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adventure_rn

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  1. adventure_rn

    No More TB Tests?

    My hospital, a large well-renowned research institution, recently announced that clinical staff wouldn't have to do routine annual TB tests anymore. It is still required for new staff, and we will have to do an annual screening questionnaire with a follow-up test if we have TB symptoms. Has anybody else ever experienced this? I never thought I'd see the day. At my last job, we had to do two PPDs and a quantiferon blood test every year. Bright side, as nurses they let us 'read' our own PPDs after the two days so we didn't have to come in for a follow-up visit.
  2. adventure_rn

    What is most important to chart on?

    Why count them? Everybody knows that they're always documented as 18 regardless!
  3. adventure_rn

    What is most important to chart on?

    It depends so much on the situation and patient. At minimum, you should always chart per your unit's policies (i.e. how many assessments and vitals you need to do per shift). That way, if you're ever in a legal setting, you have your hospital policy to back you up. Any time I'm doing something that deviates from the policy at a provider's request, I do everything I can to get an official order, and I'll specifically annotate why I'm not following policy and who (full name, credentials, and provider role) told me not to. When I'm deciding how thoroughly I need to chart on different circumstances, I will sit and think through "How likely are we to get sued over this?" to make my decision. If I'm noticing a kid's diaper rash, I'm not going out of my way to document that I notified someone; nobody is getting sued over a run-of-the-mill diaper rash. Conversely, if I've got a kid who is very unstable and I'm in constant communication with the medical team, I'm charting on that provider communication at least every hour. That's a kid who is likely to code, and if the hospital gets sued, I don't want someone looking at my record and assuming I didn't notify the provider about the early warning signs. I also chart more thoroughly if I think it's a family that's more likely to sue. If I've got an angry parent who happens to be a malpractice attorney (yes, I've been in this situation), you bet I'm extra careful with my charting. Similarly, if I've got a kid who has a poor prognosis due to a prior medical complication/error during admission (i.e. bad surgical outcome, hospital-acquired sepsis) where I think the family will have a very strong case to sue regardless of my care, I'm still extra careful with my charting. It's kind of a triage process. If the likelihood of getting sued is low, it gets a couple of words ("perineal yeast, fellow notified, start nystatin"). If it's an ongoing issue that has the potential to go sideways, it gets hourly documentation ("frequent drops in sats HR/BP/O2 sats with agitation, Dudley Doolittle MD fellow at bedside to eval, precedex bolus x 1 per order.") If it's a scenario where the likelihood if getting sued is high, it gets a full-blown significant event note ("Patient BP consistently elevated throughout shift with SBP > 150, verified with manual cuff pressure. Dudley Doolittle MD fellow and Susan SmartyPants MD attending notified of elevated BP at 0800 during AM rounds and again q 30-45 minutes throughout shift. Per Dr. SmartyPants, BP elevation is related to neuro storming, no new orders. Patient's neurological assessment unchanged from baseline, no evidence if seizures.") This is a note I had to write from an actual case, and I also charted hourly interactions with the providers ("SBP > 150, Susan SmartyPants MD notified, no new orders"). This kiddo was totally fine before admission but had a bad post-op code and ended up neurologically devastated, so there was a very high risk that we'd eventually get sued. When this infant had consistent BPs in the 170/120s - with a huge risk to stroke out - and nobody wanted to do anything about it, you bet I was charting every single interaction. I'm sure my note looked like I was throwing the providers under the bus. However, if push came to shove, they could have easily thrown me under the bus and say they weren't notified if I hadn't explicitly charted it.
  4. adventure_rn

    Nurse Charged With Homicide

    I so agree. This whole story reminds me so much of the nurse at Seattle Children's who committed suicide after a med error killed a baby (she accidentally gave 10 times the dose of calcium chloride). Instead of completing a root cause analysis, the hospital quickly fired her. This was an amazing critical care nurse with decades of experience on the unit. Even if this person made a huge med error, I'm sure the guilt is already destroying her life. I don't see how a homicide charge would benefit anyone in this scenario.
  5. adventure_rn

    Ugly Christmas sweater: tiny baby edition

    No way!! Too cute. In NICU I've seen Halloween costumes, knit pumpkin hats, and little tiny Christmas trees, but I think the holiday sweater sounds like a fabulous addition to the repertoire. Thanks for sharing.
  6. adventure_rn

    Why do RN injuries keep happening?

    Adequate staffing? Equipment and in-services are all fine and good, but if every nurse is swamped with too many patients, there isn't time to track down and utilize complicated equipment or find people to help you reposition (since they're probably busy, too). In these situations, nurses risk their backs, but the alternative is to go too slowly, miss cares/meds, and lose your job. Then, if you're injured on the job, the hospital can claim that they don't need to take responsibility due to said equipment and in-services. https://allnurses.com/general-nursing-discussion/unsafe-staffing-with-1181073.html
  7. adventure_rn

    What is your unit's provider staffing like overnight?

    I work in a 15 bed PICU setting. Our general structure is that every patient is assigned to the 'fellow' team or the 'NP' team (divided evenly), and the fellow or NP is primarily responsible for the patient's plan of care. The intensivist oversees all 15 beds, but doesn't have any patients that they manage on their own; rather, they're present to advise the fellows/NPs, update families, etc. We don't have any residents (praise the lord). The attendings do 24-hour shifts, so we always have one in the unit. They're around all day and at the beginning of night shift for rounds, then they go to bed in a call room inside of the unit. They carry pagers and get up if a child becomes acutely critical or codes. Ideally, the NPs and fellows do 12-hour shifts, so the person who is managing the patient should be awake and on the unit for the entirety of the shift. Every so often they'll do a 24 and drag a recliner into their break room/office, but they always have their phones on and are expected to be readily accessible right away. The fellows can make me a little nervous at times (especially the brand new ones), but usually, if they have a question, they'll consult the NP (all of whom have been around much longer than the fellows). Sometimes we'll have two NPs, and very occasionally we'll have two fellows which really does make me nervous (although they will generally put a third-year fellow with a first-year so that at least one of them knows what the heck is going on). It's a really nice system. This is the first place I've worked where the main overnight providers aren't doing 24s; I'd always feel really guilty calling during the night, and I'd have providers tell me, "Don't wake me up unless somebody is dying." It makes me feel so much more comfortable knowing that I can get their input any time day or night and that I won't feel guilty for waking them up. The last time I worked with a resident during the night, it went something like this: https://allnurses.com/nursing-humor-share/fun-with-residents-1083110.html
  8. adventure_rn

    Felony charges

    I'm not a legal expert, but I'm guessing it varies from state to state depending on the Board of Nursing regulations. The fact that your coworker had that same experience suggests to me that your state requires you to disclose within 30 days. In addition to consulting an attorney, it wouldn't be a bad idea to dig around on your state Board of Nursing's website to investigate the bylaws.
  9. adventure_rn

    Unsafe staffing with 4:1 ICU ratios 8:1 on floor.

    I agree, but how can any reasonable executive think that this will save them money??? With ratios like that, they're bound to have a ton of adverse outcomes and errors, which leads to Joint Commission investigation, which leads to not being eligible to receive Medicare/Medicaid, which leads to the hospital going bankrupt. If they see an increase in CLABSIs/falls/pressure ulcers/surgical site infections because nobody has time to do their jobs safely, then the hospital won't receive any reimbursement for the care. Furthermore, you'd have to account for the potential lawsuits they'd face due to negligence and malpractice. Not to mention the fact that these types or ratios will lead to a mass exodus, which will lead to an even greater staff shortage, which will become increasingly harder and harder to recover from the worse it gets (not to mention more expensive). There is so much evidence that keeping your nurses happy and reducing turnover is more cost-effective than the cost of constantly recruiting, onboarding, and orienting new people. My friend worked in a NICU that almost shut down for this precise reason. Everyone was quitting because the nurses were taking 6 to 7 patients (for reference, a typical assignment is 1:3 at most since it's an ICU setting and all patients are total care as babies); at the last minute, they canceled everybody's scheduled summer vacation due to being short-staffed, and, *spoiler alert*, even more people quit and the ratios became even more insane. Seriously, how can a reasonable person (especially a CNO who has presumably worked as a nurse and understands how insane those ratios are) think that this is a good idea? Baffling.
  10. adventure_rn

    Taking travel job, hoping for perm offer. Too risky?

    That is an interesting dilemma. While Ned's posts (and the entire travel forum) are great resources, you may get some helpful insights from the Nursing with a Criminal History forum as well. I would think that if you're worried your past would prevent you from getting hired permanently, it would also prevent you from getting hired as a traveler? (Ned, not sure if you have any insight on this?) I'd imagine that HR has to screen travelers just like they screen permanent employees (i.e. background checks, drug tests, etc.), although the background check may be more expedited. If you're hoping that a unit would be desperate enough to take you on as a traveler, it seems like they'd be desperate enough to take you on as full-time staff, if that makes sense, especially with strong references. That said, Yale may be tough, both as a permanent employee and as a traveler. I work at a large, world-renowned academic hospital and came with experience in to an ICU that was desperately understaffed, but the HR application process was unlike anything I've ever experienced before (6 written references from colleagues, including at least 2 current managers, which meant informing your manager of your intent to leave before being offered the job). It doesn't sound like you'd have any issue with references, but their institutional policies regarding criminal history may be more strict than other lower-profile hospitals. I don't think it would hurt to send out applications. If that doesn't work, you could still consider the travel route. However, if it were me, I'd proceed with caution. The worst case scenario would be if you moved your whole family out to the east coast and then couldn't secure a permanent position, or enough consistent travel positions, to make ends meet. Even if you left your current job on great terms and could return to your prior job as a back-up option, moving cross-country for a travel position and then moving cross-country back is a very expensive route (again, speaking from experience).
  11. adventure_rn

    Taking travel job, hoping for perm offer. Too risky?

    That is a great point. I had a friend who was dead set on moving to a big city on the west coast, which was home to about 10 regional NICUs. She took travel assignments all around the area to find out the reputation, benefits, drawbacks, and structure of the local units. She made connections with the managers at each one, and each unit offered to hire her on full-time (I think part of the reason she stayed on my unit was the $10,000 signing bonus). Even though she turned down the offers from other managers, she could probably get a job at any of those units if she wanted to (assuming that they're hiring). I do wonder why you want to move to New Haven. Do you have a spouse/partner that's moving there or a school program you have to move for? Do you want to move there, or do you have to? I only ask because I was in a similar boat when I moved from the east coast to the west coast, then back to the east coast a couple of years later (a.k.a. There and Back Again: A Nurse's Tale). I went as permanent staff instead of traveling because I had less than two years of experience, and I was certain that I wanted to live in said west-coast city long-term. Once I got there, I realized that although I loved the city itself, the urban lifestyle wasn't for me, and I missed being close to my family and friends. In retrospect, I really wish I had waited until I had two years under my belt and gone as a traveler. It would have been far easier, and less expensive, to test the waters by traveling than to move my entire life back and forth across ~6,000 miles in three years. Hindsight is 20/20.
  12. adventure_rn

    Force to change unit in the middle of shift

    Lol, I've been forced to float to an entirely different hospital in the middle of my shift. I started at 7 PM, was notified at 9 PM, finished my charting by 10 PM, waited for a cab until 10:30 PM, and didn't arrive at the other hospital and find my way to the unit until around midnight. The sister hospital was about an hour away; I was a city-dweller without a car, so the hospital was required to foot the cab bill out to the 'burbs (about $75 each way). This was at a union hospital, and the union had negotiated this into our contract (fortunately with a $10/hr inter-campus float). However, I have been forced to float to other units mid-shift in every hospital where I've worked, without a float diff in some cases. It honestly didn't bother me that much, granted I was being paid a huge differential (including two non-productive hours being transported from the main hospital to the satellite hospital). I might be a bit irked if I wasn't getting a float differential, but honestly, after rounds and the first med pass at the beginning of the shift, usually the busiest part of the day is over (in my specialty, anyway). Of all the nurse staffing snafus in the world, this one is an annoyance but not a major offender (and certainly not a lawsuit ).
  13. adventure_rn

    Taking travel job, hoping for perm offer. Too risky?

    Ned is amazing, and you should definitely trust whatever he says. I'm not a traveler, but it seems like it would depend a great deal on what the specific agency is offering you vs. what the hospital would be offering you. For instance, I've worked for a hospital that paid up to $10,000 in moving fees (after tax) and bought me a one-way plane ticket; in contrast, I've worked for one that gave me a $250 relocation check (before taxes)--each was for a cross-country move to and from the same location. In the former case, you'd definitely get a better deal by using the hospital's relocation resources as a permanent employee. In the latter, you may be better off going through a travel agency and using your stipend (although you obviously couldn't use it to move your entire apartment/house). In addition, I've worked in places where travelers negotiated a higher base salary when they became permanent employees because management didn't have to pay to onboard and orient them. I worked in one hospital that offered current travelers a $10,000 bonus to stay on permanently (in part since they didn't require relocation benefits). I doubt these examples are the norm, but it is possible to attempt to leverage your travel experience in order to get a bonus or a salary increase. It's possible that you'd get better beneifts (i.e. bonuses, relocation) by starting as a permanent staff, like Ned said, but that's not necessarily always the case. IMO (again, not having had travel experience myself), it does seem like traveling would allow you to test out the unit before you commit to staying there long-term. However, there are a lot of challenges that you'd face as a traveler that you wouldn't as permanent staff (i.e. a shortened orientation, poor or no benefits, being the first to float, potentially getting the crappy assignments that the permanent nurses don't want). Is there a reason you think you can't get hired as a permanent staff member right off the bat? If a unit is short-staffed enough to require travelers, they're probably desperate enough that they're hiring a bunch of people, too (unless they have a discrete point at which they expect staffing to improve, i.e. half of the staff going on maternity leave at the exact same time). I've known plenty of travelers who have stayed on as permanent staff; I've only ever known one person who wanted to stay on but wasn't able to get hired, and it was because she stirred up a lot of drama and had disciplinary issues during her assignment. If you take a travel position and do well, you could probably be hired on full-time; however, if your end-goal is to be permanent, it would be so much less of a hassle to just apply for a permanent position and see what happens. Why not give it a shot? Finally, are you even sure that Yale's psych units are using travelers, and do you know which agency they use? A few years ago, my entire healthcare system (20+ major hospitals in 4 states) put a full stop on travelers for over a year. I've also worked on units that are profoundly overstaffed to the point where everybody is being put on call and burning through PTO; those units may go for months or years without needing travelers. Ned can probably speak to this, but if you do plan to travel, you may not find what you're looking for if you're only interested in one specific specialty in one specific hospital, or even in one specific region. I guess you could reach out to Yale (or other AN members) to try to figure out what agencies they work with, or if psych in and around New Haven is hiring travelers at all.
  14. adventure_rn

    A Feather in my Cap!

    Oh, Davey, you reminded me of my first day on my gero-psych rotation in nursing school. I sat down next to the man I'd been assigned to, and our conversation went something like this: Me: Hi, I'm adventure_rn, I'm a nursing student and I'd love to ask you some questions. Patient: ... [stares me dead in the eyes] ... Patient: All my friends are porn stars. Me: Needless to say, my patient assignment was changed pretty quickly.
  15. adventure_rn

    Extreme nurse burn out need help please

    Wow, I am so sorry you are having this experience. In addition to the suggestions above, here are a few ideas that I don't think have been mentioned. First, see if your job has some kind of Employee Assistance Program. Most large corporations (especially hospitals) have some kind of benefit that allows you to have 3-6 appointments with a counselor for free. They are in place precisely for the reasons you described, and they're totally confidential (i.e. the counselors aren't affiliated with the institution and can't legally tell your employer what you say, just like seeing a regular therapist or psychiatrist). They may be able to help you work on some strategies to get by until you can start your new job. The EAP counselors may even be able to help you navigate the Short Term Disability process; in addition the counseling they also help employees navigate their behavioral health resources (like finding a long-term therapist/psychiatrist, helping you understand your behavioral health benefits, etc.) You can usually find info on your hospital's EAP (it may have a different name depending on where you work) through your hospital's HR site, usually under a tab or section about 'Employee Wellness.' Second, you mention that you're part of a union--definitely let your union know what's going on and see if they can back you up! One of the main reasons we even have unions is to protect us from unsafe work conditions like the ones you've described. I completely understand if you just want to keep your head down and not rock the boat; however, before you leave, please report these conditions to your union so that they can attempt to address them. That all sounds terribly unsafe for both patients and staff. Again, I'm so sorry that you're going through this. It is entirely unacceptable. I'm glad you have a new job lined up!
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