Where Have All the Private Duty Nurses Gone?

I have a nurse friend who has an acquaintance who is terminally ill. The wife of the patient wants private-duty nurses around the clock for him in their home. The problem is that she can't find any nurses who want the job.

The wife called my friend figuring that, since she is a nurse, she’d know other nurses who would want the private duty job. The pay was $40 - 45 an hour, and the first nurses to respond to the job would have their pick of shifts.

My friend called several nurses and couldn't get one taker. Neither of us were sure why, so I did a little searching and a little surmising.

First of all, I think the term “private duty” has sort of been usurped by home care nurses.

There are a lot of nurses visiting patients at home and giving care there, although these nurses usually don’t stay for eight hours. So, while it’s not quite the same as private duty, home care is similar. Also, years ago when private duty was more prevalent, there were few ICUs, so if patients wanted that one-to-one ratio, they had to hire a private-duty nurse. Today, if patients need one-to-one, they are placed into intensive care, where the level of technology is high and demands the skills of full-time ICU nurses.

To tell the truth, I hadn’t thought about private duty as a job option for years. The position just seems to have dropped from my employment radar screen. The last time I actually spoke to a private duty nurse was on a trip to Turkey six years ago. In our group of 11, there was a wealthy New York socialite in her early 90s who had a private-duty nurse who accompanied her on trips all over the world. The socialite had early-to-mid-stage dementia, and her conservator had hired this private-duty nurse to accompany this wealthy woman her on worldwide, month-long trips, which she took four times a year.

Although private-duty nurses almost seem like a thing of the past, there still are opportunities for those who want to pursue this type of employment, says Janet Haggerty Davis, RN, C, president of Advanced Practice Associates, a health care information consulting firm. In a piece she wrote recently for a trade publication, Haggerty said: “What is today’s fastest growing job category? Home care services, according to the U.S. Department of Labor. Reasons for the increasing demand… include an expanding older population with ready, disposable income; the dramatic longevity of children with chronic and debilitating health conditions; and the continued shift of health care delivery to the home setting.”

Have you ever done private duty nursing? If so, what was your experience?

Have you ever considered doing private duty?

What do you consider the best and worst of private duty nursing?

Tell us what you think.

Is Good Care Unachievable?

Sometimes it takes a real crisis to jumpstart action.

That’s probably what happened recently at one hospital in San Diego. I only know what I know from reading the local newspapers, but here’s the story in a nutshell, according to those accounts:

The hospital—a large, respected teaching institution—is threatened with losing reimbursement from Medicare and Medi-Cal (California’s version of Medicaid) because of serious violations which investigators say caused at least one death. The violations included putting patients “on hold” for 24 hours in the emergency department without physician oversight; delaying filling prescriptions in a timely manner; failing to prioritize the need for stat medications; failing to follow doctors’ orders in a timely manner; violating confidentiality of records; and failing to meet California’s mandated nurse-to-patient ratio.

Phew. Scary.

In one instance, a patient arrived in the ED with a low serum sodium. She signed out AMA, then returned the next day in worse condition. Lab tests showed her sodium levels had dropped even more, but IV saline was not ordered for about four hours and didn’t arrive at her bedside for another chunk of time. More than eight hours after the patient’s lab work was completed, the IV saline finally arrived at her bedside. Then—and this part is a bit horrifying—the nurse who received the IV was told to go on break. She left the saline on the bedside table and while she was gone, the patient coded and died.

When I read this, I had questions.

Why was the nurse told to go on break? Why didn’t she recognize that this was a bad time to take a break? Did anyone on the unit understand how serious the patient’s condition was? Was there miscommunication about the lab values? Why was there so much time in between the blood draws and the execution of orders?

I’m sure investigators had these and a lot more questions. In the end, among other things, the state team judged that all patients in that hospital were in immediate danger because the pharmacy was too slow to fill stat orders.

Then the feds were called in. They also laid a lot of blame on the pharmacy, and added that nurses weren’t prioritizing med orders; all were labeled “stat.”

Looking at the list of above violations, I also wonder how many of the problems might be related to the hospital’s failure to meet the state’s mandated nurse-to-patient ratio. We know bad things happen when there aren’t enough nurses on a unit and I don’t know why this hospital hasn’t been able to comply with California’s mandated ratios. Is it too difficult to get the nurses? Are they skimping on expenses? Is the hospital’s budget adequate for hiring the required number of nurses?

And the final question I have: Is this a story we’re going to hear again and again?

Nursing care in acute-care hospitals has gotten so complicated, multifaceted and paper-laden that I wonder if we’ve finally reached the point where good care is unachievable.

What do you think?

Workspaces Designed Just for Nurses

You can’t have good patient care without a smoothly working nursing staff, and you can’t have a smoothly working nursing staff without good hospital design. But how many times have you heard or said this: “When they designed this place, it would’ve been nice if they’d asked the nurses.”

Well, one hospital did.

Sierra Providence East Medical Center in El Paso, Texas (110 beds), asked veteran nurses early on in the building process what they wanted and needed, and what would help make their nursing care most effective.

Hospital CEO Sally Hurt-Steffen had a couple of considerations right off the bat: productivity and nurses who are not getting any younger.

“One of my concerns in a 275,000-square-foot facility,” she told a nursing publication, “is how far the nurse is going to have to walk between the nursing station, the patient rooms, supply rooms and medication rooms."

The solution to a potential problem: Cluster equipment and supplies at the remote nursing stations.

Another potential problem was averted in the ICU.

The direction in which the beds were originally placed was wrong. The first blueprints called for a floor plan that had the foot of the beds closest to the observation windows, giving nurses great views of patients’ feet. At the advice of the nurses, the rooms were redesigned so patients’ heads were visible.

Other features nurses at the El Paso hospital will appreciate are larger-than-normal rooms that will accommodate equipment, result in a less claustrophobic effect and provide a measure of safety for nurses; and electric-eye nightlights that will contribute to safety and eliminate the need to turn on those glaring ceiling lights in the middle of the night.

Do you like your workplace?

What’s good and bad about it?

How would you change it and what design features would you like planners to include if you could design your workplace from scratch?

What does your dream workplace look like?

Tell us and we’ll share your fantasies.

My Computer's in the ICU

I’m dead in the water.

My computer has crashed and today my car is in the shop.

I’m writing this on my laptop which yes, I’m lucky to have, but all my files are on my PC. Now I’m staring at a hole in my cabinet where the tower used to be.

Four days ago, my operating system expired. I rushed it to Computer ICU – the garage of my great geek-boy - so he could perform his magic medicine and revive the poor ol’ thing. The first thing I needed to know was the status of my files.

“Are they still there?” I asked, fearing the answer. “Tell me I can sleep tonight.”

“You can sleep,” he said, and that was about it. He’s a geek of few words.

“What’s the prognosis?” I queried further.

“Good,” he said, ‘but it’ll take some time…”

“How long?” I asked.

He explained in few words that he was going to strip the old hard drive, excise it and install another operating system and all the programs onto the additional, younger drive that he had placed in the tower two years before.

“How long?’ I repeated.

“Um…Thursday,” he ventured.

Six days? I thought. Will I make it?

I had no choice.

Over the next three days, when I told people what had happened, they offered condolences and said they hoped that my computer recovered soon.

They shook their heads and shared stories of sickly computers, hard drives that crashed, viruses that played havoc with their systems or worse yet – destroyed the host.

So maybe my situation wasn’t so bad. I stopped feeling sorry for myself -- until yesterday. That's when the engine light on my dashboard lit up. My 12-year-old Toyota was running fine, but I knew the light meant that I had to take it to the car doctor for diagnosis.

The charge for walking through the door was $119 because the mechanic had to hook the car into a computer that would tell him what needed to be done. He called later to tell me something about valves and the exhaust and corroded battery cables. I was too afraid to ask how much it would cost because I’ll have to pay, regardless of the tab.

So without a car and a computer, what woud I do?

I had a bit of paperwork to complete, a couple of letters to write and some (paper) files to clean – and some time to reflect on life without my two biggest necessities.

I’m sure I’ll live, too, but it won’t be easy.

By the way, the tab for car was about $565. It was much less for the computer. God bless the geek.

Do you have any stories of being techno-deprived?

What did you and your workmates do when the computers system went down?

Are there times when you feel too dependent on technology?

Tell us – and we’ll commiserate together.

Heavy Turnover? An Admissions Nurse Might Be the Answer

Gone are the days when patients stayed in hospitals for two weeks or more.

I can remember when some stayed so long we considered them residents. And I’m sure veteran nurses can remember a time (must have been pre-Medicare) when elderly people were dropped off at hospitals because the relatives were leaving town or were tired of caring for them at home.

Yes, these patients needed an admitting diagnosis, so doctors usually manufactured one or chose one that was barely legitimate (possible pneumonia was a favorite). The most amazing thing of all? Insurance usually paid most of the costs.

Considering today’s hospital environment—DRGs, utilization review, corporate-type budgets and Medicare/Medicaid cuts—the stories about admissions and lengths of stay “back in the good ol’ days” seem truly outrageous and unbelievable. Today, it seems, the pendulum has swung the other way.

I recently read an article about the rapid turnover of hospital beds—more the rule than the exception these days. The “churn” rate on any acute-care unit can be between 25 percent and 70 percent, according to the American Organization of Nurse Executives. On a really crazy day, a nurse can see three patients occupy the same bed (sequentially, of course). That makes for a lot of extra time, paperwork and interruption.

The Rush-Copley Medical Center in Aurora, Illinois, has come up with what they think is a solution.

It’s called an admission nurse and it is his/her sole responsibility to admit patients. If you’re saying, “I want one of those!” you are not alone. After surveying their nurses, Rush-Copley found that many of the veterans were considering leaving their units because the pace of their work was unmanageable.

The new admission nurse not only relieves floor nurses of extra work, but probably does a more thorough job of taking the history and physical. This, in turn, means a more comprehensive care plan can be implemented and new patients and their families are bound to feel more confident about the care they are receive.

What do you think about the admission nurse idea?

Do you see any disadvantages?

Tell us what you think.

15 Minutes of Gain?

They just don’t get it.

“They” are researchers at Britain’s University of Leicester and University of Northumbria who wrote a review of five studies that looked at whether there were any benefits to seeing a patient in the office for more than the usual allotted 15 minutes.

All of the studies were conducted in the United Kingdom and all found that when given a few additional minutes to spend with patients, “doctors didn’t discuss more problems, prescribe more drugs, run more tests, make more referrals or do more examinations,” according to a story that appeared on the Web site of the Health Behavior News Service.

About the only thing doctors did with the few extra minutes, according to the studies, was to spend more time discussing how patients could take better control of their health.

Hello.

Isn’t this a terribly important addition to the office visit?

Isn’t talking to patients about how to better care for their health a really good thing? A necessary thing?

I was dismayed by the reviewers devaluation of such a vital part of the doctor-patient relationship which—and this is my speculation—probably doesn’t happen very often because mostly there just isn’t the time during a regular office visit.

Most medical offices book patients into 15-minute time slots. That might be adequate for seeing a 25-year-old with a sore throat, but it’s not nearly enough time for the elderly patient who brings a bag full of prescription drugs (and maybe some others), has mobility problems, diminished hearing and/or eyesight, and is living with several chronic illnesses.

When it comes to caring for these patients, it takes a village—or at least a team of health professionals who can meet all of the patients’ medical, psychological and social needs. And that can only happen if the primary care doctors at the helm have time to figure out just what those needs are.

Certainly it takes more than just 15 minutes.

California: The Nanny State?

I know the libertarians in California are freaking out about the recent legislation passed by the state’s lawmakers that will ban restaurants from cooking with artery-clogging fat as of January 2010. On that date, “most foods that require shortening, oils and margarines” will have to be trans-fat free.

Then, as of January 2011, trans fats will be forbidden in all baked goods produced in the state.

California is the first state to take this step; I feel it in my bones (and heart) that other states will follow suit. New York City gets credit as the first municipality to enact such a law. Their ban began July 1, and my guess is that no one has died or had an anxiety attack because they didn’t get their trans-fat fix.

Some whiners think they should be allowed to do whatever they want—even eat really bad stuff that will cause them to run up medical bills at the expense of the rest of us. But truth be told, I’ll bet the high-fat foods that use trans fats now aren’t going to taste a whole lot differently when they use other oils.

And these fatty foods certainly aren’t going to have any fewer calories. When it comes to calories, fat is fat is fat.

As nurses, we need to remind people about this—and here’s a little ammunition when your audience thinks you’re meddling or nagging. (I found the following in the August 2008 issue of the Harvard Women’s Health Watch.) According to research published in the May 8, 2006 issue of the Archives of Internal Medicine, there are five health problems that put people in nursing homes: obesity, diabetes, high blood pressure, inactivity and smoking.

Eating trans fats contributes to the first three, which lead to the fourth. I guess we can’t blame trans fats on smoking, although I’d like to.

The representatives of the restaurant industry are whining, too.

They complain that how they cook their food should be dictated by public demand, not legislators. But perhaps they forget that the legislature reflects public sentiment, and anyway, many restaurants have been phasing out trans fats because that’s what their customers want. Everybody from McDonald’s to Spago’s is changing the way they cook —because that’s what customers want.

California led the nation in making restaurants and bars smoke-free and ever-so-much-nicer, and in doing so, increased their customer base. Now the state is stepping to the head of the line to ban the use of trans fats. This is an excellent move—and one less thing we have to worry about when dining out.

Are there any moves afoot in your state to ban the use of trans fats?

Do you think it’s a good move to ban the use of trans fats in restaurants?

Do you think it’s the government’s responsibility to do this, or should individuals have a choice?

Tell us what you think.