LnDPPRN

I currently work in float pool as a post partum RN between 4 different hospitals within the same company and all within a major metropolitan area. The biggest hospital has an OB hosptalist and a neonatologist/neonatal NP present in house at all times. The largest hospital has a level 2 EQ NICU. So if something goes horribly wrong with a baby on the post partum floor and the pediatrician is not around, you can grab a NP in a pinch. (ie, a baby stops breathing because of sepsis or a baby seizes secondary to narcotic withdrawal, etc.). At 2 of the other hospitals, they have smaller level 2 NICUs where a neonatologist makes rounds but is not there 24/7. I am told that the neonatologist has to be able to physically get there within 30 minutes of an emergency, giving orders all along the way over the phone. But that doesn't do much good if I need an ET tube or a UVC. The remaining hospital just dropped down to level 1 status a few months ago and I so infrequently work there that I am unsure if neonatologists round there anymore. The NICU nurses that have been there are quitting. At these "other hospitals," I am getting worried about what will happen in a true emergency without a neonatologist in house. I am unsure if the ER physician can do or is willing to do anything for us or if they are NRP certified. I could see the ER phsician refusing to come up and help due to lack of experience with newborns and that could vary from doctor to doctor. (That really did happen in a previous hospital I worked for. I heard about it in a staff meeting.) I could ask the other RNs what they would do I suppose but I am afraid they will give me bad advixe especially if it is not spelled out in a protocol. I know that the scenario I am describing is incredibly rare and none of this has happened to me in 6 years. But I tend to think of "what if" scenarios. I think it is very bizarre to not have an in house neonatolotist even if the NICU is "slow." What do you think? Am I just being paranoid? What can I do given the situation?

Your preceptor was ultimately responsible for your patients if something went wrong, so for you to get in trouble for telling her about when you give PRN BP meds is beyond me. If you can't tell or ask her anything, why were you even on orientation? And believe it or not, questions come up after orientation. Things don't magically fall into place for a new nurse after 6 weeks. Yes, you should be able to hold your own after orientation for the most part, but a safe nurse knows his/her limits and asks questions after orientation. Based on other things you said, it sounds like you weren't in their clique. And quite possibly, your BSN pursuit and pregnancy may have also been contributory factors and as those things would have inconvenienced the unit. Without being there myself, none if this sounds justified. I've been in your shoes. I was a new grad in Labor and Delivery and overall performed very well. After about 1 year of experience, I moved to a hospital in a different state to be closer to my family. The hospital was in a big city. There was a clique and it was palpable. I felt very uncomfortable. It was as if they expected me to perform as if I had 30 years of experience even though I only had just over 1 year. I felt like asking questions was going to get me in trouble, even though this hospital had very different procedures, treatments, and protocols. I did make some mistakes, but that's not what got me fired. In fact, the complaints about me got pettier and pettier over time. A lot of the complaints were delayed by about 2 weeks and non specific. And when they were specific, they were very petty. They didn't like how I thought about things or made assumptions about why I did something a certain way. I was fired after 6 months with the official reason being "not a good fit with the unit." She advised me to work in post-partum and even set me up for an interview within the same company, but I wasn't hired on. Interviewing at other hospitals in the big city sucked because everyone knew everyone and my resume, with short-lived jobs, looked suspicious. I finally got another job in a rural hospital outside the city. It was very different. There was no NICU and it was hit and miss whether or not a nurse with NICU in her past experience would be on shift at night to help stabilize preterm babies for transfer to the big city. Multiple nurses with 30 years of experience (partly in L&D) refused to work L&D (and got away with it) even though most other nurses and I were expected to float between L&D, Post-Partum, and Nursery. (The unit was so small, all 3 areas were considered one unit.) A few times, I was asked to come in on a night off because a couple of those "very experienced" nurses refused to work L&D and they were short-staffed. There were a few very good L&D nurses, some were okay, and a few couldn't read a fetal strip. However, I performed very well overall. I did tasks a lot of nurses were refusing to do. I took on a few projects to help improve the unit, and I received 2 very good evals. After a year and a half there, the rural hospital went bankrupt. The hospital in the big city that fired me in the past bought the rural hospital. I didn't find another job in time and the hospital from the big city fired me AGAIN even though I was performing much better than several other nurses. I went to the head of HR and explained why this wasn't justified, and they didn't care (not that I expected them to). I talked to a lawyer about this, and she basically said that they can fire you twice if they fired you before. Which make sense I guess. But still. I went back to the big city and got a temp job in Post Partum at a competing hospital. They liked me enough to retain me as a per diem nurse permanently. I'm very well-liked in general, and I've been there for a year now. I'm still upset about what happened with me getting fired twice, especially because that hospital owns over half the market in the big city. I don't have the confidence to work L&D anymore, because I can't risk failing again. My advice, don't burn your bridges and don't talk crap about your old employer, because you'll never know when it will come back to bite you. It's a small world. I myself didn't talk crap about the company that fired me, but it has been devastating how much the firing has affected my career and job choices.

Something has been bugging me. I've been working in Post Partum. I have orders for all kinds of PRN meds for pain, heart burn, itching, constipation, etc. One thing that I rarely see ordered PRN is utero-tonic medications such as pitocin, cytotec, methergine, or hemabate. Yes, I know not all hemorrhages are the result of a boggy uterus, but it would be nice to have these PRN if that's what my assessment tells me. Of course, if I had to give any utero-tonic, I would tell the OB immediately. And hopefully whatever utero-tonic is ordered PRN is not contraindicated. (In other words, the doctor customized the orders to the individual patient, which I find rarely happens, but I digress.) The lack of PRN orders has been bugging me because I have worked at other facilities and, even though they didn't have PRN utero-tonics either, there was either a resident, OB hospitalist, or on call obstetrician you could grab for an order if you couldn't get a hold of the patient's doctor in a timely manner. The facility I currently work for has no OB hospitalist. Obstetricians come and go all day, but no one has to physically be there at all times. In fact, I've heard L/D call overhead more than once "Any OB to L/D STAT" they've been THAT desperate sometimes. Therefore, I have this concern that if my patient hemorrhaged (despite all my other interventions such as emptying the bladder, fundal massage, etc.) and the doctor doesn't call me back very quickly (which they generally do, but it can be 10-15 minutes sometimes), she may lose an unnecessary amount of blood while waiting for a medication order. I read the policy on postpartum hemorrhages. It says I can "increase IV oxytocin rate and infuse 500ml bolus" before calling the doctor, but it is already discontinued by the time she gets to me so that doesn't help me at all. Me bolusing pitocin would be in addition to what was administered previously, which, to me, is technically another dose and another order. As for the other utero-tonics, it says "If uterus remains atonic to oxytocin infusion, give another utero-tonic medication per physician order." In other words, I have no standing orders to back me up. So then, I asked the manager my concern about not getting a utero-tonic order quickly enough. (As I can't prescribe, right?) She advised me to grab ANY OB doctor. If I can't get an OB, what about anesthesia? She didn't think the anesthesiologist would give me an order as it is not his/her specialty (he/she has to be physically be there at all times so I thought he/she would be a possibility). She said that if all else failed, I could call the ED doctor. (Oh yeah, he or she will drop what they're doing and help me with a patient he/she doesn't know, and by the time I summon him/her, I've already wasted time trying to get an OB. And I doubt he/she will give me a telephone order without laying eyes on her first, wasting more time. A Rapid Response Code won't get the ED doctor to my floor, but a Code Blue will. I suppose I could STAT page the ED doctor overhead if all else failed, but again, what a waste of time). She also said that a L/D nurse can be summoned to start pitocin IV without first obtaining an order, because a L/D RN has a "wider scope of practice" (according to who?). I asked my manager if that was written in any policy, because I couldn't find it. (I should be able to access ANY policy, right? Surely she doesn't have some secret book of super policies that us staff nurses can't readily obtain.) She said she would find the policy where it says that for me. When I followed up a week later, she said she was too busy to find it, but assured me a L/D RN could start pitocin for me in a pinch. Based on her tone, I don't think the manager is invested in helping me research this to the end if I ask her again. I'm not satisfied with where this stands right now. Any advice?