nfahren05

You will not be able to make a full time paycheck at first, it takes time to build a business of any type so be realistic about the time involved and the barriers to entry. Do some market research in your area before you invest your money and time. I went the legal nurse consultant route, did the training, and all of the "leg work" to set up a business shell only to find out two things: (1) there were already too many RN JD's in my area who didn't really need nursing consulting services because they were already qualified, and (2) since I had worked at several area hospitals, I was limited in which cases I could take on without running into "conflict of interest" situations. Eventually, I dissolved the company because it was just not going to be a profitable venture, but I did learn a lot about the law that helped me in my full time case management role.

I went the ADN route, and eventually added the BSN because my hospital decided that they wanted to insist on this to continue with them. They didn't do much to help, and even made it difficult for me to get the extra clinical experience, but I eventually finished the bachelor's degree. The BSN added very little to my nursing knowledge. I think that, for hospitals, it makes much more sense to push certification than additional degrees. Ongoing education for nurses who are already working tends to translate better to improved patient care because nurses usually self-select CEUs that are most relevant to their area of practice.

No, doubles would not typically be an issue, but you will be asked to come in on off days. CM also works 7 days per week, and holidays (24/7 in some larger facilities).

It happens. I did that once years ago, and had to work as a nurse tech for a few weeks while things got sorted out. Expensive lesson, and I took much ribbing from my co-workers, but not the end of the world or my career. Just let your manager know, and see what your options are at your facility.

Realize that no one starts out being able to "handle anything that's thrown at them." Most get there eventually, but it takes time and experience. At this point, if you are able to handle a full, or close to full, assignment on a "good" day when there are no crises, you are doing well. You really shouldn't be trying to handle emergencies or unusual situations on your own this early. Relying on input or actual hands-on assistance from more senior staff and your charge nurse is entirely appropriate. Let them help you, and when you get home, do some "Monday morning quarterbacking" and think about what went wrong and right, keep a journal if that helps. Adjusting your expectations is what will help you reduce your performance anxiety, and allow those critical thinking skills to come to the surface.

I would consider it, but I would also not spend a great deal of money on it. There are a lot of for-profit schools out there offering programs at top dollar, but it's hard to get a return on investment for the BSN (particularly for those who already have a non-nursing bachelor's degree as I did.) If your plan is for community health care, however, it may be worth it since many public health programs do want BSN's because ADN programs often don't teach that content and their graduates haven't had community health clinical experiences. Look around for local state university programs that offer online RN to BSN programs. I had to wait a couple of years until our local school offered this since when I first considered this option the only state school that did was over 100 miles away, but it wasn't long before several nearby schools joined in. I had to take one prerequisite chemistry class before I could start the nursing classes, but after that it was all online until the last semester, and I was able to fufill the clinical component at my local hospital. I can't say that my career has taken off since completing the program, but I no longer have to apologize for not having the BSN credential, and since I did it at a public university, my student loan debt is very minimal.

Would like to see mandated clerical/unit secretary support on all intensive care units 24/7/365. No way to enter routine orders for labs, consults, answer phones, etc., and manage 2 critical patients at the same time. Preferably would like to see this on all acute care units, but let's at least start with the highest acuity areas.

Overall, while ageism is certainly a factor, I think that nurses (at least bedside nurses) are somewhat protected by the demand for their skills and the relatively high median age of registered nurses in the marketplace. One problem, however, is that the non-bedside positions that older nurses tend to seek out (e.g. clinical educator, risk management, quality management, etc.) are the positions that hospital management tends to cut when times are tight so older nurses are affected disproportionately in reductions in force.

There are a lot of older (55+) nurses dropping out of clinical positions because the hospitals won't step away from the 12 hours shift requirement. We are losing a whole generation of experience because many nurses are feeling too tired at the end of the longer shifts to give safe care, especially since 12 hour shifts often end up being 16 hour shifts when there are staff shortages. National quality organizations have already backed up relative safety of 8 hour shifts over 12 hours, and have urged facilities to consider a change, but 12 hour shifts are simpler to schedule so patient and staff safety has fallen by the wayside. Many older nurses cope by moving into education, quality, risk, utilization/case management positions, but it is leaving a knowledge gap at the bedside as the nurses who are physically able to run non-stop for 12-16 hours in the ICU or ERs are less clinically experienced than their older peers. Please, if you are in a nursing leadership role, find a way to schedule those experienced and technologically capable RNs in a reasonable manner, whether it's dropping back to 8 hour shifts, prohibiting 16 hour shifts, or monitoring the number of back to back shifts that nurses work. Your patients and staff will thank you.

I wouldn't say that the BSN is useless, because it does add some depth beyond the ASN, but given the choice between a BSN and an RN with a specialty certification, I'd take the certified nurse in a heartbeat. The BSN really doesn't do much in the way of research (I had significantly more actual hands-on research experience while earning my BA than my BSN) although it does allow for some basic familiarity with statistics and critically evaluating research done by others. The BSN also focuses on some topics (e.g. community health nursing and leadership) that ASN and diploma programs don't cover well, but if those aren't your cup of tea, then pursuing the BSN is probably not worth the added expense in terms of time and money, and I certainly can't advocate for it for nurses who already hold a non-nursing bachelor's degree.

I found that it helped to know a fair amount about the US healthcare system and payer structures before that first interview for a CM position as a non-CM candidate. If you didn't have such a course in your BSN program (and most don't have sufficient detail anyway,) consider either taking a course or doing a fair amount of just general reading about the topic. Having worked for both insurance payers and hospitals, I've seen that it's generally easier to get a position on the payer side than in the hospital. They usually have deeper pockets for training than hospitals do, although certainly not as deep as in the past. Even if you can get a position through internal channels at the hospital, you'll come in functioning at new-grad level into a very fast-paced environment, and it can be brutal. I'm not saying that it can't be done, because obviously many nurses do exactly that, but it is a much more stressful way to start in a new specialty area. Not having your CCM is not a barrier to entry since everyone knows that you can't get it at first anyway (you are expected, in most positions, to get it as soon as possible) but it does close off some avenues (e.g. work comp CM since most states require certification) so look for positions that have titles like Case Manager I where there is a tiered system with CM II/III, etc. because those are ones where the employer may be expecting to be doing some training.

I can't remember any time when I had to do drug calculations without a calculator so arithmetic ability is less critical than the ability to do the dimensional analysis needed to set up the mg/kg equation to figure out the missing variable. Nowadays the pharmacy does virtually all the drug math, but every nurse should be able to set up the equations. I have only worked for one hospital, however, that actually tested new nurses during orientation.

Most insurance company positions are either concurrent utilization review or pre-certification, some are retrospective reviews. It's not clear from your comments which you were considering, but since the concurrent review is most common, will deal with that. The pay is very comparable to what you will receive in the hospital, it's unlikely that you will change much, in either direction, from what you are receiving now-expect this to be a lateral move, unless you are interviewing for a management position. What is likely to change is that most of these positions are salaried, not hourly (as in the hospital.) Some insurance companies do staff for off-shift hours, going to 8-9p so if you are looking at one of those positions, make sure that the salary reflects a reasonable differential for working non-office hours.

Managed Medicaid is one of the most challenging areas of case management, and (due to Medicaid reimbursement,) it's one with the highest ratios of nurse case managers to members. I've done hospital case management, commercial telephonic case management, and (for 6 long months,) a Managed Medicaid program similar to yours. We encountered many of the problems that you have found, e.g. members who were difficult to find, difficult to work with, and had benefits that made it difficult for the physicians to help them. I would have liked to stay longer, but the 400:1 ratio of members to CM made it impossible to get anything done, and created a huge liability risk for us as nurses. I was involved at the start-up of the project in our state, and would hope that things have gotten better by now, but I don't know. Most of the members do need social workers more than they need nurses, but for whatever reason, the company hired more RN's than MSW's. The initial assessments that we had to do for each member did require nursing knowledge and judgment, but after that, a social worker and a clerical person could indeed have helped, assisted by a nurse, only as necessary. As an answer to your question, I would say this this is mostly the fact that you were working with Medicaid, and that most telephonic case management is quite different.

I am worried that if allowed- I would be liable for a physician error that went unnoticed. Can I become a staff nurse and continue working as a floor RN? You are already liable for physician errors as a staff nurse, but only to the extent that you should be catching errors that a reasonable staff nurse would catch. If you went to grad school, and completed your NP program, you would be liable for errors that an NP should or would be able to catch. So, yes, there is increased responsibility and risk, but it never escalates to the level where you are held to the same standard as a physician because NP education is still not equivalent to physician education.