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  1. LibraNurse27

    Anyone here who loves bedside nursing?

    Hi all, I see a LOT of posts here along the lines of hating bedside, not wanting to be a nurse, regretting becoming a nurse, burnout, etc. I also burned out at the bedside for many of the reasons discussed at length here. I'm wondering if there are any nurses who actually love bedside, and if so, what do you like? There were aspects that I truly loved, but in the end the cons outweighed the pros. If you love it, what type of work environment do you have and what is your specialty? I'd love some positive and encouraging posts about bedside for new grads to read, but sadly I'm not the one to write them! I will say it can be rewarding and a huge learning experience.
  2. Aliceozwalker

    Hate My Job But Feel There Is No Way Out

    Just wanting to know people with more life experiences take on my situation. I work on a busy general medicine floor and absolutely have come to hate my job. I have managed to tough the job out for about a year and a half (new grad). Honestly, I am amazed and somewhat proud of myself for even managing that with my anxiety. I had hoped that with time my anxiety would get better but it feels the longer I am there the sicker, heavier (gaining lots of weight) and more miserable I feel. I work a ton of nights between my two jobs so feel like I rarely even get to see the sun and have no motivation to do anything but watch TV. I definitely want a way out but it is easier said than done. The patient assignments have gotten ridiculous with how short staffed we have been, on night shift nurses who are supposed to have 6 patients sometimes take on 12 patients (an entire POD with IVs, climbers, drug withdrawals, etc) with a nursing student extern. It's gotten so bad people have started to message our union about unsafe conditions but were sent back an e-mail saying that we are allowed to work outside our scope due to the current pandemic. I have posted a few times on here and recently made the decision to move away from bedside. I've had such an awful experience with bedside, I doubt I will ever return. I am feeling so frustrated because for the past month I have been applying and feeling like I am getting nowhere. I have applied to several more office-based jobs or jobs out in the community such as vaccine centres as people on here recommended. I have had a few messages back all stating that I needed more bedside experience which was crushing. The only really positive lead was my manager who stated that he would hire me for a clinic at the hospital that works Mon-Fri 8-4 (but more like 8-5). This sounds like the best-case scenario for me, but the problem is that he says a position likely won't open up for another 6-10 months. I asked if he would consider me still for the position if I went to a temporary job for 6 months and he said he would so long as I stay on casually. I am at a loss of what to do here. My parents think I should stick it out for another 10 months at my current part-time hospital job with my other strictly nights casual job. I am going to be honest in saying that I can't imagine how much sicker I will feel and how much I will mentally struggle. It's been bad enough living like this for a year and a half I can't imagine going through another 10 months. I would definitely be open to working at the hospital unit casually if I could find a better job that would take me part-time somewhere else. But all of the less stressful jobs people on the site have mentioned (clinics, offices, etc) won't seem to hire me until I get at least 2 years of bedside nursing. Did anyone else feel they were locked into 2 years of bedside nursing? Are there any other positions someone could recommend that would be lighter on me mentally or have more regular hours? I just feel so stuck and frustrated. 😞
  3. LTdick

    HATE bedside nursing

    After switching specialties a few times, I’ve come to the conclusion that I hate bedside nursing. It’s won me chronic migraines (for which I have tried a plethora of drug therapies with no relief), hypertension and most recently have been grappling with pretty serious depression. Because somehow complaining online to strangers is therapeutic, let’s dive into all the things I hate in hopes that someone feels the same way. 1. Incivility. Nursing for me has been Mean Girls in real life. Nurses (and providers) are all too comfortable airing their grievances to everyone but the source. Providers are condescending, and I’ve been publicly belittled as much as I can tolerate. Management plays favorites. PSRs have become a fancy way for other staff to be self righteous and passive aggressive simultaneously. 2. We don’t have CNAs or other support staff where I work. Vitals, butt wiping, bed making, ambulation... it’s all on us. In addition to all the other stupid things we have to do in a shift. See #3. I worked as a CNA throughout nursing school. At the risk of sounding entitled, I became an RN in the first place to get relief from the manual labor. 3. Endless documentation on the aforementioned obsolete charting system. Every week, the good idea fairy comes along and we have yet another stupid thing that we have to mindlessly chart (in 5 different places) for every patient. Hourly rounds... God forbid you didn’t document that your patient is STILL lying in the bed, watching Judge Judy... just like they were an hour ago, and the hour before that. Chart audits are on us too. I have to get out, but I don’t know how. I like the idea of pharmacy but acknowledge that obtaining a Doctorate for which none of my credits will transfer is no small decision. I like the idea of becoming an NP, but not sure what I’d specialize in. Concerned about the market being saturated. Hell, I’d toy with public health or informatics.... anything to get away from the bedside. I’m currently active military, and I am unsure where I would even like to live. I feel like I should talk to a career advisor but don’t know how. My biggest fear is going back to school, taking out more loans and spending years on a job I will also grow to hate. I see a lot of new grads hating nursing, but after 5 years, I’m just....done. Anyone else go through this?
  4. I have worked for 6 yrs now in cardiac stepdown/tele progressive care unit. 2 yrs ago, I posted about my burnout. But I thrive and stick with it again for couple yrs. Last yr covid pandemic, our floor was shut down, floated to med surg floor then back to our floor. I just started as a charge nurse and preceptor last year. It feels like I have another meltdown this yr and have no desire to work bedside nursing again. More tasks for charge nurses to do, need to improve patient satisfaction, etc. I did not get a pay raise for 5 yrs until this career ladder started last yr but I have to accumulate hours in order for them to give you a raise and advance to the ladder. But this year, I feel more not in touch with what I do as a nurse at bedside. I know Hospitalists and cardiologists trusted my assessment skills. But it is not being there for them and teaching them. It is more passing meds and waiting until snf placement. I applied for another position in our hospital. And it is in OutPatient surgery/GI lab unit. This unit last yr became our covid unit. The work setting is different. I need ideas on what are considerations I need to think about, pros and cons from transferring to a cardiac stepdown unit that enhanced my nursing skills but feels like I am not growing there professionally even though, precepting and charging are now part of my duties last yr. But I feel numb and unable to function as a bedside nurse that I was before the first 2 to 4 yrs there. Need some ideas from ya'll. Appreciate it.
  5. Corpsman2OncRN

    Ready to leave bedside after only 1 year?

    I'm an inpatient oncology RN working in NYC and just had my one-year anniversary in December (first nursing job). I love oncology, I love my patients (well...most of the time, anyway :p), and I love almost all of the RN's and PCA's I work with. However, over the past several weeks I have grown increasingly worn out and truly dread walking into work. I have so much anxiety now about how short-staffed we will be (repeated staff "high-risk" exposures leading to two-week quarantines have left those of us picking up the slack exhausted and often having to work 24-hour shifts). I'm an anxious person by nature, but it has been so much worse lately to the point where it's hard for me to even find the bright spots during a shift or for me to find that "why I'm doing this" feeling that can usually carry me through. I feel that I still have so much to learn working bedside, but so many of my coworkers are leaving and it's making me feel like I want to do the same as things just seem to be getting worse and worse and more responsibilities dumped on us to the point that I feel like my license, and worse, my patients' safety, are all in jeopardy because of unsafe ratios and new policies like not allowing patients to be on a one-to-one unless they are suicidal (not that we often have one-to-ones, but delusional/non-redirectable patients can't be managed by a camera especially when half the time the camera operators don't even alert us when something is happening, and Q20min checks are just unrealistic for one person to keep up with all day while still trying to take care of the rest of their patients). I feel like if I leave the bedside now, I won't ever come back, and so I am hesitant to do so and miss out on increasing my knowledge and skills when I'm a still relatively new nurse. I also feel awful when I look at the nurses who have been working bedside for like 30 years and think to myself that I can't even make it to two years before needing a break. But I can't even enjoy my free time anymore; I'm either exhausted from work and sleeping it off or spending the day dreading going back and seeing what kind of nightmare awaits me. I am currently in counseling (not specifically because of this, just for general depression/anxiety), just as an FYI if anyone wanted to suggest that. I don't even really know what I'm asking here but I guess I am wondering what people's thoughts are and whether it would be a mistake for me to leave the bedside now, so early in my career, just because I am feeling stressed? Just to reiterate, I *do* enjoy being a bedside nurse, it's just that this whole year has been so hard with COVID and getting inappropriate-for-our-floor admissions and policy changes that throw more work on the nurses and staffing shortages etc. etc. etc... I know many of these problems are just the realities of working inpatient but I feel like I'm at my wits end here. Any advice would be so appreciated! Thanks for reading.
  6. I would like to know if its realistic to assume that nurse practitioners will avoid some of the downsides to being a bedside nurse which is that patients attack nurses. I understand this occurs sometimes and I assume that it happens less to nurse practitioners but I cannot be sure.
  7. Hi everyone... I feel actually kinda pathetic for writing this but.. I’m one week away from finishing my 12 week orientation on a busy med/tele floor... & one thing I can take away from it is that I am miserable. I take work home with me everyday. I can definitely say my entire life I have ALWAYS been a laid back, go with the flow person... & I usually always stick it out, even when things get really hard for me. Fast forward to now- I’m having extreme panic attacks. My anxiety is truly through the roof. The hospital setting isn’t new to me, either. I worked as a tech for two years on this same floor & was just fine until I became a nurse. My managers really want me to stay. My coworkers are pretty supportive people. Overall the staff isn’t horrible by ANY means but I feel truly so burned out and I’m not even off orientation yet... looking into clinic nursing at a derm office because I myself have struggled with my skin for years and feel like I would really be passionate about helping those with skin issues... but I have this feeling that I’m selling myself short by not sticking out atleast a year on my current floor. I know I’m very capable but I might seriously lose my sanity... I am an extremely task oriented person & I feel like office nursing would fit that part of me well. If anyone has any advice/ words of wisdom/ etc I would love to hear it. I am just a tired new nurse not knowing where to turn.
  8. ericninetwo

    Non bedside nursing jobs?

    Hi all, I have 2 years of psych experience and am currently working med-surg nights (about 6 months now). I've slowly come to the realization bedside nursing is not for me. I truly wanted to give it a shot for the experience and am learning so much but at the end of the day I see myself dread going to work, especially working nights and weekends. Just wanted to know what was out there in terms of non bedside nursing roles. I have a general idea such as public health, psych, education but just wanted to see what I may be missing. For those that are doing non bedside jobs and wouldn't mind briefly sharing what you do, your experience in nursing, and just the general. Thank you all so much
  9. I have hated bedside nursing ever since I started. I even hated it when I was in school but IDK why it never clicked to me that I should pursue something else...anyway, I am on my 8th month of nursing of my first consecutive year. I say consecutive, bc I held a bedside position in an adult hospital for 2 months before switching over to pediatrics. I can at least handle this job better than my first, but I really really hate nursing so much. I can't wait to become qualified for other jobs. Is it normal to hate my job this much? I get so depressed and anxious the day before my shift starts. It's been 8 months and I still feel this way. Makes me think it's never going to get better 😞 please tell me when I can leave the bedside pretty please ... I just feel with the pandemic it's so much harder to get a job but IDK I guess I am lucky to have the one I do right now (I just hate it SO MUCH). People keep telling me it would get better but it never did. I'm losing hope and even started researching other majors I could pursue. please help
  10. Deebuzz

    Leaving Bedside Nursing

    Your emotional, physical and mental health will suffer along with your family life. I have finally decided to leave the bedside and I've never felt so happy. At only 25, I felt like I was going to be stuck in this state for the rest of my working life but I found the courage to finally make the decision that saved my health and my marriage. I went into nursing with the intention of helping people and being the one to make a difference to those who may feel hopeless. All my intentions were quickly shut down when I started working on the floor. We deal with some unappreciative, sarcastic, rude, and egotistical (patients, family members, physicians, coworkers, and managers). There is no care in nursing just bottom-line concerns. My first nursing job was ok, I worked in ND at the time, I moved to FL and that gave me the green light to officially leave floor nursing. I hate the anxious feeling before every shift, the nagging family members, pts who are rude self-entitled, coworkers who throw each other under the bus, physicians who disregard concerns, and a whole lot of other things I can elaborate about that is just downright awful. I'm glad to say my degree didn't completely go to waste as I am now an RN case manager. I believe being away from the bedside will renew my interest. I refuse to live a day dreading having to go to work, nursing has literally changed how I respond to people before I use to smile at everyone now I walk past people with my face looking like a pit bull ready to bite. Whenever someone would tell me to smile I thought, "Wow I have changed for the worst" I refuse to be a martyr for this profession. Taking care of myself is more important than risking it for people who **** on theirs.
  11. allnurses

    Fall 2018

    Version Fall 2018

    The 2018 Fall Issue of the allnurses magazine focuses on the Many Faces of Nursing with stories shared by many well-known Nurse Influencers. Read about their nursing career journeys from the bedside to where they are today and the many stops they made along the way. How Did You Become a Nurse Attorney? Hi Lorie How did you become a Nurse Attorney? Were you a nurse first? Where did you go to law school and how long does it take? What kind of jobs can you do with such degrees? Donna Cardillo (The Inspiration Nurse) - The Many Faces of Nursing Donna Cardiollo - The Inspiration Nurse - is a nationally known speaker, storyteller, and motivator. Learn her story here. Calling All Nurse Innovators Are you a nurse innovator? Do you have a cool new idea, but need time, money, and a mentor to make it happen? The Johnson and Johnson Nurses Innovate QuickFire Challenge might be just for you. Learn a… From the Bedside to the Boardroom and Beyond with the Unconventional Nurse One of the greatest assets in being a nurse is the ability to design our work around our lifestyle. Life continually changes, and what once worked, begins not to. You can push through the limits of ex… Renee Thompson and the Healthy Workforce Institute - The Many Faces of Nursing Renee Thompson - nurse, entrepreneur, keynote speaker, author, and kindness enthusiast - used to wonder "why not me." Today, she enjoys a satisfying career where she educates other on nurse bullying. … From Student Nurse to Nurse Influencer Rockstar - Meet Kati Kleber BSN, RN, CCRN-K Meet Kati Kleber! She is changing the nursing world for those just starting out in our profession. Taking her ideas and thoughts on what new nurses need to know to be successful in this field, Kati is… Many Faces of Nursing We learned all about various nursing specialties in school, but we were never told there would be days like this. So many faces in one shift!Have you counted how many faces you have each shift?This to From Nurse to Nurse Influencer Many years ago, I graduated as an RN and fell in love with my job on an Ortho unit. From there I worked MedSurg, ICU, and Tele before becoming a nurse manager. Now I work in Staff Development, and hav… Keith Carlson: Choosing the Path of the Nurse Entrepreneur We all have different motivations for embarking on a nursing career and becoming healthcare professionals. Even as our paths differ, our experiences can share underlying themes that bind us together u… The Unwritten Rules Of Dating As A Nurse Dear Nurse Beth, I'm wanting to date a former patient. He was never my patient, just there while I was on duty ... Navy Psych Tech...


  12. Sophia P

    Bedside with an MSN?

    Hi! I'm currently halfway through my nursing schooling and also working as a PCT at a cardiac unit at a local hospital. As I'm getting closer to finishing my degree I'm contemplating advanced practice programs. I want to have a MSN, potentially in nursing education, soon after graduating with my BSN but I don't want to leave the bedside immediately. Are there bedside roles for a RN with a MSN that especially involve teaching? Thanks!
  13. Newbie4567

    Leaving the bedside

    Maybe it’s the COVID, maybe its the stress of being a new nurse, but I am considering leaving the bedside after my two year contract is up. So, If you are an RN who’s left the bedside, what career path did you choose and why? Any regrets/advice for others leaving the bedside?
  14. CaffeinePOQ4HPRN

    BEDSIDE...run, don't walk!

    I don't know who needs to hear this today, BUT... You are NOT required to martyr yourself for the sake of the nursing profession! You are a human being, and deserve a lovely life. You deserve to wake up everyday and not feel knots in your stomach while preparing to go to work. You deserve BETTER! The day I transitioned away from the (abusive) hospital system was the day my life started to significantly improve. I've never looked back, and the thought of having to subject myself to the poor working conditions ever again makes me sick to my stomach. I don't envy my friends/professional colleagues who decided to "stick it out" even though they were admittedly suffering. I'd encourage anyone, new-grads or more tenured nurses, to RUN don't walk away from the hospital system if it's negatively impacting you. Ignore the zealots who tout it as a calling, that you must give your everything... That's logic is beyond stupid! You are not required to subject yourself to abuse.
  15. Peachy Em

    Leaving bedside after pandemic

    I'm a med-surg PRN float nurse. I've been in this position for about 2 months now, prior I was a med surg full time staff nurse for 1.5 years. Due to covid-19 the floats are being used for tier nursing in the ICU or put on the Covid unit. I hate my job and I don't enjoy being a bedside nurse. I knew bedside nursing wasnt for me but it's been even more evident during all this. I feel expendable, worried and underappreciated. I want to leave but dont plan on doing so in a pandemic. How long and how many job changes til you found your niche because that's my goal after this crap is over.
  16. Missmilo

    Return to the bedside

    I have been an FNP for one year and I just resigned from what was an absolutely terrible job. I have many years ( 20+) of PACU, ICU, CCU and ED experience. As an RN that is. Those willing to hire me as an NP are only offering one terrible job after another. I have spent my life working in hospitals and I miss it soo much. Yet, I can't get a job working in a hospital as an NP. They want 3 years of experience in the area of specialty as an NP. They don't care about my RN background. In fact, most worthwhile jobs want 3 years or more of NP experience. I hate the long hours, rotten pay and poor benefits that seem to be the fate of an office FNP. I hate the office environment period. I feel awful, I regret this more every day and I want to return to hospital RN life.. I want to return to three 12 hour shifts in a PACU or ED as a staff nurse and get my life back. In addition to rotten pay and benefits, My FNP experience was very lonely and beyond boring. I miss the fast pace of the hospital and the camaraderie of fellow nurses. All that time and money on my education will be wasted, but I'm starting not to care about that because I'm so miserable. Has anyone else done this? Has anyone out there quit and gone back? Will I be able to go back? Will hospitals allow it? ANY advice on ditching this career path is greatly appreciated. Thanks.
  17. In hospitals across the country, experienced nurses provide orientation to an ever-revolving door of new hires. The need to retain beside nurses is well known and solutions widely researched. Yet, work conditions in acute care settings are slow to improve and many nurses turn away (or run) from bedside nursing. According to NSI Nursing Solutions, Inc., hospitals saw the highest turnover rates in 2018 when compared to the last 10 years. From 2014-2018, hospitals turned over a staggering average of 87.7% of staff. While most hospitals identify nurse retention in key strategic planning, it is not followed through in operational practice and planning. According to the report, only 43.2% of hospitals have put their strategic plan into formal retention strategies. Do Graduate Programs Play a Role? I recently read an editorial, authored by Maureen Kennedy, MA RN FAAN in the American Journal of Nursing, questioning if the push by colleges for students to attend graduate or doctorate nurse practitioner programs is contributing to the devaluing of bedside nurses. Research has clearly shown hospital working conditions to be the primary reason nurses are leaving the bedside. Most of us have experienced long hours, lack of flexibility and poor leadership while working in acute care at some point in our careers. And, the large need for advanced practice nurses in today’s healthcare environment, as well as the need for qualified nurse faculty, is undisputed. Hospitals typically don’t have work environments that offer nurse autonomy or promote professional practices. Nurses may see an advanced degree as offering job opportunities that are more supportive, with greater autonomy and less stress. The editorial’s author summarized the issue by quoting a colleague: Keeping Nurses at the Bedside Healthleaders magazine recently published an article sharing what three nurse executives did to retain RNs with the right skills and experience needed to deliver high quality care. Here are a few of the ways the executives improved their facility’s retention rates for the long haul. Improve the Organizations Reputation Rush Oak Park Hospital in Illinois was plagued with a negative reputation because of consistently poor quality outcomes. The hospital’s reputation bled into the work environment resulting in nurse dissatisfaction. In addition, there was a “revolving door” of chief nursing officers leading to inconsistent leadership and vision. Karen Mayer, chief nursing officer, knew the work environment needed to change and hospital leadership was up to the challenge. Over a period of years, leadership worked to improve quality indicators to improve patient care and nursing job satisfaction. After many years, turnover rates decreased from 22% to just 8.3%. Entice Nurses Back to the Bedside Press Ganey’s 2017 National Database of Nursing Quality Indicators RN Survey found newly licensed nurses and those who have been in practice 2-4 years at highest risk for attrition. Claire M. Zangerie, chief nursing executive at Allegheny Health Network saw the same trend within her organization. Under her direction, the RetuRN to Practice Program was created to address some of the issues leading to attrition. The program was designed to attract nurses who have stepped away from nursing and want to return to the bedside. As a result, the workload of all nursing staff was successfully lessened. Attract nurses with flexible scheduling RetuRN participants offer managers at least 3 hours availability at any time, on any day, day shift or night or any weekend or holiday. The nurses help ease workload in high need areas and perform “rover-type” duties, such as admissions, discharges, patient education, covering other nurses’ patients for breaks or for continuing education. Extensive on-boarding, remediation, training and support is offered to RetuRN participants to ease the transition back to the bedside. Support Professional Development and Work Environment Kelly Johnson, vice president, patient care services and chief nursing officer at Stanford Children’s Health understands a healthy work environment and professional development programs are critical to retaining nurses. Therefore, Johnson developed and implemented several programs to support nurses in various stages of their career. Nurses have opportunities to continue growing through personal success plans, a succession planning development program, certificate and advanced degree programs. The organization has also committed to creating a healthy work environment and culture. This includes initiatives embracing HeartMath concepts that empower employees to “self regulate emotions and behaviors to reduce stress, increase resilience, and unlock their natural intuitive guidance for making more effective choices”. The goal is to create a work environment that is caring and healing, where nurses care for each other and themselves. What programs or initiatives have you experienced that improved the work environment of bedside nurses? Additional Resources NSI Nursing Solutions 2019 National Healthcare Retention Report Want to Keep Nurses at the Bedside? Here’s How Nurses at the Bedside - Who Will Be Left To Care?
  18. I'd like my unit to transition to bedside shift reporting. My staff is adamantly against it. I think it will help our pt satisfaction scores! Does anyone have any suggestions/experiences as to what did or did not work? We don't overlap shifts, so I anticipate some issues with OT? HR is working with me on this one. I'll take any ideas I can get! Thanks!
  19. RN, BSN with 2.5 years experience working float pool. Most of my experience is med/surg though. Keen to start my master in the next couple of years. Unsure of career decisions I originally started my degree knowing I didn’t want to work in a Hospital, half way threw I changed my mind when doing placements. So when I graduated I started working float pool. Now 2.5 year on I’m having a dilemma, part of me wants to get more acute care experience. I really enjoy having pt that are acutely unwell Or when there’s a medical emergency. But the other half of me wants to go into the community. Either dr office or public health nursing. I enjoy working with a wide range of people, different ages, different conditions/concerns ect. Not having to do shift work. I feel I have more opportunities to advance my career in these area too. Plus Working 5 days a week doesn’t bother me. conflicted on what to do next. So desperately ready for a change from my current job.
  20. Anybody? Do you lose your skills? Do people ever go back?
  21. I’ve changed multiple details in this article to protect the identity of the nurse I interviewed. I offered to pay her for her time, but she refused, so I made a donation to the American Nurses Foundation Coronavirus Response Fund in her honor. The fund, Coronavirus Response Fund for Nurses, focuses on: Providing direct financial assistance to nurses Supporting the mental health of nurses – today and in the future Ensuring nurses everywhere have access to the latest science-based information to protect themselves, prevent infection, and care for those in need Driving the national advocacy focused on nurses and patients Sandy is an ER nurse in a hospital with only 10 cases since the Covid-19 outbreak began. Her state is in the first phases of re-opening and the number of cases has doubled in the last week. I first talked to her over three weeks ago, so a few days I checked in. She told me, “not much has changed. They are setting unrealistic metrics, the census is increasing, the staff is increasingly compromised…believe it or not, it’s worse…but we’re hanging in there for the vote.” And by “vote” she means a vote to unionize, which could happen in the next few weeks. Unions Unions are a controversial topic in the U.S., and it can be tough to find unbiased information. I remember when I was a new nurse back in 2006, I was told that if you even said the word “union” you could be fired. This was in North Carolina, where I had been taught “Unions are illegal.” I discovered it is illegal to dismiss an employee for trying to organize or join a union, but it can be hard to prove that someone was fired for those reasons. The US Bureau of Labor Statistics states that approximately 13% of Americans belong to a union (down from 20% in 1983). But, 18% of RNs belong to unions. A union is an organization of workers formed to protect and advocate for the member's interests. Nurses don’t have a single labor union. Some of the most active include National Nurses United and The American Federation of Labor and Congress of Industrial Organizations. Twenty-eight states are “right to work” and twenty-two states have mandatory union participation, including California, New York and Illinois. It is important to note that most unions are not organized or led by nurses. Dues can be as much as $90 each month, but nurses in unions are paid 20% higher than nurses in non-union facilities. Pros to Nursing Unions Job security, better working conditions, guaranteed wages and pay increases, seniority advantages, education reimbursement, better benefits, a guaranteed process for grievances, ability to strike, legal representation. Research has shown that hospitals with successful unionization have improved patient outcomes and better employee satisfaction. Cons to Nursing Unions These are cons to unions, like bad eggs -- it’s very hard to fire someone who isn’t doing a good job. In health care, with lives on the line, this can be a frightening concept. Many nurses are against the idea that an incompetent nurse can keep her job if she’s in a union. Though some sources say unions favor seniority over performance, Sandy says in the union she’s pushing for, pay raises are merit-based. Mandatory striking is another issue. If you are a member of the union, it is possible you’ll have to strike, though striking is a last resort and only occurs if the majority of the nurses decide if the strike takes place. Sandy says, “It’s a one-day strike maximum in this union.” Another issue is that union negotiations have the potential to create adversarial relationships between employees and employers. Other complaints are about union dues. Why a Union? When I asked Sandy about the Covid-19 situation at her hospital she said, “I feel very unsafe at work, but it’s not at all related to PPE. It has everything to do with staffing. We agreed on a 3:1 ratio with nursing administration in our high acuity pod, but now it’s crept back to 4:1.” “An elderly patient came in for a kidney stone with a 98.7 temp. Then the temp started to spike, the pressure started to drop. She developed slurred speech and her mentation declined. She started shivering and spiked 103. We were trying to get a blood draw before she could go to pre-op, but her blood was clotting like crazy. Phlebotomy is no longer coming to the most critical pod in the ER so labs take 2 hours to come back. So you might think 14 patients in the ER seems manageable with 5 or 6 nurses, but it blows up with traumas coming in, people getting stabbed, people who are emergent. You can’t predict what will happen and we need to have staff available.” “There’s no one on call. There are no float nurses. How am I supposed to respond effectively and safely to 4 patients when I’ve got a status epilepticus needing intubation, a septic patient, a patient who needs intubation, and a fourth one who is waiting for a urinary stent and pulling out his IV?” “People are quitting, and our ER is full of new graduates. One primed some antibiotics and didn’t do it correctly. Just stupid stuff. The ED is down to who can survive it. The PRN folks have been cut loose – furloughed and encouraged to take travel assignments. There is no one to cover FMLA. We’ve lost 30 nurses in 3 months due to a combination of firing and quitting.” “Our director mandated we won’t get lunch breaks because we have low productivity in the ER. So, we don’t get paid for the 30 minutes of lunch. All the pictures you see of nurses getting free food for being heroes. Those pictures are with managers, educators and supervisors. Work Situation At the end of March, Sandy said she was working every other day. She was distressed because she said, “We lost another good nurse. She gave her two weeks’ notice and they told her not to come back.” She went on to say, “I’ve been flexed a few times at 70% of my base pay. We have to use PTO to cover the other 30%. When workers have had positive exposures, there’s been no quarantine, no nothing. If someone is a PUI, and they’ve tested positive, there’s a sheet with all the names of those who have provided bedside care, but they are not told – you’d be more likely to find out in the newspaper that you were exposed, than from hospital administration." PPE Situation “In the ER, we always have plenty of surgical masks, N95 not as much. We didn’t see any N95s for a while, but on March 24th they suddenly came out of hiding. That’s when the education on PPE, how to use it, scenarios, etc… really started.” People of Interest “When we get people with symptoms who don’t need to be hospitalized, we are sending them home and not testing. Someone is supposed to be checking on them to see if they are compromised. How would you even know if you are desatting, if you are desatting? Who has a pulse-oximeter at home? A patient went home on self-quarantine, she couldn’t breathe and by the time EMS arrived, she had died. This is not okay. We have to change what we are doing, how we are responding.” Covid-19 is Just Reinforcing What We Already Knew About Our Hospital Sandy says, “The need for a union is so dire. Our focus needs to be on supporting each other and taking care of our staff, but sometimes I get so angry, I want to jump ship. We have to focus on getting people to believe there is strength in numbers. You may be fine in your nursing job, you may have adequate staffing and bathroom breaks, but you have to stop thinking about yourself and think about the bigger picture.” Would you like to be interviewed? I'm going to continue to interview nurses on the frontlines. If you'd like to be interviewed or you have a particular area of nursing you are interested in, let me know. I've already got a few other interviews out there for you as well: At the Bedside with Covid-19 - Stories from the Frontlines At the Bedside with Covid-19 - Part 2: John Methadone Clinics and Covid-19: More Stories from Nurse on the Frontlines
  22. I used facebook to reach out to nurses working in hospitals in many places in the U.S. I’ve rounded all numbers to protect the identity of the nurses who agreed to be interviewed. I offered to pay all the nurses I interviewed for their time, but they all refused, so I’m making a donation to the American Nurses Foundation Coronavirus Response Fund in their honor. The fund focuses on: Providing direct financial assistance to nurses Supporting the mental health of nurses – today and in the future Ensuring nurses everywhere have access to the latest science-based information to protect themselves, prevent infection, and care for those in need Driving the national advocacy focused on nurses and patients Ann works in a state that implemented a stay at home order in late March. It appears to be flattening the curve to the extent that many hospitals are almost empty. The state has only had approximately 10,000 confirmed cases with 300 deaths. In her county, there have been 150 cases with 12 deaths (total population of the county is 120,000). She used to work in a large, urban hospital but after four years started to feel burned out. Now she’s at a small hospital in the suburbs and is much happier, though there were some staffing issues at first. “I started in ICU 1.5 years ago and I wore many hats. At first, we were understaffed with a 1:4 ratio of ICU/stepdown patients (mixed) and no help. Now we have CNAs, and the ratios are now at a max of 3 (if you have 4, they are all stepdown).” Ann’s partner is also a nurse – she’s at a nearby hospital, but she is planning to give notice in a week to do travel nursing and relief work in areas that have been harder hit. I’m planning on interviewing her partner as soon as she gets settled. According to nurse.org travel nurses are earning over $10,000 per week to work in New York City right now. Changes? I asked Ann how her life as a nurse has changed since Covid-19 emerged. “I’m being flexed a lot – almost every shift. I went 2 weeks without work. Before Covid-19, I switched from full time to PRN, but I always had shifts 1-2 days each week.” Ann says the hospital is still paying a percentage of her pay. “For the last 3-4 weeks I’ve been getting paid to stay home.” There is currently a very low patient census with only 1 or 2 patients in the entire ICU. Ann continued, “COVID came in and all the other sick people disappeared -- no stroke, heart failure, COPD, pneumonia. People are afraid to come in and are staying at home.” Ann’s hospital has gotten creative with staffing. Healthcare workers who have reduced hours have been asked to be screeners in ER or to work as triage nurses at the phone for suspected Covid-19 patients, but they get paid their nursing pay. “The triage nurses take the calls and tell them to come in or not come in.” Testing Ann said they are only testing people who are admitted to the hospital. CDC guidelines recommend that state health departments modify guidelines to suit their state’s situation. The CDC says clinicians should, “use their judgment to determine if a patient has signs and symptoms compatible with COVID-19 and whether the patient should be tested. Most patients with confirmed COVID-19 have developed fever1 and/or symptoms of acute respiratory illness (e.g., cough, difficulty breathing).”1 Priority Testing Priority 1 testing is reserved for hospitalized patients and symptomatic healthcare workers. Priority 2 testing is to ensure that those who are at highest risk of complication of infection are rapidly identified and appropriately triaged: Patients in long-term care facilities with symptoms Patients 65 years of age and older with symptoms Patients with underlying conditions with symptoms First responders with symptoms Priority 3: As resources allow, test individuals in the surrounding community of rapidly increasing hospital cases to decrease community spread, and ensure the health of essential workers Critical infrastructure workers with symptoms Individuals who do not meet any of the above categories with symptoms Health care workers and first responders Individuals with mild symptoms in communities experiencing high COVID-19 hospitalizations ER screening questions In the last 14 days have you: Traveled to China, Iran, South Korea, Italy or Japan Come into contact with a confirmed Covid-19 patient Had symptoms Fever greater than 100 Difficulty breathing Cough Are you currently experiencing fever over 100, difficulty breathing or cough? Triage protocol can be found at Triage of patients with suspected COVID-19 infection For areas with widespread community transmission, If there is fever or history of fever and at least 1 sign or symptom of respiratory disease, place a mask on the patient and then separate them from other patients in a single-person room with closed door. Droplet precautions should be instituted. At Ann’s hospital, if the patient is not sick enough to be hospitalized, they are told to go home and quarantine– right now her hospital is not testing them. She said, “Even if they are hospitalized, if they don’t present as a classic Covid-19 case, then they are not being tested. We are being told it is due to the lack of tests.” When I asked her if she knew how many testing kits were on hand and why they were in limited use, she said she didn’t know. I called labs and hospitals and had no success finding out the availability of testing kits in the area. Testing is ramping up in some states. On April 27th, 2020, I googled “Where is covid testing on the rise” and saw Minnesota, Indiana, Virginia, and Illinois are increasing testing due to a sharp rise in the number of cases. The same will likely occur in Ann’s state if Covid-19 gains a foothold there. How about training? “We’ve had training on how to take care of the prone intubated patient - how to put them on their bellies for safe care. I’ve gone online and read articles and we’ve done education on what it looks like and how it increases oxygenation.” “We also had a refresher course on PPE donning and doffing - how to do it and what is expected.” PPE? When I asked if there was enough PPE, Ann replied emphatically, “NO” “We get one new surgical mask daily. Prior to this they were one-time use. It says right on the box that they are to be worn a max of 40 minutes, but we are wearing them all day.” “It just feels so weird that we are rationing supplies when the hospital is so empty.” “We get an N95 that we have to wear for the entire week. We are wiping them down with sani wipes and placing them in paper bags when they aren’t in use, but the material will eventually break down.” “We turn them in and they are collected and are kept in case they need to be recycled or reused. As of right now we are not actively redistributing used masks. I think they are holding back because they are afraid we will run out.” “Gloves are not an issue. Gowns we are not reusing. We have those stupid paper gowns, the yellow ones, and we toss them. There’s an assigned nurse to guard the PPE – it’s locked up and you have to request PPE and sign a form.” I asked Ann how many times each day she had to visit the PPE distribution station? “In a 12-hour shift with 1 Covid patient I made about 7 visits and each visit took 2-3 minutes. You know, you’re a nurse, what impact that has on your day, on the care you can give.” Census I asked Ann if there had been many Covid-19 patients at her hospital. She said, “We are seeing patients trickle in. There are just a few between med surg and ICU, but there’s a larger hospital nearby that is supposedly full of Covid patients – we think they are coming here, but aren’t quite sick enough to be admitted, being turned away, waiting it out, getting sicker and then going to [the larger hospital].” “We tend to have one in the ICU at any given time and 2-3 on med surg floor. We are being told it’s coming and to brace for it. The entire third floor, which is a 40-bed med surg unit – is dedicated to covid with an additional 12 ICU beds. When asked how many Covid-19 patients she has cared for she said, “I have taken care of 2 – No deaths, all recovered, none required intubation, both middle aged, only one with comorbidities.” I wondered about the statistics about people going on ventilators – how do the Covid-19 patients compare with other patients who are ventilated? “In a year and a half in this ICU, I’ve only had 3 people not make it off the vent. Most are getting well compared to the covid patients.” Presentation “A lot of these patients present with low O2 sats, but are asymptomatic, they feel okay in terms of breathing. The O2 levels are really low because the virus is attaching where O2 would attach – it’s filling the receptors and blocking the O2 binding sites. It’s like Carbon monoxide poisoning. It’s affecting other organs in bodies. A positive is that patients with blood transfusions see a turnaround in 2-3 days and are not dying. That fresh healthy blood is making a difference.” According to Dr. Marc Moss, the division head of Pulmonary Sciences and Critical Care Medicine at the University of Colorado Anschutz Medical Campus, “There are other conditions in which patients are extremely low on oxygen but don't feel any sense of suffocation or lack of air. For example, some congenital heart defects cause circulation to bypass the lungs, meaning the blood is poorly oxygenated.” “A lot of coronavirus patients show up at the hospital with oxygen saturations in the low 80s but look fairly comfortable and alert”, according to Dr. Astha Chichra, a critical care physician at Yale School of Medicine. “They might be slightly short of breath, but not in proportion to the lack of oxygen they're receiving.” Chichra said it's becoming clear that patients who aren't struggling for breath often recover without being intubated. They may do well with oxygen delivered via nasal tube or a non-rebreather mask, which fits over the face to deliver high concentrations of oxygen. Hypoxic patients who are breathing quickly and laboriously, with elevated heart rates, tend to be the ones who need mechanical ventilation or non-invasive positive-pressure ventilation, Chichra said.2 What do you do when you get home? "I don’t wear scrubs home. My partner's facility keeps and launders her scrubs to sanitize them – so we both change at work, but I bring my scrubs home and wash them. I go straight to the shower, no hugs. I brush my teeth and gargle with antiseptic solution since the virus can live in your throat for 3 days. I bleach the bottoms of my shoes and leave them in the car, and I keep hand sanitizer in the car. “ “Since I have to change at work it poses this whole issue of changing in the ICU bathroom and then walking through the hospital without a mask. I wonder what is getting on my clothing. We have to leave our masks at work so I’m walking out to my car without a mask. I think I’m going to start bringing my own mask from home to do that.” When I asked about the rumors that some hospitals had told workers they couldn’t wear masks because it might frighten visitors, Ann said, “We are allowed to wear out masks at any time here.” Before we ended our phone call, Ann had a request for an article: “I think Covid-19 is showing where our hospitals are failing. Hospitals are having problems with payments, they’ve lost funding because we are cancelling all elective procedures – hospitals are taking a huge $ hit. It’s an interesting dynamic and I wonder where will things go with healthcare? Will folks realize that for-profit hospitals are a huge failure?” Well, Ann, I’ll look into that for you, but for now, stay strong and stay safe! What’s happening in your state? Do you have any stories to share? How many testing kits are available at your hospital? Thanks in advance for your comments. References 1 - Overview of Testing for SARS-CoV-2 2 'Silent hypoxia' may be killing COVID-19 patients. But there's hope.
  23. Hello - In addition to my Cardiothoracic scrub position, I was nominated to join our new ‘ICU / PICU / SICU rapid response team’ that will be responsible for assisting in bedside rescue surgeries (mainly decompressive laparotomies for ACS and thoracotomies for cardiac tamponade). Does anyone have any experience with this, and any tips / suggestions? Here are the key responsibilities of the ICU Rapid Response Team “RRT” Scrub Nurse: Setup of sterile field, including gloving-and-gowning of primary and support practitioners;Initiate life-saving measures prior to arrival of primary practitioner including measures as recommended by ACLS (e.g., closed chest compressions);Identification and direction of ICU nursing personnel to obtain requisite instrumentation including, but not limited to: thoracotomy tray, laparotomy setup (bookwalter retraction, etc.);Working with RRT Circulator to establish sterile perimeter in room; and,Primary operative assistance in the sterile field (including first assisting if resident / fellow is not available).
  24. SafetyNurse1968

    At the Bedside with Covid-19 -Part 2: John

    I used facebook to reach out to nurses working in hospitals in many places in the U.S. I’ve rounded all numbers to protect the identity of the nurses who agreed to be interviewed. I offered to pay all the nurses I interviewed for their time, but they all refused, so I’m making a donation to the American Nurses Foundation Coronavirus Response Fund in their honor. The fund focuses on: Providing direct financial assistance to nurses (RNS SEE ELIGIBILITY HERE) Supporting the mental health of nurses – today and in the future Ensuring nurses everywhere have access to the latest science-based information to protect themselves, prevent infection, and care for those in need Driving the national advocacy focused on nurses and patients John works in an ICU in a large, urban hospital with 50 confirmed cases and only 4 deaths in a county of more than 300,000 people. In John’s state, there are 12,000 confirmed Covid-19 cases with 450 deaths. Their stay at home order occurred on March 30 and has been extended to June 10, 2020. PPE situation I asked John if he feels safe at work. His response was disturbing. “No, because they aren’t following protocols. I’ve worked in the ICU for almost 20 years. I love my job, and I’m passionate about educating staff on best practice, but I just got written up for trying to get my fellow coworkers to follow isolation protocols.” “To take a Covid-19 patient off of isolation, you have to have 2 negative tests greater than 24 hours a part – and even then, if the patient is still febrile and symptomatic respiratory wise –they are to remain on isolation as if they have Covid unless the physician discontinues the isolation. But nurses are opening the door and taking away the isolation cart – they are deciding the patient is fine. My question is, who am I supposed to go to when I see a break in policy with covid and the supervisor has no idea what’s going on and it’s putting me and my patients at risk? Another issue is how we deal with aerosolizing procedures. Any time you break into the vent line --Respiratory Therapists have to do that to change the filters in the vent --every time you open that circuit, the CDC says for 3 hours afterwards, anyone going into the room needs and N95 mask, but my hospital is doing 2 hours. I mean, technically, covid patients should be in negative isolation since it’s droplet, but limited rooms make that difficult. For patients who are not vented, you used to need an N95 for any Bipap, cpap or vapotherm that was over 6 liters, but they just changed it to >20 liters. And it’s all about PPE.” John says the hospital is assuring them that there is plenty of PPE. “They won’t give us numbers and they are asking us to recycle surgical masks, eye wear, N95, into a bag – But we don’t know the method. When will it happen? No information is being given.” “I was one of those people wearing a mask prior to it being mandatory. People looked at me like I was nuts. Now it’s mandatory.” To protect employees, John says they’ve closed down almost all entrances to the hospital, and no visitors are allowed. “The staff come through one entrance and there are screeners who take our temp with an infrared sensor, hand you a mask, and you sanitize your hands. John describes three levels of masks. “The one you get at the door is the cheapest – for housekeepers – it’s a level 1 – much thinner. Level 2 is a true surgical mask. Here’s the problem, people are walking from the parking area, getting on an elevator unmasked, not maintaining a 6 foot distance. These people are filling the elevators to get the mask, without wearing a mask! It’s insane. The N95 are under lock up with a guard. The only way to get one is if you have a covid suspicious patient, and they count everything. There are five locations in the hospital where N95s can be obtained, all of them guarded by nurses or security guards. If you have a patient on isolation, they bring you a PPE cart. If you run low on the cart, they bring you what you need.” Reuse of N95s “You have to reuse the N95s – they keep changing it. Right now I think it’s 1 per shift. There’s an egg crate container for your mask and it goes in a paper bag, but my concern is that the next time you have to reach in the bag you are contaminated. The bag must be thrown away after holding the mask. I’m using a Tupperware method to let mask dry out without contaminating myself.” According to the CDC, extended use is preferred over reuse. “A key consideration for safe extended use is that the respirator must maintain its fit and function. Workers in other industries routinely use N95 respirators for several hours uninterrupted. Experience in these settings indicates that respirators can function within their design specifications for 8 hours of continuous or intermittent use. There is no way of determining the maximum possible number of safe reuses for an N95 respirator. Hang used respirators in a designated storage area or keep them in a clean, breathable container such as a paper bag between uses.” Testing kits When asked how many test kits are available, John replied, “No one knows. There is rumor that our hospital isn’t testing anyone because they want to keep the perceived numbers down, make us look like a nice place to visit.” Census “Our hospital has only had 5 truly positive Covid tests, we’ve had 10 or so presumed positive, and a ton of PUIs (patients under investigation). We are waiting for test results for more than 100 people. But all of them are coming back negative. So we shut down the covid unit and sent most of the nurses home on pandemic pay. There is no one to test, no one is coming in. Patients are coming in for open heart surgery, which is incredibly stressful to the body, and then are becoming covid symptomatic. The tests we are doing can’t be accurate. If they don’t have covid then what do they have? I saw a patient with classic symptoms. She had thrown microemboli, she had bruises in her toes, but both tests were negative. When they did a bronch – the bronch was positive. The nasal swabs aren’t getting it. My question is, before doing a nasal swab, the patient is supposed to blow their nose, but you can’t do that on a vented patient. So maybe it’s not deep enough. We are seeing many patients with symptoms of covid who are testing negative. We have two other patients who we are pretty sure are covid positive, but they are not sending the bronch washes for testing.” (A “bronch” is a bronchoscopy – a thin tube is passed through the nose or mouth into the throat and lungs. Common reasons for a bronch are to get a sample to send related to symptoms or something unusual seen on a chest X-ray, or to remove foreign bodies or other blockages from the airway.) John went on to say, “A heart patient came in with a PO2 of 45 and after getting open heart surgery, covid symptoms appeared. He had two negative nasal swab tests. He was bronched but the sample wasn’t sent for covid testing. You’re supposed to send all samples for covid testing. Another patient was tested multiple times with the nasal swab and came up negative. Finally she was bronched and it was positive.” Here’s a Youtube video from Mt. Sinai on how to do a proper Covid-19 test: Proning I asked John about proning patients. “Proning patients has been around for a long time – we used to do a lot of proning. Our staff are all young and none of them have proned, so last week we had two classes on how to prone.” According to a review of literature conducted on April 11, 2020, Covid-19 can cause pulmonary edema, multi-organ failure, and acute respiratory distress syndrome (ARDS). The prevalence of ARDS among COVID-19 patients has been reported to be up to 17%. The prone position can be used as therapy for improving ventilation in these patients. “The main mechanisms of prone position in improvement of ARDS patients’ condition are affecting recruitment in dorsal lung regions, increasing end-expiratory lung volume, increasing chest wall elastane, decreasing alveolar shunt, and improving tidal volume. Patients remaining in lengthy prone position sessions leads to decrease in mortality of patients. However, correct selection of patients and applying the proper treatment protocol for prone positioning are key to its effectiveness.” I had never seen this, so I asked John to describe it to me. Read this step-by-step article describing how to do it and what it looks like. “It’s like sleeping on your stomach. With your left leg on a pillow, your head is turned the same direction as the left leg and the right arm is behind the patient with the patient’s right shoulder touching the bed and the hand is palm up. We also turn them the other direction. You aren’t completely flat. They do have proning tables, but they are so expensive. The biggest problem with proning is keeping the face and ears from breaking down from the weight.” ECMO Another therapy that John is excited about is extracorporeal membranous oxygenation (ECMO) “We started doing this 4 years ago as a last resort. You insert a massive canula into the jugular, or the femoral artery, you can even stick the canula into the heart. It pulls the blood to the machine, filters it to remove carbon dioxide, oxygenates it and returns it.” John went to Emory to learn how to do it. “What I love about ECMO is that it is nurse driven. Most hospitals have perfusionists doing it, but here, we run them. It’s intense. You need 2 nurses to 1 patient. It totally works – saves lives.” ECMO essentially replaces the function of the heart and lungs. It can be used for months to support patients until lung and/or heart function can be restored. For more information on ECMO, read What is ECMO? All of these nurses are experiencing skin breakdown behind the ears, so if you know of where I can get them a behind the head ear loop holder, please comment!
  25. Hello, all! After working in clerical hospital roles in multiple facilities and having an up close view of what nurses do on a daily basis, I have realized that I would DREAD working bedside in a hospital. I'm wondering, though, is it possible just to head straight to a clinic or doctor's office upon graduating? Also, is an RN or LVN more likely to work in one of these roles? Honestly, my absolute dream would be to work in a public health setting! I would love to work with underserved populations. Basically,--and I feel bad saying this--I am looking for a relatively low-stress nursing job (although I know they're all stressful to a degree!). I've witnessed so many resuscitations (more attempted than successful), death/dying, and sudden emergencies and I am just NOT looking to have that be part of my job. I want nursing to be for me, but I'm afraid that my desires may not be reasonable or possible. I hate to put it this way, but I would strongly reconsider moving forward with nursing if it meant that this were not possible. As I said, I feel guilty admitting all of these things, but I truly am interested in nursing because I feel great satisfaction from helping others, I'm a natural advocate, I keep calm under pressure, and I love to read about everything health-related. I've viewed both the RN and LVN courses at my local college, and every subject seems completely thrilling to learn about. Also, for background, I live in the Houston area, am in my mid-twenties, married, and have a baby on the way. A good work/life balance is important to me as we want additional children and I certainly want to be involved in their lives. Currently, I'm considering all nursing avenues, and a Bachelor's degree is as far as I'm willing to go at this point (I definitely would be eyeing a public health degree if I did take this route!). Also, as far as the LVN vs. RN question, I've met a lot of LVNs who have expressed regret for not pursuing an RN degree because of pay and wanting more opportunities. All I'm seeking to do is make a decent paycheck for a comfortable lifestyle and to work outside of bedside. Basically, I'm at the point where I'm tired of thinking/debating what I want and start doing--and that means finding what works for me and not settling! I am finally feeling liberated and ready to do this! Any thoughts or advice on any of this is more than helpful to me--I would appreciate it so much! tl;Dr: Debating between LVN, RN, or BSN--whichever will offer me the most opportunities of working outside of bedside. I do NOT want to work bedside upon graduating and am wondering how possible this is to avoid. I would strongly reconsider the nursing path if this were NOT possible.