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RobbiRN

RobbiRN RN

ER RN
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  1. RobbiRN

    How would Medicare for all affect nursing?

    42 days. If you can see one at all. Another major failing of the US system is that the ER is the only place forced to provide treatment without upfront payment. We find the cancer, then refer uninsured or under-insured patients to an outpatient oncologist who requires an upfront payment they can't afford. They flounder in in the outpatient world until they are close enough to dying to justify admitting them through the ER.
  2. RobbiRN

    Ripe for Exploitation

    You're right. One of the pitfalls of sweeping generalizations, and there are several in my article, is that some fine points get missed. I've assertively voiced my opinion for years and had a few minor victories along the way, but I've never been so keenly aware of how convenient it would be for new management to trade me out for a cheaper, more compliant replacement.
  3. RobbiRN

    Ripe for Exploitation

    The Most Trusted Profession Nursing ranks as the most trusted profession in Gallup’s annual poll for the seventeenth year in a row with a score of 84. Doctors and pharmacists come in a distant second and third with scores of 67 and 66, and the list fades from there. Politicians are tied with car salesmen, continuing their grip on last place with a score of 8. The honor of being part of the most trusted profession should not be taken lightly. Patients are keenly aware that we spend the most time with them, our motives are not tainted by financial gain, we usually care, and we’re positioned to share an honest, enlightened opinion. In theory, nurses are really cool people–great for relationships, good with confidences, least likely to inflict unnecessary pain, and excellent for decorating hospital marketing brochures with bright scrubs and big smiles. (And we usually pose for free, you know, because they asked.) We may be all these things. In a cruel twist of irony, some of the same qualities that consistently win us first place on the most trusted chart also make us ripe for exploitation: We’re eighty-five percent female, programmed to please, and unlikely to fight back. Risk for Exploitation - Why?? 85% Female Profession First, just being an eighty-five percent female profession still makes us vulnerable to inequality. "On the Basis of Sex," a recent movie about Supreme Court Justice Ruth Bader Ginsburg, stages a brilliant moment. Felicity Jones, who plays Ginsburg, is arguing a sexual discrimination case before an all-male panel of judges. One of them looks down on her and declares in a voice laced with condescension, “The word 'woman' does not appear even once in the U.S. Constitution." She stares him down and quips, “Neither does the word ‘freedom,’ your honor.” It’s a moving moment of assertive confrontation on her pathway to becoming the first female Supreme Court Justice. It’s a reminder of how far we’ve come. Women have made major strides. We just finished Women’s History Month. We even have a Women’s Equality Day. There’s a myriad of opportunities open to us, but we still glaringly lag male counterparts in easily measured areas like equal pay for equal work and representation in government office. A friend of mine in Spokane, WA, works at a major hospital where the nurses are threatening to strike. One item of contention is the $41 million in salary paid to the fourteen executives at the top while the workers are facing eroding benefits. A breakdown of the executives’ salaries posted on social media shows an equal number of men and women, but the women make half of what the men get. Statistics vary, but females employed in the U.S. make about twenty percent less than males. The discrepancy is still about five percent for doing the same work. The number of females elected to government office continues to increase, but women still only hold about one in five elected positions. If money and power are any indication, an essentially female profession is still inherently vulnerable. A Desire to Fix Things Second, our innate desire to rescue, fix things, and make people happy increases our risk of exploitation. There’s a profoundly odd inverse relationship between love (caring) and power in human relationships. As power increases, love decreases, or, as love increases, power decreases. Most of us learned this lesson the hard way during our early teen years when we first fell in love. After a few weeks or months of infatuated bliss, we were slammed with the devastating realization that the other person no longer cared. We may have found ourselves desperate to save the relationship, willing to do anything to try to please the one who had stopped caring, making us vulnerable to manipulation and various forms of abuse. The one who cares the least obviously has the most power. Nurses are correctly described as caregivers. We don’t need a lot of concocted programs or checklists to push us to improve patient satisfaction. We’re usually programmed to please. It’s in our genes. Most often, it’s why we signed up. So, what happens when we’re short-staffed, equipment isn’t working, supplies are missing, and patients become demanding or even belligerent? Our first response is to skip breaks, work with full bladders, walk faster, and try harder, often postponing or neglecting our own needs to make sure others–patients, visitors, and our bosses–have what they need or even what they just want. Many of us work while sick or injured ourselves, giving for the sake of others. As sensitive people who care, we’re inherently vulnerable to “takers” who don’t care beyond their commitment to their own welfare. Nurses - Not Fighters Finally, nurses are generally not fighters. While this is an obvious corollary to our basic instinct to fix things, there are other constraints firmly entrenched. New nurses are increasingly entering the profession deeply in debt. The push for increasingly higher levels of education has a hidden benefit for employers–a submissive workforce. Student loan debt averaged about $33,000 in 2018. More than ever before, new RNs just need the job. A young, smart coworker was venting to me in the breakroom a few weeks ago about a new policy removing our ability to override several frequently used medications. Her observations were valid, and her rationale had merit. When I suggested that she send an email to management, she quickly backed down. “Are you kidding me? I can’t afford to rock the boat. I’m a single mom with $48,000 in student loans. My kids come first. I’m bought and paid for.” A lot of great ideas never get past venting in the breakroom. The ultimate restraints are the legitimate needs of the patients entrusted to our care. Even when the workload is grossly unrealistic because we had a couple of call-offs, we still imagine that the people in those rooms are like our own family. Some of them really need us, and we don’t want to fail the ones who do. In the ER, we have no control over how fast patients pour in. As EMS stretchers line up in the hallway and patients back up in the lobby, we’re forced into working dangerously–again, and we shift into a nearly frantic survival mode of putting out fires. We just try harder, work faster, and, yes, cut corners (putting ourselves at risk) when survival depends on it. At times our productivity is super-humanly-amazing, off the charts–and simultaneously enabling. Those who profit from the accepted inequities in our system bank heavily on our dedication to our patients. If bus drivers, teachers, IT specialists, or professional athletes strike, it’s an irritation or an inconvenience. If we strike, even if enough temporary replacements are pulled in, patients could die. If enough of us went on strike at once, a lot of people would die. There are some significant pockets of resistance, and a few major battles have been won, but generally, our profession of non-fighters has demonstrated remarkable restraint. Those in power expect that we’ll continue the established path of pacifism. Bargaining Power Paradoxically, the greatest constriction of standing up for ourselves, the welfare of our patients, is also our best bargaining chip when we do take on the powers propagating the exploitative system. I sometimes think of our current nursing profession like a wife in an abusive relationship, fearing for our own safety and that of our children, those entrusted to our care. The battered wife knows there may be casualties if she resists, but at some point, she chooses to take the risk. As a profession, we cannot condone harm to innocent, needy people. At some point, honor demands we take a stand. The core problems plaguing our profession run much deeper than staffing levels. This year, there are massive rumblings about fixing our national disgrace. The U.S. remains the only industrialized country on the planet that does not provide some form of universal access to healthcare. We are the only system enabling rampant profiteering at the cost of human lives, pretending that healthcare is a commodity like a new car or pearl necklace. Storm clouds are gathering, and two serious questions for the rest of our Nation are looming large on the horizon. Who causes the greatest harm to our patients? And who will step up to rescue them?
  4. RobbiRN

    CEO Says More Nurses Won't Improve Care

    I read Mark Gridley's April 6 statement referenced in this article. He asserts: "According to many evidence-based studies, there is no conclusive evidence that staffing ratios improve quality or patient outcomes." Really? Then why not just set your patient to nurse ratio at 50:1? You could use the extra money to hire a couple more suits with clipboards to track your five nurses' activity to make sure they are all working in compliance. You could also give yourself a bonus. Next, Gridley argues: "Illinois already faces a severe nursing shortage and does not have enough nurses in the state today to meet the proposed mandates." A shortage means we need more, not less, Mr. Gridley. Google the word "shortage." He adds: "I speak from personal experience; I was a Licensed Practical Nurse for many years and understand the concerns and challenges of providing quality bedside care in a wide variety of settings and situations, to an even wider diversity of patients." How long ago were you an LPN, Mr. Gridley? Was it before the last decade exploded the clutter and complexity of getting even the simplest tasks accomplished? Did you ever try going 12:1 on a medical unit while covering another nurse during her one thirty-minute break during a twelve hour shift? Did you ever work 6:1 in an ER with a STEMI, a CVA, and an unresponsive overdose all tossed into your mix within twenty minutes? When was the last time you did one of those "undercover boss" days, put on some scrubs, and tried to keep up with a real nurse for twelve hours?
  5. RobbiRN

    Safe Staffing Levels for In-hospital Nursing Units

    Does the ratio formula include the charge nurse or other management who don't take patients? Or does the ratio mandate an actual patient care ratio?
  6. RobbiRN

    Safe Staffing Levels for In-hospital Nursing Units

    Safe staffing ratios may not solve everything, but we can't work safe when we're spread too thin. Every time I mention the ratios mandated in CA, FL managers retort (and travelers concur), "Yes, but they just cut all their ancillary support staff to make up the difference." RNs are staffed at 4:1 in our ER after the minor care patients are pulled from the mix. I'm curious how this looks to CA RNs?
  7. One more example of how the ER has become the catch-all for every other failing in our system . . . The cops used to haul drunks away, now they drop them off and leave. Can you get help if the patient across the curtain from your crashing GI bleed is an acute MI or CVA instead of a belligerent drunk who seems to be more manipulative than drunk? I'm just curious what qualifies for a re-allocation of resources.
  8. RobbiRN

    Thoughts on vegetarian/ vegan diet

    I strongly believe we are honor bound to teach, or remind, patients of the benefits of a healthy lifestyle including a proper diet, sensible exercise, and adequate sleep. These are the foundation of good health. Many patients could eliminate most of their medications with better lifestyle choices. I "preach" lifestyle all day every day. I look them in the eye and say it with passion because their life may well depend on getting the basics right. They know I care and appreciate the effort. As I stated in my first post here, not eating meat does not make a person healthy. I feel no need to preach a vegetarian lifestyle. I never start the argument, but I will gladly defend myself when I'm teased about my choice to eat a big bag of fresh greens and carrots and a garden burger. ("That's not food. That's what FOOD eats.")
  9. RobbiRN

    Pit Bull Service Dogs

    In the real life inspiration for this post, a second nurse who owned large dogs offered to draw the patients blood when the first nurse felt threatened. The second nurse also backed down when the dogs acted aggressively. A third RN who owns a bit bull announced, "You guys just don't understand pit bulls," and she finished the patient's care. No one was bitten. The dogs' strong odor permeated the air three doors down throughout the two hour stay. Nearly everything that is regulated requires a license -- even owning a dog in our county. But somehow this law places service dog owners on the honor system. So who will be liable when someone gets attacked? The owner, the hospital, the states for passing a stupid law, or all the above? Or, will we find a new way to blame the nurse?
  10. RobbiRN

    Pit Bull Service Dogs

    You are assigned a patient who brings two pit bulls with him to the ER claiming that they are service dogs. While it is illegal to falsely claim that a dog is a service dog, we are not allowed to challenge the claim or ask for proof. The patients complains of abdominal pain, but he has wounds on his hands he states are from separating the dogs when they got in a fight. He has no one else with him to help with the dogs, and they are on long leashes which allow them free access to the majority of his room. When you prepare to draw his blood they jump onto the stretcher, standing on either side of him. What would you do?
  11. RobbiRN

    It Never Occurred To Me.

    Excellent. That's that best ending to a touching nurse-patient story I've heard for a long time. Maybe write a book?
  12. It's 11:34 a.m. The triage complaint is listed as possible stroke, with dizziness and facial droop listed as secondary complaints. A fifty-six-year-old female still in her street clothes is partially curled up on her right side scrolling through her phone. Patti arrived six minutes ago via private vehicle, walked in from the parking lot, and was brought to the room in a wheelchair. She doesn't appear to be in any acute distress, moving freely while repositioning herself on the gurney, breathing easily, with good skin color, and strong fine motor skills going into the phone-work. Her husband is leaning back in his chair at the bedside with his left ankle crossed over his right knee, reading a magazine. Nothing in this room conveys a sense of urgency. "The triage note says, 'possible stroke.' Can you tell me what happened today that brought you to the hospital?" I slide on a blood pressure cuff and a pulse oximetry clip as we talk. "I've been having headaches for a couple of months. But they've been worse for maybe two weeks now. And I've had some dizziness too." Her facial movements are symmetrical. She speaks clearly, without difficulty. Her vital signs are all within normal limits. "The note also says, 'facial droop'. Can you tell me about that?" The husband takes over. "She was just sitting at the table after breakfast this morning about nine o'clock. The left side of her face kind of pulled to the left, and she was having a hard time talking. It happened twice, about ten minutes apart, and it only lasted for a minute or two both times. She's had seizures so we didn't know if it was a seizure or what? Her face just pulled to the left." His description of pulling to the left doesn't sound like the "facial droop" described in the triage note. "Can you demonstrate how it looked to you?" The husband uses the muscles in his left cheek to pull the left side of his mouth laterally toward his ear." The patient adds, "I was having a hard time swallowing and I couldn't talk." "Any new or different medications recently?" "No," they say in unison, shaking their heads. About an hour later, we have normal findings on her EKG, chest x-ray, CBC, CMP and coagulation labs. Her repeated vital signs are also normal, and she's in a sinus rhythm with no ectopy on the monitor. She breezed through her NIH stroke scale with no neuro deficits. I'm headed to the room to let them know her CT has been read as "no acute intracranial findings." Intuitively, the husband's recreation of her face pulling to the side is still dogging me when he suddenly bursts through the privacy curtain, running toward me. "She's doing it again." Patti's sitting up at a ninety-degree angle, gripping both side rails. She's clearly anxious now; her eyes are wide, and she rocks rapidly back and forth. She's still in a sinus rhythm, but her heartrate is up to 110, and she's breathing fast. Her lower jaw is pulled laterally as far to the left as it can go, confirming the husband's choice of words in his description that "her face just pulled to the left." Somewhat relieved, I feel her tight muscles displacing her lower jaw radically to the left. "Can you move your jaw?" She shakes her head and tries to talk, but her voice is throaty, and her articulation is predictably muddled. "Is there anything else that feels wrong to you right now, other than your jaw being locked off to the side like this, making it hard for you to talk?" She looks at me and shakes her head, mumbling a garbled "no." "Patti, I can see you're really anxious. This doesn't look like a stroke or a seizure. I think it's a much lesser evil. Try to relax while I get the doctor in here to look at you." Dr. Spicer agrees that her presentation is consistent with a dystonic reaction causing a spasm of her jaw, lips, and tongue muscles. She's allergic to Benadryl, and, after considering Cogentin, he gives me a verbal order for 0.5 mg of IV Ativan. Her symptoms resolve rapidly, and, instead of being sleepy, she's just loopy enough to be happy and fun as we process her admission and move her to the observation unit. Patti's case is interesting for a couple of reasons. In looking for a potential cause, the most likely culprit appears to be her carbamazepine. They said 'no' when I asked about any new medications, but it turns out that her husband had changed jobs two months ago, forcing a change in insurance and doctors. The new doctor took her off Dilantin, which she had taken for years without incident, and put her on carbamazepine. The headaches had started a few days later, but they hadn't made the connection between the medication change and the headaches until we explored the timing together. Usually, a dystonic reaction happens after the first dose of a new medication or after an increase in dosage, neither of which applied in Patti's case, unless she had accidentally taken extra medication. We add a carbamazepine level to her labs, and the result comes back a little over the high end of the therapeutic range. Acute dystonic reactions are relatively rare in our flow of ER patients. Acute dystonic reactions to carbamazepine are also rare. Carbamazepine is sometimes prescribed to treat dystonia from other causes. The real key to the story was the husband's description that "her face pulled to the left." More specifically, just her jaw pulled to the left, but he was accurate in describing something that didn't sound like facial droop. (Try looking in the mirror and alternate between using your facial muscles to pull only your cheek or your jaw laterally. It's easy to see how he got his description.) It's unfortunate for Patti that she became one more causality of a system which forces changes in medical care because of a change in employment. The good news: there's no facial droop, no stroke, and no seizure. The simple longer-term fix for drug induced acute dystonic reactions is to discontinue the offending agent.
  13. RobbiRN

    An allnurses Fix On Healthcare

    Most of those who responded to the original thread stated the need to go to single payer. Just a reminder, this article is not a a summary of my opinions, it is a distillation of this thread: https://allnurses.com/general-nursing-discussion/what-would-you-1135286.html The "Fix It Healthcare" site and the movie are excellent. Here's the link: Fix It Healthcare At The Tipping Point |
  14. RobbiRN

    An allnurses Fix On Healthcare

    Thank you for your response. I have two questions: 1. Would you say that current levels of litigation are justified and no significant reform is needed? It is my understanding that the ACA did help those with pre-existing conditions to get insurance and those who qualified for medicaid to get medicaid. Many cheaper plans were wiped out because they were deemed insufficient under the law causing a lot of people to loose their plans. Locally, those with medicaid say that can't find any doctors who will take their "insurance." They just come to the ER instead for their minor and chronic problems. Those pushing the ACA through essentially gave up on containing costs by cutting backroom deals with insurance, pharma and the hospitals in order to get it passed. My premiums, copays and out-of pocket expenses have all increased since the ACA was implemented. Has anyone who has private insurance seen a decrease? Question 2: Has the ACA made healthcare affordable for the country?
  15. RobbiRN

    An allnurses Fix On Healthcare

    I share your concern about government's inability to run things well. As MunoRN clarified, government as the payer does not make government the provider. Can you suggest another way to "take the power away from the insurance companies"? Ending insurance profiteering and meddling by denying or directing care were strongly targeted in the responses, but making government the single payer seems the only viable way to do it.
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