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Truthfully, I'm still waiting for a counter argument that doesn't imply that i'm anti-nurse, or not experienced enough to understand, or in some way am demeaning and personal because I'm making points that aren't exactly popular among nurses, or pointing out arguments that are just factually incorrect. You said to be more open minded. I'll challenge you to do the same.

No, but in the United States it is, and any meaningful change towards something better in the near future is highly unlikely. Also, let's not pretend that other countries deliver healthcare without being cost conscious. Any time there are finite resources such as beds, staff, equipment, etc, there's a degree of awareness that we need to have in our utilization of those finite resources.

Yes. Run along now.

I like how quickly this turned into being for or against nursing. Such a typical reaction. So isn't touting 19 years of experience as a justification for not being able to back up a claim. That aside. I'll say again that the reason nursing gets stomped on when it comes to budgeting is because few nurses actually want to learn about how the budgeting works. When I say that getting involved with cost savings and having strong nursing leadership can help bring money for continuing education and reinvestment back into nursing like staffing, equipment, etc, I'm saying it because I've seen it work in my, granted, humble **ten** years of experience in multiple settings ranging from large academic tertiary centers to small community hospitals. Oh, and my work on my PhD in **Nursing** and **health policy** where I actually studied nursing budgetary patterns and staffing trends. Fun fact: There's a difference between 19 years of progressive evolution in a profession and just doing the same thing for 19 years while the world around you changes. My argument remains that there should be nurses at the bedside and in the business office, and that nursing should be the ones dictating budgetary constraints and needs, not some finance guy with an MBA and a finance degree. But in the absence of nursing doing its part as the largest healthcare group, guess who takes on that role? The finance guys and MBA types fill that role. Nursing remains its own worst enemy on this one, as it tends to do.

I think a 24-48 ICU stay is called for, and agree with the posting above saying that the dopamine is kind of just a bandaid. He'll definitely need more of a work up, and more intense monitoring in the meantime in case the dopamine needs to be titrated or a pacing wire needs to be floated emergently. The only other thing that I can think of is that it was his first HD treatment, maybe he was experiencing dialysis hypotension that can elicit a vagal reflex causing bradycardia and hypotension. Either way, an ICU stay is probably still called for if that's his response to a preliminary HD treatment.

citation to support this claim, please. hospitals that are non-profit status can use their profits for capital improvements to get tax breaks. Claiming that "a large part of the health care budgeting crisis" can be attributed to this is spurious at best. Here are a few examples of mechanisms for hospitals to obtain grant monies or tax exemptions for capital improvements Federal Resources for Capital Financing

Get the vaccine. Every employer that I have had has not only required documentation of having been vaccinated, but did blood work to make sure that I had the antibodies and was immune. Plus, with everything you'll be exposed to as a nurse, you'll want all the help you can get.

So, the question is really of overdose vs adverse drug effect then. Two different concepts. An overdose implies a toxic state affecting actual organ function. Most drugs have a LD50 scoring (median lethal dose) and many researchers have tried to find this number for marijuana, but they just couldn't give animals enough THC to kill them. Though at those doses, I'd imagine it would be quite.....unpleasant. So let's put aside the idea of overdosing on marijuana and focus on adverse drug effects. Someone can get a bad high, or just be sensitive to the drug, or just smoke some really potent product and have a strong reaction, or they got product laced with a different chemical like cocaine, meth or god knows what. Adverse drug effects are the inherent risk in anything from an energy drink to an aspirin to giving TPA for a stroke in an ER or ICU. Beyond marijuana being illegal, I hardly consider it to be any riskier than most other drugs. I would dare argue as to its safety comparatively. I don't think I understand your comparison of alcohol and marijuana as comparing dilaudid and tylenol, however. They're different drugs, but do serve as an interesting example of how one legal drug could potentially be more damaging than one that was made illegal under less than forthright political interests and spurious claims by "experts" at the time. Also, the estimated LD50for alcohol in a 75kg human at one time is roughly 14 shots (40% ABV), give or take.

Some of the studies being cited here actually makes me nervous about the amount of misinformation nurses could be giving their patients. I'm all for caution, but a few cross sectional studies, even if well designed, don't justify the definitive causal links that are being suggested in the above posts. Marijuana may be associated with mental health issues, but associations aren't causation as anyone who has taken a research class at any point will have heard, hopefully. Reason being is that the mental health issues could be underlying issues not caused by the marijuana itself. Using could be self medicating, or maladaptive coping like with other illicit drug use. So blaming marijuana use is kind of a stretch. But back to my original point of vetting your articles and at least learning what makes for a good study before posting something claiming it as evidence. This may be a whole other debate, and sound incredibly elitist, but this is why a BsN should be entry to practice because you at least get some exposure to research methods and what makes for a good study vs a poorly designed one. Otherwise, who knows what other misinformation nurses are giving their patients on a variety of things based off some "study" that they read.

Thanks for your input! Some of my friends there in public health circles have suggested I try working with NSW Health, so it's nice to hear that it's an option.

I'm hoping some of our Aussie nurses can help me out on this one. I am finishing up my PhD in Nursing later this year, and I will be moving to Sydney mid 2017 to live with my partner. I've been a nurse for ten years in critical care and trauma, with some management experience as well. I'm in the process of figuring out applying for registration, but had some more general questions about nursing in Australia, and more specifically, Sydney. Does anyone have any insight into things like what to expect from the job hunt once I have licensure there? I will be applying for permanent residency at the same time, so I will be eligible for most employment I think except for government jobs reserved for citizens. Having a PhD will open up some doors for faculty or administration roles, but I feel as though I should work at the bedside for awhile at first to get a feel for nursing in Australia. Having been back and forth between the States and Australia a fair amount over the last few years, I've met a few nurses in Sydney who all love what they do, and my overall perception seems to be that nursing there is very similar with some key differences. So, any insights or words of wisdom would be greatly appreciated.

I'm hoping some of our Aussie nurses can help me out on this one. I am finishing up my PhD in Nursing later this year, and I will be moving to Sydney mid 2017 to live with my partner. I've been a nurse for ten years in critical care and trauma, with some management experience as well. Does anyone have any insight into things to expect from the process of applying for endorsement? Or what to expect from the job hunt once I have licensure there? I will be applying for permanent residency at the same time, so I will be eligible for most employment I think except for government jobs reserved for citizens. Having a PhD will open up some doors for faculty or administration roles, but I feel as though I should work at the bedside for awhile at first to get a feel for nursing in Australia. Having been back and forth between the States and Australia a fair amount over the last few years, I've met a few nurses in Sydney who all love what they do, and my overall perception seems to be that nursing there is very similar with some key differences. So, any insights or words of wisdom would be greatly appreciated.

With your varied and extensive experience, have you thought about clinical consulting or even global health? I'm in a similar boat, though in critical care where the stressful part isn't necessarily the job, but the politics and personalities of dealing with coworkers and administration. I'm looking at biotech companies and clinical education which definitely comes with its own issues, but at least they'll be different issues. If you're really wanting to shake things up maybe working for a global health organization that provides mental health services in underserved countries might be something new while still utilizing your skill set. There's also flexibility with some groups of doing 6 month to a year contracts. Definitely take time to regroup and consider what you would like to do because you might be surprised at what doors are open to nurses with your experience. It's not all clinics and hospitals for nurses anymore. There are opportunities in global health, biotech, government agencies, teaching, and basically anything related to health so it's just a matter of taking stock of your skills and what yore looking for in role and then going for it.

For day to day stuff, I really liked critical care made incredibly easy. It helped a lot with understanding the basics and is a really easy read for learning waveforms and blood gas interpretation and whatnot. For the more nitty gritty stuff, I still refer to The ICU Book by Marino. It's a thick, kind of intimidating book that goes into a lot more detail on just about everything. When i had a really specific question about, say vent mechanics, that's the book that I would go for. Hope that helps!

I was taught that it depends on the situation and that it's your highest degree earned. So BSN MSN DNP is rather redundant and looks a bit silly. DNP would suffice. I only use my CCRN-CMC-CSC when writing from the perspective of my critical care role. PhDc only comes out in my academic role when I'm writing a grant or submitting abstracts. The only place where my full credentials are listed at any one time is my resume/CV. It is still striking to me how much nurses like to put each other down though whether its for having certifications or for not having certifications. I'm in the minority that thinks that we should take after some other countries and require specialty board certification to practice. For example, requiring every ICU nurse to sit for the CCRN within a certain time frame of beginning their career in critical care. It sets a national benchmark for knowledge and practice within a specialty much like board certification for physicians. Again it boils down to the fact that if we want to be seen and treated as professionals, we should probably seek to uphold the highest professional standards.

You make a really important distinction here in what's technically reimbursed vs floor stock since nursing budgets are usually built into room rates in some fashion. What's crazy is that some hospitals take inventory and floor stock to more extremes than others. I've seen hospitals that keep all of the personal care items in omnicells. The nurse actually needs to log in and take out tooth brushes, mouth wash, iv tubing etc under the patients name so that it's billed or at least associated with the patient. So while things are technically considered floor stock, they're still budgeted in some way through the room rates of the unit. It gets into a whole other issue of how nursing services should actually be billed, but i think that's a whole other thread in itself.

I didn't bother addressing your mentioning of nurses pulling meds that end up not being administered because it was irrelevant to the greater point. Nurses will at times pull an extra medication anticipating it being needed. Whether its needed or not is irrelevant as it doesn't always get billed to the patient, and is there not reimbursed, thus the unit takes a loss. What you don't seem to get is that healthcare is a business but not like other private sector industries because while there are private hospitals, for profit hospitals and not for profit hospitals, their reimbursement and customer base is a wide range of reimbursement types depending on insurance status, type of insurance etc. We also provide a different type of service, like you said. But, nursing being the largest workforce, and woefully unprepared, as evidenced by this fruitless back and forth, for the responsibility that involves, business types with accounting degrees and MBA's run the show and budgets. In institutions where you see nursing leadership with more education and higher positions within the organization, you see tend to see better staffing, better continuing ed resources and other things like that. I think the IOM report on the future of nursing puts it best at basically saying that nursing will be a driving force in healthcare delivery modeling. It's just woefully unprepared for that level of responsibility and involvement because most can't see the bigger picture beyond staffing ratios. Or rather, they can't see that better ratios come from having a seat at the table and the other things that I already mentioned. Also, I'm ignoring the communism comment because it's absurd and you're from Florida.

Where do you think the money comes from for supplies and staff? That's right, a budget. It's tough to justify much to management when a unit is over budget constantly, with costs eating away at the bottom line. Ideally, yeah, it should be about proper staffing and having the necessary equipment, but it's more complicated than that. I've actually worked in units where what I described happens so it's not some dream world, though you do work in Florida, so I can understand why you would think that. But if you think this has to do with one gauze here or there, you're missing the point. It has to do with 80 nurses on a unit all engaging in wasteful activities. Making nurses aware of costs associated with care is pretty important, and I've seen cost sharing actually work in facilities where portions of savings go back to the nursing budgets. This us vs them bitter victim mentality that's also anti-academic is why nursing practice and empowerment varies by region and facility. Hospitals are businesses and operate as such. Convince them of a good investment, and they tend to be resistant at first but with good nursing leadership, change is possible. So no, it's not delusional, it's having been around the block and working in various facilities at various levels in multiple roles from staff nurse to efficiency consultancies.

I'm in academia as a PhD candidate but I'm also a bedside ICU nurse so I don't see the article as anything far removed from realities of nursing care delivery, and will very candidly say that part of the reason Nursing doesn't get ahead is because we refuse to acknowledge realities of healthcare delivery in this country. Unnecessary labs without orders is a compliance issue that costs money because hospitals don't get reimbursed. Grabbing that extra med out of the pyxis or omnicell that isn't billed to a patient adds up if every nurse does it. Every time a medication is taken out through an over ride or not accounted for, say if you take out 2 lopressors but didn't adjust the count to reflect that, it gets billed to the unit rather than a patient. A levophed drip can cost several hundreds of dollars depending on the concentration, so don't spike a new bag if the patient is arriving from the OR with one already infusing just because its easier and doesn't require untangling. That adds up to thousands of dollars per quarter right there. These are just two examples of how nursing can help in cost containment. We are the largest part of the healthcare workforce and could wield enormous power if we got over this attitude that anyone who presents new ideas must not be a current bedside nurse or is too removed to understand nursing care. Cost containment is partly in nursing's domain because nursing departments operate on budgets. So being budget conscious with good nursing leadership means more funding for nurses, and that translates to FTE's, raises, funds for staff development, vacation hours, lunches for staff, that sort of stuff.

Given that most of the commentary shows an egregious level of ignorance towards modern perceptions of mental health, I will recommend that you ignore the negative comments in this thread. They seem to be based on cultural attitudes and biases towards mental illness rather than actual evidence base and policy implications, making any advice unhelpful at best and triggering at worst. Truthfully, I'm somewhat disgusted that this is allegedly an "advice column." The best advice that I can give is to simply not mention your psych history to the board, your school or the other students. It's really not anyone's business to begin with, but if you do decide to disclose, mental health is protected under the ADA so unless the board could prove that you are unfit to practice at the time of application, they really can't do anything. Also, there are reasonable accommodation aspects through the ADA that your university would need to comply with if you so desire. So, you are protected. The bigger challenge will be dealing with attitudes towards mental health within the nursing community as evidenced by some of the commentary within this thread. You're going to feel inadequate because you're learning new things, but remember that everyone feels that way in nursing school. It's part of the territory with being driven out of ones comfort zone. Self care will be important to manage stress, and a lot of cognitive behavioral therapy and behavioral activation to help continue to manage your depression. If anything, your perspective on mental health will make you a really great nurse because unlike most, you'll actually get it when a patient presents with medical issues but also mental health issues that are just as important. That's true in any setting of nursing whether a general ward, a psych floor, or an ICU. It sounds like you're covering all of your bases, and that takes initiative, so give yourself credit for that. Depression is a constant battle, but you're doing it. Remember that. You'll be fine.

I dealt with the same types in my ICU orientation, and the best advice that I could give is to play the game and be your own best resource by referencing books like the ICU book, critical care made incredibly simple, etc. ICU nursing is definitely about details, but the types of detail matter more as far as prioritization. You'll quickly learn which nurses focus on which details such as a clean room, labeled drips, stuff like that. I'm that extremely laid back ICU nurse that's more big picture oriented. I've had many nights where I've taken an admit, intubated, started 14 drips and cannulated the patient for ECMO, but get yelled at by a type A nurse for the room not being pristine. I would argue that it's the type of details and prioritization that matter, and that is what new ICU nurses need to learn. I've walked into rooms where the counters are spotless, but the sedation and vasopressor IV bags are almost empty when I walk in. You can see where the prioritization was flawed. I would take a dirty counter with a sedated patient with a blood pressure any day over a clean counter with a patient tanking right when I walk in the door. The other part to my advice has to do with being your own best resource and just more confident in your knowledge base. That takes time. And those nurses won't like it when you are able to back up your decision making process with real clinical rationales, but they'll likely back off too. In the mean time, ask questions, seek out constructive feedback from people you've identified as good resources, label your drips and keep your room clean. The first year of ICU nursing is difficult enough, and it's pretty sad that the most stressful part is just dealing with other ICU nurses rather than the actual aspects of caring for critical patients.

I've had a lot more patients saying something to that effect lately. My standard line is "I'm a nurse, not a concierge."

Usually patients on CRRT are hemodynamically unstable. That's one of the clinical indications for CRRT. The AACN has put out several pieces, including a few protocols, for determining exclusion criteria for early mobility as well as for determining stages of mobility. You can literally just google them. I'm generally against doing much more than active range of motion and maybe chair mode in the bed if you have that capability while the patient is on CRRT. If the patient can walk around, then they're just not a CRRT candidate. They should be getting HD. The corollary to that being that if a patient is sick enough to be on CRRT, they probably don't meet AACN criteria for ambulation in early mobility protocols. The point about walking ECMO patients is sort of apples and oranges considering that ECMO has broader range of uses from super acute, super sick patients to walking, talking stable patients who are using ECMO as a bridge to a lung transplant or a heart transplant. CRRT on the other hand is for patients too unstable to tolerate HD. Generally speaking, you can't compare a stable ECMO patient walking to a patient on CRRT since the populations are different and the reasons for starting ECMO vary, but the indications for CRRT are usually pretty clear.

There's a lot of legal ambiguity in states where marijuana is legal or legal-ish since it is illegal at the federal level, but licensure for nurses is handled at the state level by state agencies. It presents a jurisdictional issue, and a series of technicalities that make for a complicated issue. My state has a medicinal marijuana program and marijuana is decriminalized, meaning that possession of less than a certain amount carries a nominal civil fine. To my knowledge, the state board of nursing has not taken a definitive stance on the issue, but is obviously leaning towards being against use of marijuana by nurses. As far as patient counseling, what nurses are being told is the obvious "don't smoke up before or during work, and don't show up to work stoned" kind of patient teaching. What's more interesting to me is that, since it is decriminalized here, would the board of nursing have grounds to act against someone without a complaint being lodged against their practice but rather simply because they're known to use marijuana? I think that's something that will just have to be challenged in court when the case comes up, and it totally will eventually.