What would you do in this situation?

[kerussll]

I am a new grad and I have worked for a home health company for 2 months now. Generally, we are in homes of kids with disabilities who need minor nursing interventions such as repositioning, respiratory therapies, dressing, hygiene, etc. So far I had only worked in two homes with adult children who needed minimal help and could talk me through everything I needed. The job is not bad, but I have to say the orientation process of introducing a new nurse to a new home is appalling.

Last week I was asked to fill in for a nurse who had called in sick in another town. I was told to go there, and another nurse would be there to show me around. The secretary from the agency who called me had no details about the patient's condition, but assured me the other nurse would show me everything I needed to know. When I arrived I found the patient to be a girl who could not be more disabled in any way. She was blind, deaf, severely retarded, and paralyzed. We were taking her to school, so the other nurse and I hopped on the bus and went with her. Once there, I found she needed continuous tube feedings, transfer with a hoyer lift, chest percussion therapy, and to be transferred around school from class to class. None of this I have ever done before and needless to say I didn't know my way around the school as I had never been there before. The nurse training me was with me for 3 hours, and did show me everything as best she could. Then she left me on my own and went home. (As she had been instructed to by our agency because they didn't want to pay for 2 nurses the whole day.) I felt completely overwhelmed and wanted to cry. I didn't know where to go in the school and was afraid something would happen with her equipment and I wouldn't be able to figure it out. Plus I felt totally uncomfortable, not knowing how to interact with someone who couldn't see or hear me.

This seems so wrong to me to do to any nurse, let alone someone with as little experience as I have. Would I be right to tell them I cannot work alone in a new house until I have worked a few shifts with another nurse and feel comfortable with it? I don't want to be difficult, but it's my license on the line if I screw up! Thanks a lot for listening.

[NotReady4PrimeTime, RN]

I had a similar experience when I was a new grad. I was called to replace the regularly-scheduled nurse in a home of two teenagers with juvenile Huntington's disease. The girl was older and had more severe disease at the time, with rigidity and dementia; her brother was still able to attend school and a second staff person attended with him. I was left alone in the home with the girl who was non-verbal and unable to communicate. The night nurse gave me a tour of the apartment, showed me where the meds and feeds were kept and showed me the care plan. (Imagine my shock to learn that part of her care plan included me cleaning the bathroom and washing the floors in the bathroom and kitchen!) I'd never used a Hoyer lift before and had no idea what to do with it. I was okay with themeds, tube feeds, suctioning and diapering, but there was so much I wasn't okay with. The shift passed so slowly! And to add insult to injury, when I was paid for the shift I found out that the agency normally placed LPNs in that home, so I was paid as an LPN. I never went back.

One home I worked in for several weeks was not a nice placement at all and things finally came to a head there when the mother (and the agency supervisor) instructed me to allow her to endanger the child. (The child's room was on the second floor, no lift or elevator; the older brother carried the child upstairs each night when it was time for bed. He had been in an accident and had lost a significant amount of blood, was wobbly and light-headed, but still expected to carry the child upstairs.) I never went back after that.

I was also placed in the untenable position of being the only RN on the premises at a nursing home for a night. No warning, no asking me if it was okay, I just arrived and was told, "Here you go. Don't forget to check for sick calls at 0530."

If you find that your agency continues to send you on assignments without sufficient preparation, you'll need to be assertive. Tell them that you cannot provide safe care without adequate orientation to the patient and the circumstances. Tell them that you're not willing to be their float, that you want a stable case load and proper support in each home. If they won't agree then start looking for a new job. It's not just your license on the line, but your patient's life and well-being. No one deserves to be treated badly, by intention or by default.

[caliotter3]

I have always told my employers that I am not open to working fill-in on a case unless it is a case that I have worked in the past. Lately, I have been doing it, but only because I have felt comfortable. Your agency should honor your wishes if they want to retain your services. You might want to explore your available employment options in case you can not obtain cooperation in this matter. You are not out of line in your preference here.

[kerussll]

Wow Janfrn,

It sounds like our agencies are very similar! I also work in an LPN home, only making LPN wages. The nearest RN home is an hour and a half from where I live so I only work there about once a month.

Update: They just called me again today and said they wanted to train me in a new house. I insisted I get at least one full shift of orientation and they agreed but acted really surprised and put out by that request. Then I find out the kid has a trach! I've never even worked with one before that wasn't put in a dummy. I can't believe they were going to give me an hour training and leave me to fend for myself! That poor kid!