Unfamiliar territory with no orientation

[ratgirl63]

I just started a new position with a Home Health Agency that I thought was for home health care. It turns out to be really private duty nursing (taking care of medically fragile kids for 12 hours a day). My first patient was a young CP girl with a G-Tube. Received one day orientation and next day on my own. Two days with her no problems. The case was somewhat boring as I had to sit in the child's room all day. No T.V., no reading, just sitting. This girl was not going to be my permanent placement as the regular nurse just wanted a few days off.

The agency called me to start a new case. Ten month old baby boy, G-Tube, trach and a genetic disease that leaves him open to infection that could turn him south in a few hours time.

When I interviewed with the Home Health Agency I was up front about my knowledge with Peds, Trachs, G-Tubes, and Vents. Basically, I worked an adult Med-Surg floor for a year after graduating. I had no experience with Peds, very limited with trachs (two older patient's that had trachs forever and self cared for them), and no Vents. This new patient has a tract and is a Ped. I asked if there would be some in home orientation so I could become comfortable with trach care with this baby. The agency told me the Mom would orient me for everything I would need. ummmmmm really! Is this good? My gut feeling is NO. If things went south, baby's trach plugs or dislodges and comes out, I better be comfortable with acting fast on this little guy. Is it unreasonable for me to be asking for some hands on orientation with this unfamiliar case?

My gut feeling is telling me I could be setting myself up for a law-suit, loss of license, or worse the loss of this baby's life.

My first day is supposed to be Sunday, should I call and tell them I'm not comfortable with the case without adequate hands on orientation? Or am I just being a nervous new nurse?

[Eleven011]

I am also new to private duty, but that would scare the bejezzes out of me! I had one day of orientation in each of my two cases, and they only had g/j tubes and oxygen (and varies AFO's/suction, etc). I would def. call and say I was not comfortable. There might be another nurse that was off that day that could at least be there with you. Also my agency said that although parents usually do know alot about the cares, they are never allowed to "train" us. Good luck!

[Nrsasrus, ASN, RN]

I'm a new nurse, too. Whenever I am confronted with a situation that makes me uncomfortable I remind myself that I know more than I think I do so my gut instincts are important. I also ask myself what is the worse thing that could happen if I screw up. If the answer is something bad or if I don't know the answer I ask someone. Sure I have had some more experienced nurses roll their eyes at me on a few occasions but I don't think there has ever been a nurse who harmed some one or lost his/her license by asking for help.

[fireball78]

I started working for a private duty nursing agency 2 1/2 months ago myself, and I can tell you that if I was presented with the case you mentioned, I would say "no". Is the case a new case to the agency? If not, tell them that you would not be comfortable in the home unless an experienced nurse (who has been on the case orients you). Parents are invaluable in the home setting and can be great teachers, but they are not nurses. Parents can also hinder nursing care based on what they feel is best, but is not what is appropriate for the patient. You need another nurse to orient with to refresh on trachs and suction, when to suction, how to prepare and what to do in an emergency (baby could accidently pull out trach). If the agency is not receptive to your concerns, then this is not the right agency for you!! You worked hard for your nursing license and you need to protect it. This is just my opinion and I wish you the best.

Good luck!

[JustBeachyNurse, LPN]

Most reputable agencies require a nurse to complete trach/vent training class with hands on lab (even if have previous experience in trach/vent). parents can orient to the case (schedule, routine, location of supplies, what works best for the child) but they cannot train you on a skill that you have never done before. You need to call your clinical manager ASAP.

One day of case orientation is pretty typical as one working in HH/PDN theoretically has clinical experience to basic nursing and assessment skills. (Hence why many states & agencies require a minimum of one year of current clinical paid work experience)

The orientation is patient specific (daily routine, medications, patient condition, supply location, emergency plan, how to use patient specific equipment (i.e. you should have had experience and agency training on how to use a feeding pump but since there are different brands your patient orientation would include how to set up and use the patient's particular feeding pump), etc.) and usually a single shift with either a clinical supervisor or a nurse preceptor who has worked the case.

The one agency I work with would hire someone like you who has a year or so of adult med-surg experience but would require you to take a two full day hands-on lecture & skills lab pediatric class. Then a minimum # of shifts orientation on a case with a nurse preceptor (not all nurses are qualified to work as a preceptor and additional training is required). Only those experienced with trach and or trach/vent care would be permitted to start on trach/vent cases.

[JustBeachyNurse, LPN]

Oh, try asking for vent/trach training not orientation. Parents can orient to a case but they cannot train a nurse on skills necessary for a case. Orientation is an overview. You need specific skill training. Basic trach care is a nursing skill but vent training is a higher level skill not covered in nursing school.

Call NOW.

[ratgirl63]

I did go with my gut feeling on this and had to firmly stand my ground with the agency. I talked with the Clinical Nurse Manager and clearly explained my hesitation about this case. She stated she understood where I was coming from but was still pressuring me to go and have the Mom give me the training I would need. Nope! Not happening! I stated the only way I would remain on this case was if I had in-house training by another more experienced nurse. And yes, fireball78, this is a new case for them and I was going to be first nurse caring for this patient. Mom had "fired" the previous agency and is starting new with my agency.

[JustBeachyNurse, LPN]

Good for you. It's not like we get more than basic trach care in nursing school if any. I don't know many nurses that get pedi trach care in clinical rotations...it's specialty training post graduation where you learn this stuff.

[SigneKnapp]

new nurses that have no experience with trache care should not try to care for anyone with a trache. The trache is an open port for infection. Aseptic technique is required for care anywhere near the trache.

[PerfectlyPlump, ADN, RN]

Sterile gloves and all? Or is it CLEAN technique at home? Does the technique vary with how long the pt. has had the trach?

[PediLove2147, BSN, RN]

Sterile gloves and all? Or is it CLEAN technique at home? Does the technique vary with how long the pt. has had the trach?

When I did home care it was a clean procedure. I didn't even wear gloves during suctioning. The home is a whole different ball game than the hospital and people are sometimes surprised how different it is.

I agree OP this case sounded dangerous and I probably would have said no too but in the future, parents can be great at orienting as long as they are not the only ones doing it. With my case, I had a nurse train me one day and the dad the other. The nurse showed me how to follow policy, fill out paperwork, and of course patient care but dad knew his kid VERY well and was able to give me tips and walk me through everything without getting hung up on "how's it's supposed to be done" which at times can be nice.

[SDALPN]

It's clean technique in the home. The poster above you has it wrong. (and to the poster above, trach is spelled without an "e")

The home environment isn't sterile so everything we do is considered clean. We can use sterile technique for things like central line dressing changes, but it isn't truly sterile. For example, with dogs in the home there will be hair and pet dander that could be in the air.

Most nurses I see don't even wear gloves while suctioning. Usually because when they started pdn they were told not to use lots of gloves because they are expensive. And other nurses choose to just wash their hands. The parents almost never use gloves either.