ability to cover the allied nursing sub-specialties (PT, OT, RT, speech, etc) on 11-7 shift. On the fourth of ten scheduled nights of orientation my preceptor was a no-call / no-show. I assumed charge on 120 neuro stepdown and LTC beds with 1 LPN and 5 CNAs that night and loved it. My preceptor was never heard from again. My DON came in early the next morning, and asked why I had not called her for help. I explained honestly that I had not required any help, but if I had I would have called her. She was beaming before she was done interviewing the rest of the 11-7 staff. As a deeply people oriented person, I do have to accept some of the credit for my success; but vast credit is due as well to the faculty of the Ellis Hospital School of Nursing in Schenectady, New York. Besides requiring we be able to give a better bed bath than any CNA, my class knew, without exception, that even though we could do all the things we were going to delegate, as RNs we posess a body of knowledge and scope of practice unique in patient care. I knew I could do some things better than my people were doing them, but I had to delegate so I could do the stuff only I could do. I also learned how to look stuff up. I carried a bag to work every night that would just barely qualify as carry-on baggage. Besides spare clean whites and an extra stethoscope I had three textbooks and a couple handbooks in there. My drug book was always out whenever I was passing meds, I believe looking something up is the sign of a concientious professional, not an admission of weakness. My staff quickly decided mine was a rational point of view. If there was not time to look something up, 911 was a phone call away for me. One thing I learned in the business world that I wish was in my nursing curriculum: Constructive delegation. As RNs we all have to delegate, but none of my nursing instructors taught me to delegate constructively. For me it is a three step process. 1. I have to decide what my minimum standards are. 2. I have to communicate and delegate those standards clearly to someone capable of carrying them out. 3. (this is the hard one) I have to stand back and give them space to exceed my expectations. I got my minuimum standards down to four rules for my CNA's on third shift. 1. I require the vital signs I ask for by 2400 sharp. They must be measured accurately and charted promptly. 2. Scheduled rounds must start sometime between 5 minutes early and exactly on time. 3. Call bells must be answered immediately. I am talking five rings on the annunciator, not five minutes. 4. When you are off the floor, someone needs to know where you will be, and someone needs to know they are covering your call bells. As long as four of those things wre happening, I was sweet as pie and found a legitimate reason to give every staff member under me a meaningful compliment every shift. Cross the line, and you are going home, now, off the clock. I would prefer to work short staffed then babysit. You are required to report to the DON's office during normal business hours tommorrow. I will write you up between now and then, and you will be permitted to tell your side of the story to her. You are not to report for work on my time until I have the DON's personal assurance you are capable of meeting the minimal standards of your certificate and this facility. Collect your things and leave the building immediately. Here is 35 cents to call your ride (I kept some change in the carry-on sized bag). There are both a payphone and a place to wait out of the weather at the convenience store across the street. Wherever possible I would close with a compliment, "I hope to see you tommorrow night. You are capable of outstanding work and have a good rapport with patients x, y and z." This has turned into another long answer to short question. The shorter version is my diploma program was excellent preparation for bedside nursing, but it was the interpersonal skills from my business background that gave me wings. We all test our limits, it's the nature of the beast. _Enforced_ limits tend to be obeyed. I have yet to meet any RN, from diploma right up through PhD FAAN who has learned to delegate or communicate with co-workers in a nursing program. Those of us that do it learned it somewhere else. I have identified two common traits. One is infectious optimism. Unspoken rule number five on my floor is if you are being paid to be here, you have to smile. The way to get that to happen is smile most of the time, and usually sooner rather than later people start smiling back. The other seems to be applying the nursing process to 'healthy' co-workers, ancillary staff and self, beyond applying the nursing process to 'sick' patients. Even with the small number of diagnoses available, we posess an extrodinarily powerful tool for improving professional and interpersonal relationships. Off the cuff I am willing to bet more than half of your problem children are feeling powerless. What can you do to empower them so they can do a better job for you and your patients? Off my soap box, Scott

Prepared, yes, ready no. I will try to explain. I graduated from a hospital based diploma program in 1996. I continued working in the computer field through school, my only experiences in patient care before my first shift were from nursing school clinicals. I went into nursing because my computer customers were more interesting than their computer problems. I walked into my first shift knowing I _could_ do everything I was going to require of my CNAs, and my LPN; and was confident in my ability to cover the allied nursing sub-specialties (PT, OT, RT, speech, etc) on 11-7 shift. On the fourth of ten scheduled nights of orientation my preceptor was a no-call / no-show. I assumed charge on 120 neuro stepdown and LTC beds with 1 LPN and 5 CNAs that night and loved it. My preceptor was never heard from again. My DON came in early the next morning, and asked why I had not called her for help. I explained honestly that I had not required any help, but if I had I would have called her. She was beaming before she was done interviewing the rest of the 11-7 staff. As a deeply people oriented person, I do have to accept some of the credit for my success; but vast credit is due as well to the faculty of the Ellis Hospital School of Nursing in Schenectady, New York. Besides requiring we be able to give a better bed bath than any CNA, my class knew, without exception, that even though we could do all the things we were going to delegate, as RNs we posess a body of knowledge and scope of practice unique in patient care. I knew I could do some things better than my people were doing them, but I had to delegate so I could do the stuff only I could do. I also learned how to look stuff up. I carried a bag to work every night that would just barely qualify as carry-on baggage. Besides spare clean whites and an extra stethoscope I had three textbooks and a couple handbooks in there. My drug book was always out whenever I was passing meds, I believe looking something up is the sign of a concientious professional, not an admission of weakness. My staff quickly decided mine was a rational point of view. If there was not time to look something up, 911 was a phone call away for me. One thing I learned in the business world that I wish was in my nursing curriculum: Constructive delegation. As RNs we all have to delegate, but none of my nursing instructors taught me to delegate constructively. For me it is a three step process. 1. I have to decide what my minimum standards are. 2. I have to communicate and delegate those standards clearly to someone capable of carrying them out. 3. (this is the hard one) I have to stand back and give them space to exceed my expectations. I got my minuimum standards down to four rules for my CNA's on third shift. 1. I require the vital signs I ask for by 2400 sharp. They must be measured accurately and charted promptly. 2. Scheduled rounds must start sometime between 5 minutes early and exactly on time. 3. Call bells must be answered immediately. I am talking five rings on the annunciator, not five minutes. 4. When you are off the floor, someone needs to know where you will be, and someone needs to know they are covering your call bells. As long as four of those things wre happening, I was sweet as pie and found a legitimate reason to give every staff member under me a meaningful compliment every shift. Cross the line, and you are going home, now, off the clock. I would prefer to work short staffed then babysit. You are required to report to the DON's office during normal business hours tommorrow. I will write you up between now and then, and you will be permitted to tell your side of the story to her. You are not to report for work on my time until I have the DON's personal assurance you are capable of meeting the minimal standards of your certificate and this facility. Collect your things and leave the building immediately. Here is 35 cents to call your ride (I kept some change in the carry-on sized bag). There are both a payphone and a place to wait out of the weather at the convenience store across the street. Wherever possible I would close with a compliment, "I hope to see you tommorrow night. You are capable of outstanding work and have a good rapport with patients x, y and z." This has turned into another long answer to short question. The shorter version is my diploma program was excellent preparation for bedside nursing, but it was the interpersonal skills from my business background that gave me wings. We all test our limits, it's the nature of the beast. _Enforced_ limits tend to be obeyed. I have yet to meet any RN, from diploma right up through PhD FAAN who has learned to delegate or communicate with co-workers in a nursing program. Those of us that do it learned it somewhere else. I have identified two common traits. One is infectious optimism. Unspoken rule number five on my floor is if you are being paid to be here, you have to smile. The way to get that to happen is smile most of the time, and usually sooner rather than later people start smiling back. The other seems to be applying the nursing process to 'healthy' co-workers, ancillary staff and self, beyond applying the nursing process to 'sick' patients. Even with the small number of diagnoses available, we posess an extrodinarily powerful tool for improving professional and interpersonal relationships. Off the cuff I am willing to bet more than half of your problem children are feeling powerless. What can you do to empower them so they can do a better job for you and your patients? Off my soap box, Scott

a good knowlege of breavement processes etc in order to deliver sensitive care. Can anyone Help??? Maybe a little. Sam, I have been a hospice volunteer for five years, as well as having had several terminal patients within a year or two of long term care. Without knowing more specifics about your question, start with something simple like Kubler-Ross' model of the five stages of grief. They are Denial, Anger, Bargaining, Depression, and then Acceptance. An appropriate intervention for a family member in depression is going to be wasted on someone else in the family who is angry. At the end of the day, if I can get the family members talking to each other, I know the next time I come on the floor to start another shift they are going to be somewhere else, further down the road toward recovery and acceptance than they were before. HTH, Scott