So when did nursing get to be a job where 90% of what you do everyday consists of filling out 20 different forms documenting the care you are supposed to provide? Of course that is if you have time after all that writing. Why is it that nursing is not nursing anymore? Why can’t we CARE for patients instead of just checking off checkboxes that say what we would do if we had time to get into our patients’ rooms? I understand documenting to a certain extent….but is it really necessary for us to say three different ways on three different sheets that yes  we did in fact brush our patients’ teeth that day? And why do we have to justify why and how we gave pain medication on numerous forms? As a nurse are we not capable of assessing a patient and determining what needs to be done? Why is the medication record not enough anymore?

There are so many more important skills a nurse has that could be put to use rather than spending most of the their day writing on useless papers that are put to them by people in offices far removed from patient care. These people do not understand what nursing consists of. I feel like a kindergartner sometimes as I make sure to fill in every box on my flowsheet…..leave one undone and you just might find yourself in timeout…

Anyway, just a few thoughts on the new direction of healthcare…where nurses work from the desk and only care for patients once all i’s have been dotted and every last t crossed! Then if your patient wishes to have a massive MI or bleed out from a ruptured ulcer….well you can see if you have time to provide nursing care.

Ok, you are catching me in a bad mood today! All of this healthcare reform talk has got my feathers puffed up like a crazy rooster about to attack (except for the fact that roosters are male and I’m not but, you get the point). All I keep hearing over and over is how nobody can afford insurance and how the government is going to cut costs out of Medicare and make healthcare affordable for all.

What I don’t get is why in the pre-natal Medicaid clinic in the hospital, at least 60% or more of the patients I see have their nails done, pedicures and carry Iphones or Blackberrys. What happened to the good ol’ pay as you go phone, they don’t require you to carry a media package that costs $115.00 a month. Let’s not forget the expensive purses and jewelry that is usually sported and the kids that are dressed like they stepped off the cover of a Dillards magazine.

What about the emergency room loaded with patients that have NO insurance yet, fit the same profile as far as accessories. They don’t want to pay $90 to see a Dr. for an ear infection that they have had over a week and decide it is an emergency, so they are seen, sent a bill for about $1,000.00 and never pay it. What about the patients that do have Medicaid yet come to the emergency room for every little cough, bump or scratch. Some prefer to ride the ambulance because they think it will get them seen faster for their sprained ankle. Good tax dollars at work there!

It infuriates me to no avail that my tax dollars are spent in this way! NO ONE in this country is denied medical treatment if they do not have insurance in an emergency room. If you have been in a car wreck and need surgery yet, you are uninsured; you are still given the same stat treatment. You get your surgery, you are still taken care of in the intensive care unit, given whatever medications, equipment and therapy you may need.

I fully admit there are those that truly need Medicaid; I have a family member that is one of them. It’s the abuse of the system that drives me insane. One day, just out of curiosity, I had a well dressed pt. come in with her medicaid card. I just happened to step out back as she was leaving…. in her brand new 7series BMW.

Why do people expect physicians to work for free? Do people not understand that they have to pay for their office, their nurses, their staff? What about the $350,000.00 loans they are trying to pay back from going to school an extra 12 years. We have the best physicians in the world in this country yet the government keeps cutting reimbursement.

If you owned a restaurant and the meal I (the government insured) ordered costs you 15 dollars to make but, the max I pay you is 12 dollars…uh I’m no mathematician but I think that would constitute a FAIL! So in effort to make up for the 3 dollar loss every time you fed a patient like me, you have to charge the (private insurance company) 22 dollars to make up the difference. So in effort to cover their overhead and rack up their profits they up the insured’s diners rates.

It’s all a mess, the fraud, the abuse, it’s sickening. The private industry is a wreck, they keep hiking rates because of this cycle. It’s crazy the profit they turn! It to makes me want to vomit. Bring in good ol capitalism, what this country was founded on! Let them truly compete against one another to bring down costs. Instead they have created monopolies that dictate what the physicians can do and how they can treat their patients because they literally own the states. Healthcare reform is a must but, socializing medicine will put us in the same boat as so many others. I heard a patient bitching the other day in the waiting room because they had to wait two hours to see the Dr. , I was thinking to myself, just wait to see if Obamacare passes, you will be waiting two and a half weeks.

I’m by no means a Harvard grad or carry a masters of any sort but, I do have common sense, a huge heart and love my country. If someone is hungry I will feed them, if someone is thirsty I will give them a drink. The American population as a whole is full of wonderful, charitable human beings. Look out how we donated to Haiti. I’m not talking about the government but, the personal donations of millions of caring, selfless, loving Americans.

I am going to stop this rant now because I could go on for HOURS! Just had to get that little bit off my chest, my feathers seem to have de-poofed a bit. Guess we will just have to see what happens.

This post is more of a question to you, the readers, than it is a definitive statement.  My question is this: what is a nurse to do when there’s a conflict between her clinical suspicion and a doctor’s orders?

I vividly remember an incident that occurred on a surgical floor when I first started in practice.  A nurse I’d gotten to know (over shared cups of coffee while charting) was clearly distressed about something.  When I asked her what was wrong, she reluctantly relayed the following situation:

A patient had been admitted to the floor to a surgeon with a diagnosis of abdominal pain.  The work-up was still in progress and a GI consult had been obtained.  After two or three days, there was still no diagnosis, but the patient still complained of increasing pain.  It was Saturday in the early afternoon, the surgeon’s partner, who was covering for the weekend, had already rounded.  The patient was getting increasingly demanding for pain relief, so the nurse called the covering surgeon to tell him that she was concerned about the increasing pain and her feeling that the patient’s abdomen was more tender than it had been the day before.

The surgeon stated that the patient had “nothing wrong with them” and that they were just drug seeking, then declined further therapy.  The nurse called back a few hours later, again with a petition for more pain meds given the patient’s increasing complaints of pain.  The surgeon got angry and belligerent, again refusing more medications, again stating that there was nothing wrong with the patient.  The nurse disagreed, and so called the GI doctor to pass along her concerns and her dilemma with the surgeon’s refusal to address the patient’s symptoms.

The GI doctor assessed the patient, but felt that there was nothing he could do other than give more analgesics, which he did.  The next day the surgeon was absolutely livid- screamed at the nurse, screamed at the floor nursing director- stating that it was absolutely inappropriate for the nurse to have “gone behind his back” to call the GI doctor when the surgeon covering for the admitting doctor had already declared the patient “fine”.  He asked that the nurse be written up and a note placed in her personnel file.

On Monday, the patient ended up going for a diagnostic laparoscopy by the original surgeon when he returned to work.  I forget what was wrong with the patient, it was not life threatening, but there was some minor pathology found which accounted for the pain.

So back to my question: what is a nurse to do?  Yes, you can document your doubts and suspicions to cover yourself, you can state the doctors’ response to your queries, but what can you do if a doctor shuts you down and doesn’t address your concerns?  Are there usually policies or protocols to follow to allow for bypassing the doctor or at least getting a second opinion?  How does a nurse protect her patient in a situation when there is a perceived threat to their well being through indifference?

It seems like having a pre-ordained structure to address differences of opinion would relieve exactly the kind of antagonism, anger and suspicion that caused this observant professional to be disciplined just for trying to protect her patient.

Most of us have been in the situation where things happen beyond our control. Well….when a patient gets the bright idea to rip out some tube or line or other very important and most often not easily reinserted piece of medical equipment….who gets the blame most often? NURSES. Now, I really do not find this to be fair. While we are the ones that are responsible for those that we care for, we cannot be at the patient’s bedside at all times. We have meds to gather, physicians to round with, charting to do, and yes every now and then we have to use the restroom or eat. Though I can say that there have been days I have not entered the bathroom door at work and I was lucky to shove in a bite or two of whatever happened to be lying on the break room table for lunch. Most of us have more than one patient as well which makes it impossible to watch each one at all times.

Anyway I say all of this because we as nurses get blamed for crazy patients pulling out their chest tubes, central lines, endotracheal tubes, and yes even ventriculostomy drains….NO nurse wants to make that call to the neurosurgeon and tell him such news. I have seen nurses in tears over this. I realize that taking a patient back to the OR on a Sunday afternoon is not fun, but it truly isn’t always OUR fault that these things happen. Most often it is that the patient is not sedated enough (per your orders), has Houdini powers and managed to wiggle out of restraints, or had been perfectly with it until they started seeing the bugs on the ceiling and decided to rip out that chest tube to use as a weapon….It really wasn’t my fault….I’m just sayin…

(This is guest post by Sandra Stevens, a Career Blogger. For more information on Certified nursing assistant Training you can visit her blog over at http://cnatraininghelp.com)

Have you been thinking about a career as a nurse?  Are you looking into nursing schools for your new career or to attend upon graduating from high school?  If so, you might want to consider training to become and working as a certified nursing assistant first.  You might even have noticed that some nursing schools require applicants to have the CNA Certification.

A CNA certification does not take long to obtain.  In fact, you can find many courses that only run for 3 to 6 weeks.  During that time you will have classroom instruction, demonstrations and clinical lessons.  You will learn to perform a variety of nursing assistant skills.  The duties of a CNA depend on the setting in which they work.

Nursing assistants often help to teach patients range of motion exercises.  A nursing assistant will take and record vital signs.  A CNA will help patients with their activities of daily living.  Nursing assistants are often asked to help bathe and groom patients.  A nursing aide can help patients to use the toilet or to change patients who are unable to use the restroom on their own.

If you decide that you want to or need CNA Training, you will want to find a nursing assistant training course that is fully accredited to provide you with the credentials you need to take the examination for certification.  You must attend your classes and make good grades on your exams to prepare for the certification exam.

When it comes time to take the certification exam, you will need to answer a series of multiple choice questions.  After that portion of the test, you will need to demonstrate nursing assistant skills to the person administering the examination.  Once you pass the exam, you will be eligible for your certification.

Consider working as a CNA for a few months before applying to enter into a nursing school.  This will give you time to work as part of the nursing team.  You will learn to provide kind and compassionate care for patients.  The time you work as a CNA will prepare you to move on to a career in nursing with more responsibilities and challenges.

Working as a CNA, will give you time to practice your bedside manner.  You will learn a great deal about how to work with patients who are scared and sick.  Of course, you will also learn how to work with and interact with other members of the healthcare team.  This will benefit you when the time comes to do your clinical rounds when you do attend nursing school.

It will be easier for you to gain acceptance to a nursing school if you have your nursing assistant certification.  In fact, you will find some schools for which this will be a requirement.  You will even find that some of your coursework in nursing school as a result of what you already learned during your training and work as a certified nursing assistant.

Are nursing unions really necessary? I am trying to look at this from all angles of medicine. The first point of view I am going to take is that of being a patient. I have been very fortunate in my times as a patient to be surrounded by amazing, educated and capable nurses. A good nurse is worth their weight in gold. Nurses are not only the number one patient advocates but, they are the eyes and ears of the physicians. Most of the nurses I have come across in the past 11 years are great but, there are those few that made me wonder how they kept their license but, they did lose their jobs. So, as a patient, does a union make it harder for hospitals/clinics/etc. to fire bad nurses? The reason I ask this is because I was married to a union guy. I have a ton of friends that are union members but, none of them medical. I hear them make fun of the companies they work for saying, “they can’t fire me, I’m union” that has always made my skin crawl! What the hell did they mean by that? The way I was raised if you were not productive, then you simply, got fired. Why would a company continue to pay a lack-luster employee? So as I was reading about the new national nurses union which empowers 154,000 nurses, are the risks the same for not being able to get rid of bad nurses?

Ok, angle number two is going to be that of a nurse. Let me just start by saying that, there are non-unionized nurses where I practice. The number one complaint I hear from my friends that work on the floor is the staffing ratio. Too many patients for too little nurses, this does nothing good for anyone involved. The nurse is overworked and is more prone to make an error. The patient is put at an increased risk from overworked staff; you sure don’t have to be a medical professional to know a small medical error may lead to a huge problem for the patient, sometimes death. A medical error by a nurse means trouble for the hospitals. After all, it’s the hospital that hired the nurse. The attending physicians are drug into this mess as well; after all it was their patient. So in my little simple mind correct me if I’m wrong here but, wouldn’t it just make more sense for a hospital to provide ample staff to ensure the safety of their patients? Would this not lead to an improvement for all? Fewer errors, less lawsuits, lower malpractice coverage and nurses that are doing what they were trained to do, take full care of their patients! Wouldn’t it make sense that if a nurse was caught using drugs that they stole from the hospital they would lose their license? Simple, if you are a dumbass and can’t do your job, or maybe you are late all the time putting immense stress on the staff covering your duties you uh…GET FIRED?

Third angle, MONEY! That being said, nurses from this area make approx 3 times more a year if they work agency to cover strikes. I know many nurses that went agency to work the strikes in California, they banked. But agency nurses that fill in during strikes would not make 3 times the money if, well, there were… no strikes. I know agency nurses that work in specialty areas that make more than the full time hospital employees, usually 1 ½ times-2 times more. Let’s take the operating room for example; it takes a minimum of six months to train a nurse, to cover operating room call. So if a hospital is short handed, it makes more sense for them to pay more to a nurse that is already trained to make up for the shortage until the position can be filled or, a full time staff nurse can be trained to fill that specialized spot. So how much more do unionized nurses make versus non-unionized nurses? I have no idea, I know no union nurses.Well, this could ramble on forever and I don’t have an attention span that long. I was just wondering what ya’ll thought. Are nursing unions really necessary?

In October, at the Blogworld Expo I had the privilege of hearing “Nurse Ratched” who blogs at her site Nurse Ratched’s Place speak on a panel. The most fascinating thing she discussed (at least to me) was a phenomenon she noted of nurses always undercutting other nurses. She had written a blog post about it entitled “nurses eat their young” and she felt it was the most pressing issue facing the nursing community today.

Her main focus was the ever-increasing pressure to further your nursing degree. She remarked that when she started out, a two year plan after high-school earned you a white starched cap and the ability to care for sick patients on hospital wards. You were a “nurse”, you had a uniform and everybody understood your position in the hospital But then came the split between “real nurses” aka RNs and licensed nurses aka LVN/LPN. Then the pressure for a bachelor’s degree. Then a masters and finally now, a movement towards a doctorate in nursing science – a doctor of nursing!

As an “old school” nurse her concern was focused on how inadequate she and her fellows (with many decades experience!) were being made to feel by the insistence that their education was insufficient. I can’t help but agree and wonder whence comes all this spiraling degree obsession. Because I’ll let you in on a little secret: I feel like it kind of demeans the value of my education, too.

Currently there are masters of nursing programs across the U.S. that prepare people with basic nursing training to perform advanced skills – anesthesia (CRNA), baby delivering (nurse midwifery) and primary care (nurse practitioner). And I can certainly understand maybe three levels of differentiation such as LVN (for floor or office nurses perhaps), RN (for more critical levels of care such as ICU or ER) and masters for people who will be assuming a primary role in the therapeutic care of patients without constant/immediate supervision. This progression would allow the choice of length of time spent in school, the amount of responsibility a person is willing to assume and degree of specialization.

But a doctor of nursing? What would that really mean? What extra clinical skills would be taught that are not currently encompassed by the masters programs? There is no evidence in the litterature that the current masters programs are inadequate, so why the push for another level?

Since a lot of nursing masters programs consist of a lot of online training and non-standardized clinicals in non-academic settings, I also wonder if this really meets the advanced qualifications of a doctorate. There are NO doctor of medicine programs that can be completed online, no clinical training that can be done outside of an academic program and there’s always the little matter of clinical training after school – residency. Four years of full-time school (there aren’t any part-time med schools, either) then 3 to 10 years of additional full-time (80+ hours/week) training afterwards to earn the title of “doctor.” I’m sorry but 2-3 classes per semester, taken online over the course of several years should not imply the same depth and breadth of training implied by a doctorate.

But what about nursing research you might say. Well what about it? What is specific to advanced nurse-performed research that is not covered by a more traditional doctorate. You want to do bench research? Get a PhD in molecular biology. Want to do epidemiology or population studies? Then get advanced degrees in statistics or anthropology or genetics or whatever other specific thing is of interest. If you want to be a DON, go get a business administration degree.

But I think it demeans the training of and care by the LVNs on the floor of a hospital to say that you need to have almost a decade of training to take care of patients.  Is there really a problem with the nurse structure in healthcare or do we need to re-vamp the entire system?

1)  I could go to work in my pajamas because the hospital provides the scrubs, so I got to change when I got there. I could take a cute outfit to put on after work for any about town errands or about town bar hopping afterwards.

2)  I did not have to fix my hair because I would be wearing a surgical hat. A ponytail knot and I was out the door. There was an ample supply of hair essentials in my locker such as: hair dryer, curling iron, hairspray etc.

3)  I did not have to put on make up, my patients only saw my eyeballs. I would usually put on mascara but there was no reason to put on my full face only to be in a mask all day. Now, if I woke up a little earlier I would put my face on as not to scare my co-workers but, as far as my patients went, they didn’t see my face.

4)  I didn’t have to buy scrubs. The hospital requires that surgical scrubs be processed in a certain way, therefore they provided them and we put on a new pair each morning. If we had a patient that had any type of infection, the scrubs were changed in-between cases. Tell me that does not save some major cash!

5)  A guarantee in the operating room is a fast paced atmosphere and almost always an adrenaline rush. Even if the surgical case was an elective, scheduled case, trying to turn the room for the next case in a quick manner is a must. If you are slow at turnaround, not only does your boss yell at you, your surgeon will not make your life easy. If you bust your butt then not only do your supervisors notice but surgeons will start requesting you personally.

6)  You make some awesome friends because, the operating room is it’s own universe. We may bicker amongst ourselves but let an outsider try and jack with one of us and we would stick together. There are no float nurses in this field because it is such a specialty. The benefit of that is you are with the same herd most of the time. It’s like a family, a dysfunctional family per say but, still a family.

7)  A guarantee you would do something different, every day. You never know what traumas will roll in. You never know what surgeon is going to throw a fit and you never know what new drama has arisen since last shift. The operating room is notorious for some good drama, hehee.

 The operating room is a fun place to be, I think it’s a pre-requisite that you be a little off your rocker to work in this environment, I obviously fit in just fine. One thing you better have is, a skin made of steel because; you will be yelled at on numerous occasions by different surgeons (most of them apologize after their sphincters relax). I always enjoyed yelling back, there’s just something that makes you feel good about standing your ground. Actually, we didn’t yell at each other all that much, only days that end in Y. Then we would go drink a beer an laugh (if we were not on call of course).

I do not know if this is a practice in most hospitals, but where I work it is. Some patients are considered “very important people” when they come in to the hospital and this allows them to pretty much do as they please. There really are no rules for these patients or their families. You might say…but that is unfair…everyone should be treated the same…what makes them more important than grandma? Well, apparently money and influence go a long way. I personally do not agree with this practice. Administration rarely show face in the units….but when VIPs are present…look out cause they will be in your room all day. They are catered to and given special privileges when it is others that could use the help more. I noticed one of the administrative team took a VIP patient’s husband to lunch one day…and I was thinking… but that other young girl down the hall has been eating off extra trays because she doesn’t have any money to buy food. And I am not blaming these patients for receiving this treatment, most of the time it has nothing to do with them asking for it.

I know hospitals need money to run and these people have money and influence and are possibly contributors to the cause…but still it just isn’t right to treat one patient one way and another a different way just because of an income difference.

When I read Rachael’s new post on how to be a better scrub nurse, it got me thinking about how many cases we have done together and she left out something I thought was very important. What did she forget to mention? A great scrub nurse will learn as much as they can from their surgeon. Most of the surgeons I worked with were amazing teachers. I wanted to know why they were using a vicryl tie rather than a silk. Why did they choose the sh needle? Why the 6-0 prolene on a bv-1? I always asked a ton of questions, I studied my instruments and, I did my best to learn my surgeons technique. One thing that would always crack me up is when the surgeon would say “I do this the same way every time”. When you scrub for multiple surgeons who each have their “own way” of doing the same procedure, sometimes your ESP doesn’t always work but, if you read their preference cards you might save yourself an ass-chewing.

Another tip for being a good scrub, learn your surgeons personality, this doesn’t take long. If they don’t like to talk…then shut up. If they like classical music and you don’t then…shut up. If they have been on call for three days straight…then shut up. It’s the surgeons room, not yours, just go with the flow. Your reason for being there is to take care of your patient. My surgeon should be able to focus all of their attention on the patient, they should not have to stop to ask for things that they obviously need. Not a hard concept. If blood is going all over the place, get more laps. If the bovie falls onto the floor, get another bovie. Well, you get the point.

As nurses, whatever specialty we are practicing in: operating room, emergency room, obstetrics, home health, office etc. if we take a little extra time, to learn a little more (and not just those mandated c.e.u. hours), it ensures we are bettering ourselves as caretakers.