Often on this site we see forums about nurses versus allied health professionals. But as you well know the same tension exists, between different nursing professionals. So basically this is what this thread is about.
Let's talk about what LPN or in some cases RN floor nurses in LTC would classify as the "The rude emergency department nurse ". And again, this is not to stereotype all ER Nurses as i have called in report to many awesome life loving positive ER Nurses. I never worked as an ER Nurse, so i do not know the struggle, but i was hoping this post would give the "Lazy Imcompetent LTC Nurse" and the "Rude Bitter ER Nurse" as classified by one another a chance to share wach others frustration.
So at this time, im going to speak for the "Lazy incomptent LTC Nurse" and share some of our struggles and frustrations.
1. Chatting with a residents primary physician, obtaining physician order for the resident to go to the hospital, calling report to the hospital and meeting resistance from the ER Nurse.
A. While i know that in my heart of hearts that not every single LTC fall warants an ER visit. But when the doc says send them , they must be sent. Even if i know the resident is fine. Its the way it is. Some doctors put full trust in the assessment skills of LTC Nurses, others are overly cautious (they earn that right with 8 years of medical school). So the orders you bark when we call to give you report, well there gonna go in one ear and out the other. Because to be very bluntly as a Nurse im not taking an order from a Nurse. A doctor has given me an order, ane in order to protect my license i will do my duty as a nurse abd carry out the order. So wasting your breath barking orders will just raise your blood pressure, and take me away from the other 42 residents under my care. At the end of the dat whether you take my courtesy report or not, they will still be coming to your ER so make the most of my willingness to be polite and give you as much info as possible because when its over and i feel you are trying to bully and harrass and pitch a fit, the phone will hang up and my DON will back me up.
2. NOT UNDERSTANDING POLICY
A. As i assume, you ER Nurses are used to just doing. Suctioning, U/As, reinsertions of enteral tubes, Nebs, reinsertion of suprapubic catheters etc. etc. And just cant understand wvu this cant just be done at the nursing home, its not the incompetence of the nurse, its facility policy. So no, we did not suction, because we have no order to so. Call our facilities Director of Nursing, Adminstrator, Corporate Nurse Officer, Medical director, If you wish to voice your concerns. But please dont take ir out in the LPN on the floor who is trying desperately to finish a 40 patient med pass, and complete 10 skilled nurses notes, and all the hospital transport paperwork we didnt write
the policies.
3. No we cannot call to mind everything about our residents like ICU and ER Nurses can. We do not know every allergy our residents have, or every dx a resident has. Just like doctors who care for maby patients, we have to reminded and reminded and remind ourselfs. So when we cant answer a question without doing a little reseach dont write us off as guilty of incompetence or laziness.
Just a few , but i encourage you guys to share the ER Nurse struggles and what frustrates you the most. Im going to quote the Assitant Director of Nurses at our Nursing home who has been an LPN for 27 years and one the best i know! Take it with a grain of salt.
"Ive done Med Surg, Ive done NICCU, ive done ICU, i was an ER Nurse at a rural hospital, i was a home health nurse. But, nothing compared to the stress being in a facility full of stable elderly residents, as crazy as it may sound,".
I'm wondering if they would even have suction, suction catheters, etc. I'm sure that with an order they could obtain such equipment, but LTC may not have such things sitting around in patient rooms.
I just can't get over the part about not being able to suction without an order in the original post.
I'm not picking on LTC nurses here, just this particular point, but... you seriously wouldn't suction the patient and get an order later?
You are assuming that the facility will actually have a functional suction unit readily available. Ours is not; has not been for some time, DON and administrator are aware but it is still on the fritz.
Woah woah woah ! Lets back it up ! First of all, im a proud male nurse! Second of all , the comments are heading in the direction. The post was not meant to ruffle feathers or take anything away from great ER Nursew who sabe many lives in an absolute great area of nursing! This post is to maybe give these EE Nurses who have done this life an insight to a different enviroment. make no mistake about when i call to the ER i got thre allergies , the problem, the V/S, the basics, but when the ER Nurse asks me what day did they have there stroke, what all medications are they on that could cause this or that, well ill be hapy to get that for you but ill have to loom it up! Sometimes that turns into rudeness, and uncoopetation, and if you continually try to degrade my judgement or competence i will hang up the phone! And the DON has no problem with that! When people go to the ER from there home they get no report. Im polite im couteous, but i a good nurse, if you insult my judgement and competence , then when your ready to call back and focus on the "Resident" we will talk. Its common courtesy! I can call the ER and have seven kinds of attitude because it wasnt my schedules day the med pass interupred but i dont. Its common courtesy. And reply to the above poster comment yea we should all get along but we dont. Simply because of altered perception r/t lack of personal experience aeb everyday reppetive issues. So i feel this is a good place for us to give insight to each other from one area of nursing to another. Its a blunt post not a degrading or derogatory post.
There's got to be some sort of nursing process. Yes, there are LTC facilities who send everyone who falls to the ER to be medically cleared to return to the facility. And that is a policy/standard that should happen. A fall is an unexpected event that could have consequences that can't be determined in a LTC facility.
With that being said, when you call the MD regarding a fall,you should have all of the information needed to be able to either advocate or relay to the MD the specifics--"Resident Xyz fell out of bed. Vitals are stable at _______________, however, they take Coumadin for ________"
When a resident is brought to the ER, you give report to EMS, EMS gives report to hospital. I make sure that paperwork is sent and a call to advise paperwork is being sent, and if they have any questions how to get in contact with me. And how the resident is to get back to the facility. And the name and number of HCP (or where to find it on the paperwork).
It is rare that ER nurses don't know that to cover everyone's behinds, a resident who falls needs medical clearance.
But for every resident who falls and is "fine" there's just as many who fall and break something, somewhere is bleeding, etc.
The time and place to make decisions about that is at a facility who can institute interventions. Not when you have a resident whose fall results in loss of function or worse....and a family who is "what do you MEAN that Mother wasn't sent to the ER?!?!?!?!"
Specializes in LTC,Hospice/palliative care,acute care.
A) My question wasn't for you. It was an honest question for the OP. Your response is both snippy and unhelpful.
B) Neither do we.
It's great how you can read emotion and intent into a brief comment.Was not meant to be "snippy"Just concise,some of these long replies on this thread are difficult to read.Sorry you did not find my comment helpful.
I'm wondering if they would even have suction, suction catheters, etc. I'm sure that with an order they could obtain such equipment, but LTC may not have such things sitting around in patient rooms.
Probably not sitting around in the patients rooms, but by all means, all facilities should have a crash cart, fully stocked with this equipment ready to roll. Though I have to admit, I have worked at a few where said cart was in looks only...most of the needed equipment had been used and not replaced. Now, the anal butthead that I am insisted that something be done at each facility or I could not work there. I cannot fathom needing the equipment on a cart, grab it and run down the hallway only to find it full of empty containers!
Specializes in LTC,Hospice/palliative care,acute care.
We run codes now and have some AED's and crash carts.Each unit is supposed to have a suction machine and an oxygen concentrator set up and ready to roll in an emergency.Nurses can be bone heads,so can physicians and family members.Treating in place with palliative care is a wonderful thing but unless the family and resident are fully on board with the process when the resident stops responding to treatment and goes into end of life they are going to the ER.We don't (yet) run routineIVfluids for hydration .We can get a PICC inserted in the facility for long term antibioticsand perform lots of portable studies but the little old ladies and gents have multiple co-morbidities and can tank fast
The facility that I work in does not have a crash cart, an AED, a working suction machine (at this time--it worked a few decades ago I'm sure), or a requirement for staff to maintain CPR status. Most of our residents are DNR and those that aren't get shipped to the local
ER when something goes wrong. All of our nurses and a few of the CNAs (astounded that they have to obtain it themselves) have maintained their CPR licenses, but if you code in my building, you're pretty much up a creek.
Sometimes when I call the ER, my frustration level is already very high because of the limitations of what I have available, so when I get a "snippy" ER reply, it's easy for me to give a snippier response back. In all fairness, most of the time the ER nurses have been very reasonable to work with and I try to remember that anyone can have a bad shift. I did have one episode this week when one of my residents was found unresponsive on the floor and her BG was 39 (resident also has nasty venous stasis ulcers on both legs). I got it up into the 80s but she started vomiting uncontrollably and her temp was too low to read on my aural thermometers (they read down to 93.5F). I called the ER to reach the on-call doc and after I identified myself to the ER nurse and asked for the on-call doc, the first question I got was "Is this call for one of your residents?" I did NOT answer with my first thought which was, "No, I'm calling cause the facility cat just harked up a hairball and I need the doc's advice." Then the nurse asked for a full explanation of what was happening with my resident before giving me the on-call information that I needed. Once I gave report, the nurse's attitude changed, since it was a "legit" problem. This experience, however, is one exception to the general relationship that I have with the ER nurses here; most are calm, courteous, professional and helpful.
It is often the ER doctor that I have the most issues with. I'm required to call the on-call (ER) doc before sending a resident to the ER, or for orders in the middle of the night (small rural area--at noc, the docs go home and there is no doctor in the hospital; same on-call doc for the nursing home and hospital), and the docs here are notorious. (Thank God we now have a PA here who is proactive and reasonable and spends her on-call shifts at the hospital--I love, love, love working with her, both professionally as a nurse and personally as I won't put my life in the hands of the other providers available in this community). We had one of the docs refuse to come in to see one of our residents after a bad fall, stating that he'd see her during his regular clinic hours the next day--turned out she had a fractured collar bone, so he felt justified since there was nothing to do but immobilize the arm (and provide pain meds, which she didn't have).
The nurses at the ER also have some legitimate issues with our facility, as my current DON is a lunatic (she truly is, this isn't sour grapes talking) who often won't let the day nurses contact the doc for serious medical concerns because she has decided that it's not a big deal. Which means that we noc nurses are handed the responsibility to call the on-call provider to address concerns that should have been handled during the day during their clinic hours, because we noc nurses don't have the DON standing there telling us not to call. She has, however, left instructions for me specifically that "even if this resident gets worse, it's not an emergency, so don't call."
On the side of the ER: I would "pitch a fit" too if a nurse, in whom I expect to know 1)how to read and 2) how to use critical thinking skills doesn't have the chart or EMR sitting IN FRONT OF THEM when they call. Barring a code, or a soon to be code, we SHOULD have already done our initial exam. We SHOULD have already looked to possible causes for the fall (meds, illness, resisting care, etc). We SHOULD have already taken vitals, looked at the MAR and made sure our resident was clean and dry prior to transport. The ambulance crew cannot simply beam into the facility, nor can they beam out, so barring you don't have three residents going to the ER at once, you should be able to pull up the EMR or hard chart BEFORE you call to give report and BEFORE the resident arrives at the ER. We should also try our darndest to convey any special info, such as whether or not they prefer to be called King Richard or want you to feed their stuffed animal imaginary treats before you try to stuff a pill in them.
In conclusion (now that my proverbial chest has been proverbially bared) I see both sides, and I think if we tried really hard, this could become a non-issue. SNF nurses, next time you have to visit an ER for something, look, listen and feel, to use an old CPR line. Look around you and think, "If I worked here, and knew a SNF patient was about to come in, what would I want to know?" Listen to what you see them ask family members and patients as they are doing intake (don't deliberately eavesdrop, but just pay attention to the kinds of things they feel are important) that you, as a SNF nurse, might think they don't need or don't want to know. Consider how you would feel if an elderly demented resident was trying to jump off a stretcher in the middle of a crowded ER and you've got a code going on, crying babies, ill-tempered interns, lab techs and rad techs all asking different questions, etc.
ER nurses, go and visit your elderly mom, grandmom, aunt, neighbor, etc. in a nursing home and look around you. How would you like it if you had a woman in a wheelchair following your med cart down the hall all night long hurling ethnic slurs, cursing you, screaming at the top of her voice that she was going to send you to an imaginary jail for beating up her imaginary son? Listen to how many children you hear. I bet the answer will be slim, to none. We don't get many kids visiting, and our elderly population LOVE them. Geriatric residents are, more and more, pretty much ignored by the rest of the world. By this time in their lives, the children are raised, the job is done, and the hobbies are too physically or mentally demanding to continue. They have a lot of free time on their hands, y'all. How would you feel if that were your mother, father, etc.? Would the guilt of not being able to put your eyes on them in the middle of the night make you want the nurse there to send them to the hospital when you get their call? Will YOU trust them with your loved one to use their judgment?
Over the years, I have often found that the shoe we would like others to wear on the their foot is not the same glass slipper we want on ours. Just my two cents!
It's great how you can read emotion and intent into a brief comment.Was not meant to be "snippy"Just concise,some of these long replies on this thread are difficult to read.Sorry you did not find my comment helpful.
On the side of the ER: I would "pitch a fit" too if a nurse, in whom I expect to know 1)how to read and 2) how to use critical thinking skills doesn't have the chart or EMR sitting IN FRONT OF THEM when they call. Barring a code, or a soon to be code, we SHOULD have already done our initial exam. We SHOULD have already looked to possible causes for the fall (meds, illness, resisting care, etc). We SHOULD have already taken vitals, looked at the MAR and made sure our resident was clean and dry prior to transport. The ambulance crew cannot simply beam into the facility, nor can they beam out, so barring you don't have three residents going to the ER at once, you should be able to pull up the EMR or hard chart BEFORE you call to give report and BEFORE the resident arrives at the ER. We should also try our darndest to convey any special info, such as whether or not they prefer to be called King Richard or want you to feed their stuffed animal imaginary treats before you try to stuff a pill in them.
In conclusion (now that my proverbial chest has been proverbially bared) I see both sides, and I think if we tried really hard, this could become a non-issue. SNF nurses, next time you have to visit an ER for something, look, listen and feel, to use an old CPR line. Look around you and think, "If I worked here, and knew a SNF patient was about to come in, what would I want to know?" Listen to what you see them ask family members and patients as they are doing intake (don't deliberately eavesdrop, but just pay attention to the kinds of things they feel are important) that you, as a SNF nurse, might think they don't need or don't want to know. Consider how you would feel if an elderly demented resident was trying to jump off a stretcher in the middle of a crowded ER and you've got a code going on, crying babies, ill-tempered interns, lab techs and rad techs all asking different questions, etc.
ER nurses, go and visit your elderly mom, grandmom, aunt, neighbor, etc. in a nursing home and look around you. How would you like it if you had a woman in a wheelchair following your med cart down the hall all night long hurling ethnic slurs, cursing you, screaming at the top of her voice that she was going to send you to an imaginary jail for beating up her imaginary son? Listen to how many children you hear. I bet the answer will be slim, to none. We don't get many kids visiting, and our elderly population LOVE them. Geriatric residents are, more and more, pretty much ignored by the rest of the world. By this time in their lives, the children are raised, the job is done, and the hobbies are too physically or mentally demanding to continue. They have a lot of free time on their hands, y'all. How would you feel if that were your mother, father, etc.? Would the guilt of not being able to put your eyes on them in the middle of the night make you want the nurse there to send them to the hospital when you get their call? Will YOU trust them with your loved one to use their judgment?
Over the years, I have often found that the shoe we would like others to wear on the their foot is not the same glass slipper we want on ours. Just my two cents!
This is real. Thanks for going all out and just telling it like it is. The LTC world is very lucky to have you. :)
Hoosier_RN, MSN
3,968 Posts
Some days have the equip, luckybif it even works