When a contract hospital needs me to have more skills than I do....

[KalipsoRed21, BSN, RN]

So I started my second ER travel contract. For the last year I have worked as a travel nurse at one facility and I had to move on because I didn't want to pay taxes. I would say my skills as an ER nurse are moderate. Meaning I am ACLS, PALS, BLS certified. I have a lot of experience with cardiac drips and chest tubes as such due to my first nursing job. The job I learned to do ER had a 14 bed emergency department. I have assisted with intubation and arterial lines in the past, however, I feel that the hospital I learned to do these things at had very strict and safe policies which makes it a very difficult task for me to do at other facilities. Or is what this facility asking me to be able to do as a traveler to much?

I have worked on my own at my new assignment for 7 shifts, prior to that I got 3 days of training from the nurse who can't tell her head from her ass and everyone there knows it. The computer system is Meditech and I'm not very familiar with it yet so it takes me a while to chart. On my 4th night on my own they gave me a guy who had a pneumo, a lady with a K of 6 and a heart rate of 40, and a guy who's sats were 80% on room air. I did the chest tube with the MD, by then it had been about 90 minutes where I then found out my high K lady had calcium gluconate, and a ton other meds ordered. Of which a different MD was griping at me because "her K is high and if it keeps going up her heart will stop." In the back of my head I'm like 'no ****' but when the other doctor said we are putting in a chest tube now, I kind of had to drop everything and do that. So I get the K lady stuff done (I'm in there for like an hour) and finally look at my 3rd guy to find they have ordered all of the pneumonia meds 3 hours ago so I'm really late on those too. Everyone is super busy with sick people like mine and there is no one to ask questions because they are to busy. I struggle through it, cry all the way home, and call in sick for the next shift. (There were other things, that happened that day so just imagine that 3 patient scenario for every patient I got.)

Today I went in, held my own until I got a lady with pneumonia that they decided to intubate and stick an art line in. The doctor is not saying much of what he wants but kind of just expecting me to know, so is the staff. I've done intubations before but the meds came as a pre filled kit, and I have also assisted with art lines but the doctor set them up himself and got everything he wanted for those prior to starting. All I ever did was chart, monitor vitals, and pushed the fully marked meds when told....and my doctors always made sure to say the dose they wanted prior to me pushing it. Here it was like 'give the meds'. Well I'm a traveler I don't want to **** up, I don't know if everyone uses the same doses so I ask, they look at me like I'm a new grad. Then they are like, aren't you charting everything. Well #1 I'm not use to their charting and I didn't have a pen or paper when they started because there was no time out or anything and #2 at my previous job you were the bedside nurse or the charting nurse in such situations. You did not both do procedure AND chart. So I start feeling pretty agitated and call the charge RN and tell here I am not capable of doing this procedure. She tries to fight me. I don't fight back, I just say sure I'm probably not able to fill this contract if this is the expectation. They pull me off the floor and tell me they will settle this with my agency tomorrow.

I'm just feeling like, geez I just did a year long contract at a hospital twice this size and didn't have this issue. However, the last hospital didn't have crazy expectations. Like they had rules on what travelers could take and it made it WAY more reasonable for me to do my job. Furthermore, just how does one 'just know' what doses to give to intubate and for an arterial line. Or 'just know' which items a doctor will need/want for these procedures (They don't have kits, you have to find each piece of the kit.)

Needless to say I'm pretty depressed, feeling like I don't even know how to be a nurse, despite being one for 8 years. I don't think I can go back.

[NedRN]

No techs? Not sure what anyone could say here other than try to stick it out. The longer you survive, the stronger you will get. Hopefully you know what is needed now for intubation (no cart?) and a-line. A lot of facilities will make up bags of necessary components for an a-line for a quick one grab. Consider doing that for personal use. Meditech sucks, everyone knows that.

[Argo]

Probably why they have trouble filling their vacancies. ... they want people to know what they want and don't want to tell them what they want.

As far as sedation, I have done a lot of it through the years and if they didn't tell me what drugs they wanted, I'd use what I'm comfortable with at the dosing I know with the standard backup of rescue drugs ready. I can set up an art line on any monitor in very short order. Also very comfortable with meditech. Some people know certain skills better than others. They just want certain skills that they are used to having available but they need to be clear what they want. I agree with ned that you should stick it out, it will make you better overall.

[KalipsoRed21, BSN, RN]

Thank you both. Argo, I do not know how to set up an arterial line in a short order. At the hospital where I assisted in a few, I dressed them afterward and used them for medication administration, but they were helicoptered out or transferred almost immediately after the arterial line was placed. I have never hooked any arterial lines to a monitor. But anyway it turns out that apparently who ever decided to hire me at this hospital never took a good look at my skills inventory check list which states my experience and frequency at these sorts of procedures. Both of which said intermittent experience and less than 6 times a year as frequency. The hospital tried to say that I over stated my skills, but fortunately for me there was an obvious, written record that they printed off when they hired me of my skill set. Not to mention that I know I stated in the interview that the last hospital I did ER for wouldn't even let any of their travelers do sedations, not even conscious sedations. But I guess that boils do to he said she said. There are things that I can tough out, but learning complex high risk procedure on the fly is not one of them and is irresponsible for any nurse to do. I paid 50K for my stupid RN license. I'm not leaving it to the wolves until that ***** is paid off.

[NedRN]

I think I could inservice a novice on aline setup in 10 minutes. It is a trivial skill that is not generally an RN task (other than knowing where to place the transducer and how to zero on a monitor - also trivial), usually a tech will set it up. I'm surprised that you don't have sedation skills after 8 years in the ED. Not your fault, but it shows how different hospitals can be and new practice settings can be a reality shock. I had no clue myself after three years of staff if my skills would translate to other hospitals so I tried per diem for local agencies before I became a traveler.

Full disclosure: I'm not an ED nurse, but after 20 years of travel in the OR, I've spent a good bit of time in them and have some good friends who are ED travelers and I've spent a good bit of time discussing ED practices with them.

You are absolutely right that you shouldn't learn critical skills on the fly. Nor are most hospitals willing to train travelers. Treat this as a good learning experience and plan how you want to move forward. Personally, I would suggest taking a staff job at a trauma center for six months to a year if you want to continue to be a traveler. Shop for one with poor support staff and high expectations for nurses, something similar to this department you were just at. That will prepare you well for any travel assignment.

[Sun0408, ASN, RN]

OP what do you mean you've never hooked an A- line up to a monitor and only used it for medication administration?? The last part is what I'm really confused with.

[ms boogie, BSN, MSN]

Thank you both. Argo, I do not know how to set up an arterial line in a short order. At the hospital where I assisted in a few, I dressed them afterward and used them for medication administration, but they were helicoptered out or transferred almost immediately after the arterial line was placed. I have never hooked any arterial lines to a monitor. But anyway it turns out that apparently who ever decided to hire me at this hospital never took a good look at my skills inventory check list which states my experience and frequency at these sorts of procedures. Both of which said intermittent experience and less than 6 times a year as frequency. The hospital tried to say that I over stated my skills, but fortunately for me there was an obvious, written record that they printed off when they hired me of my skill set. Not to mention that I know I stated in the interview that the last hospital I did ER for wouldn't even let any of their travelers do sedations, not even conscious sedations. But I guess that boils do to he said she said. There are things that I can tough out, but learning complex high risk procedure on the fly is not one of them and is irresponsible for any nurse to do. I paid 50K for my stupid RN license. I'm not leaving it to the wolves until that ***** is paid off.

Arterial lines are never to be used for medication administration. That is not what they are for. It sounds like you need standard/further education on the purpose for these lines. You will cause harm to a patient if medications are pushed through an arterial line.

[Sun0408, ASN, RN]

That's what I was getting at too ms boogie. I was waiting for a clarification. I'm thinking the OP maybe confusing Aline's with central lines.

[Argo]

I hope you don't make a practice of giving meds through art lines. Central lines sure.

I agree with ned, you should definitely bump your skill level up and either work at a larger very busy level 2 or a level 1 trauma center ER before moving forward. Both arterial and central lines are basic critical care skills.

[LV3677]

Um, yes, I am very confused as to why you would infuse something through an arterial line, which is used for real time measurement of blood pressure, and is not indicated for medication administration. Are you sure you weren't speaking about central lines? That would make much more sense.

[bebbercorn]

OP, did you call your charge nurse for help, or was there a resource nurse? I would expect that someone would have to cover your other pts while you were with a sedation. I would be peeved if I expected a traveler to be able to handle an a-line, but if you made it known that you weren't comfortable doing it, they shouldn't have made you try. Maybe they understood that your intermittent experience included set-up, monitoring and use? I'm not sure how detailed your skills check list was.