And if you didn't catch that before:

Thanks, StrongOne for the embed....I'm passing it on, too.





(My first youtube post. Neat.)

You all WILL be voting, right?

To US citizens who might be trolling by....

Check this out, which was worth 75 minutes of my time. (Actually longer, since I did read the book, also worth my time).

here

And at very least, love of god, go vote.

On the upside, you get this warm fuzzy feeling that you did the right thing. Bonus, you get to guiltlessly complain about political decisions for the next four years.

If you don't vote and are over age 18 and a citizen, get the hell out of my country. Move to Zimbabwe, where they aren't inconvenienced by voting.

Specialty BLS

RehabNurse asked me a question: did the ICU help me get into my new niche, dialysis. The short answer is yes, I did.

The slightly longer answer is that in many ICUs, patients require dialysis just like anywhere in the hospital and because they are so critically ill, it must be slow (i.e. 24 hour) dialysis. It's called CVVHH or CRRT...continuous renal replacement therapy. Which means the ICU RNs run the machines all day/night until one of two things happen. (The dialysis nurses actually understand the machine, test it, maintain it, and handle all access between the machine and the patient.) (There are excellent reasons for this division of labor.)

Reasons for stopping slow dialysis are: the drug the patient ingested is gone, their kidneys woke up and they're now making/clearing urine or the patient's heart (read: blood pressure and HR) can tolerate a regular speed hemodialysis treatment. Then the dialysis RN comes in and does the specified hemo treatment at the ICU bedside.

I loved doing CRRT while I was in the unit. Some ICU nurses love the ICU because of the adrenaline. I loved it for the multiple organ system failure, the very sickest of the sick. When we're still doin everything possible, and one system after another fails, dialysis becomes inevitable as do pressors. My unit's resource nurses knew I loved the 1:1 CRRT patients, so I got them often. (Some ICU nurses hate doing CRRT.)

But anyway. RehabNurse's question, and doing my BLS renewal today got me thinking about nursing specialties. I got the dialysis version of BLS today, which is new to me.

I've gotten the rehab/SCI/TBI version of BLS, which is BLS plus How To Do Compressions On A Patient In a Halo and Love Of God, No Chin Tilt, Jaw Thrust Only!!!

The critical care version of BLS: Yawn. Just tube 'em.

The dialysis version included: Pump the blood back manually. Put their legs up, open the saline wide. If it's an air embolism, it's entirely your fault...left trendelenberg and pray. And if you shock 'em while they're dialyzing, you'll fry the machine.

What's your version of BLS?

Not loving....

....the call at 0615 this morning to ask where I am. "Er. I'm in my bed. Why?" Thought I'd clarified that schedule change a week and a half ago. Apparently not.

Miscommunication rampant in my new role. Not loving that.

*****************

Have to re-do BLS tomorrow (Sunday) because I can't find my current card (though I have the current ACLS card). (Why I did not put these two things together in my wallet? I don't know.)

Brushing up on Another One Bites the Dust...

Client.

Much to tell about dialysis and my new role, very excited. But with the little time I have today, I have to tell you about the first part of my morning.

I am no longer a "staff nurse." I work the bedside in a consultative role. I provide a service, namely dialysis, to patients who need it while they are staying in the hospital for whatever reason. And ESRD patients have a lot of reasons to be in the hospital. I have been on orientation (and still am) since early September mostly because we cover twelve area hospitals, and work alone. Each hospital is different; each system has its own rules and protocols. I don't use a timeclock. I get my to-dialyze list the night before and I go to whichever hospital needs me.

I have a LOT to tell you about why this is the coolest thing since cheese was invented.

A quick story:

This morning, I woke at 4 (which I hate, but will change). I drive 20 miles to a hospital across town to meet my preceptor. First on our to-do list is a young woman who is on periotoneal dialysis. We check our supply room and paperwork on the ICU first. We sneak quietly into her room a little before 6, and D is teaching me about the peritoneal dialysis machine. I know the physiology behind it, but I'm learning from him details about what concentrations of dialysate might be used for what conditions, what dietary restrictions PD patients have (and don't), and how the machine is set up. I'm learning about how the patient cares for herself at home, what she does, what she has to do to modify her life to do her own treatments.

The machine looks good, the treatment is complete. We take down the numbers we need and assess the output of the dialysate, talk about what it means, what I'm looking for.

The patient wakes. She's used to seeing dialysis RNs at this time of day. We introduce ourselves, ask about how her night was. We discuss her concerns about treatments, what she's discussed with the MDs, what her plan for her self-care is, how she's going to do this in conjunction with her ICU and floor nurses (who don't know how to use PD). We mask/glove/etc up, and disconnect her.

She has concerns about her dressing, and we do a sterile change for her. We discuss another of her comorbid conditions, ask how she's managing. After that, she has no other concerns, seems to be doing fine (telemetry and vitals all show stable). We bid her a good day.

We visit with the patient's ICU nurse, ask the nurse similar questions. We talk about what we did, and educate the nurse about the dressing, some basics on the machine, discuss the patient's plan of care today, her labs and meds. We're happy, the ICU nurse is happy, jots down some notes to pass on for the next shift. We borrow the chart and write a progress note, enter a charge into the computer then compile OUR paperwork.

Then we thank the nurse and head out the front door by 0730, on our way to a different hospital.

....

I. LOVE. That. Go in, assess the patient's needs, provide a helpful service or two and usually some teaching. We even help the nurses that are at the bedside of the patient, even sharing some new information to them when they're open to it. (And we nurses generally are curious about new things.) (Can I give this blood pressure med? Will this dialyze out? Does this dressing need to be done with sterile technique?) We didn't interact with the physicians until later today, but that's part of it, too. Chart, charge, bad-a-bing, out the door, on to the next consult visit.

I LOVE that.

Yup. Think I might love this job.

Good money as a nurse.

Listen up.

Kim from emergiblog pointed to an article here about why nurses don't stay in nursing. Go check it out first.

Kim asks us whether or not we've "bought in" to nursing. She loves nursing; I get that. She is committed to it; I get that. I respect these views. I love nursing, too. Her question is: have I "bought in?" It's a broad question, and I suspect she's asking Will I leave this profession in five years? I don't know, maybe. There's great stuff about it. There's very stupid stuff about it, too.

I got a lot of jest and harrassing when I left the ICU to dialysis. Snickers of: "Ah, she took the lure of the money." "I thought you wanted to be a *good* nurse." "Isn't that boring?" But a lot....A LOT of the jesting was rooted in cracks about the money. I want to speak to Kim's open-ended question and to the jesting about money I got.

Have I bought into antiquated ideas about self-sacrifice? No. Have I bought into the idea of more education for lower pay? No.

Personally, I find that entire system retarded. I'm sure Kim does, too. I'm going to offer one primitive solution to the problem, however. One bedside nurses who do not believe they hold any fiscal power can do to help themselves. But it can help you, and can help your fellow nurses, too.

My idea is: Talk frankly about money. Simple, huh? And yet, completely taboo in American society.

Here's the problem:

I work for a paycheck, period. I'm a buddhist, I don't get a saintly reward for my butt-wiping today. For all the times a physician tears into me for insisting on pain medication for a patient. I happen to like my work, but would I do it for free? Are you insane? It's HARD WORK.

You don't work because you're a good person. You work for a paycheck. You are in all likelihood a good person who works for a paycheck, but you don't work for the sheer joy of dragging your butt out of bed in the morning. Because you work hard, too. With body fluids. And people who call you four-letter-words. And do not have manners.

WHAT IS WRONG WITH NURSING THAT WE EVEN HAVE THIS MYTH THAT WE AREN'T WORKING FOR A LIVING? The myth is that we do it for fulfillment. Great. Why is fulfilling mutually exclusive to well-paid? Trouble is....If nobody can be blamed for that stupid idea, why do RNs not hold those cutting squeaky checks accountable for believing it?

Here's my rationale:

I learned many lessons in computer consulting. One of them was I learned to talk about my billable rate/salary. I think it's something many men, regardless of profession, do and understand. Talking about the salary. It's how, in computers, you know what the going rate is. How much do I charge for my services? Well that guy's makin this amount and he's out of school and knows nothing and nobody, and this guy's got ten years on me, so somewhere down the middle might be a start. Factor in such things as whether or not I've got competition, whether or not I'm trying to underbid or whether I expect my client to agressively haggle my price.

Talking about the money is expected in IT. No one functions without it. It's frequently handled with some subtlety....there's typically contract obligations about discussing your rate. But you can talk about the rate you got from your last client. And you can say whether, with this client, you're doing better or worse. You can mention whether or not there are perks.

Women often don't do this.

It's stupid of us.

Nurses don't usually do this (though I notice male nurses more often do). I don't get why. CNOs talk. Why shouldn't they? It is my belief that in my region, this network is a large part of the reason that salaries are so uniform across the region's hospital systems. They have information. So should you.

*********

I am under a contractual obligation to not tell you my new pay rate. So I won't.

So lemme tellya some facts about the hospital system I just came from. I live in Colorado, and my state pays BADLY across the board. Because it's so great to live here. Doesn't matter if you're a staff nurse, nurse practitioner, or traveler nurse. Travelling nurses often have the advantage that they can hop onto their company's website and compare payscales across the country. I love these guys, because they're happy to share this information with me. Ask a traveller not what s/he's makin, but what travellers expect to make in your city and in other cities s/he's been to. You should know.

New grads were offered $22/hr last year in the two biggest hospital systems in town. The nonprofit in this town (not surprisingly) pays a pittance better than the for-profit. At the nonprofit, there's a salary cap on experienced nurses at $38/hr. (Don't know the other's cap.) Raises are neither competitive nor performance-based. Expect 3% annually if you showed up most of the time, and there is no automatic cost-of-living.

In 2006, I started at a base of $20/hr. Who knows if this trend of roughly a buck a year better new grad offering will continue. Nurses already at the bedside who have experience do not keep up with a 3% flat increase. A new grad hiring in would have surpassed my base rate by next year, had the trend continued.

And don't think that didn't make me sore. New grads should make good money; I don't begrudge them a good starting rate. Experienced nurses should make more.

Want to know what payraise to expect when you're interviewing? Few interviewers or managers will tell you because they can't promise or it becomes contractual. Tell your interviewer you'd like to shadow a nurse on the unit you are shopping to work for. Then ask him or her. (Perhaps for a pay range if that's an easier question, or the typical annual percent for raises then you do the math.) If she prefers not to discuss her pay, ask another nurse you bump into in the med room.

This needs to be normal for us. We all win when it is.

Travelers can expect about three bucks an hour or so more than the poor slobs who work as staff. With no benefits. It's almost not worth it, unless you really are here to ski/board. Stiff competition to travel in Colorado in the winter months.

Expect a night shift differential of $5/hr, double what some places pay. Expect to be nickel and dimed where that night diff ends up being only 7.5 hours of a 12 hour shift or some crap. Ask the details. Expect $2.50/hr for weekends (and that seems common). Again, look for fine print on what 'a weekend' means. Often, how the business defines weekend is not what a normal person calls a weekend.

Same thing for holiday. Don't believe the allure of Double-Time For Holidays when you work night shift. It's typically half of what you think it is. Four hours on Christmas night and eight of Christmas Eve, so you'd have to work both to get your full double-time. Human resources only does these deeply-stupid sounding schemes to save money only because we don't hang them from the rafters by their ties for it.

Why don't we mention to them that we can? We know CPR and they don't. We won't let them hang until the point that their airways are r e a l l y compromised, right?

I am not aware of any hospital in town but (possibly) one who offers a diff based on your education (ADN v. BSN). I don't know how much it is, but they do have a structured clinical ladder that includes education and meeting-attending. Some hospitals pay tuition benefits, but ask how much and then compare to the cost of a credit hour. (You may find a gap.)

At least one managerial position in my system offered between $25 and $36/hr based on experience, requiring 24h pager. (I actually laughed, and no, my girlfriend of 25+ years experience including strong managerial background plus BSN and two credentials didn't take the job.) (Are they mad?)

I am not aware of sign-on bonuses currently offered in the biggest hospital systems in town. I suggest you ask about bonuses during your interview process because if you don't ask, it will never be offered. The worst that you can hear is 'no.' Because you know they want to hire you, so you have nothing to lose and potentially a lot to gain.

Rumormill has it, the best paid hospital nurses work for local government. Rumormill also has it that those nurses love their benefits. The local government's hospital website LISTS base offerings. It is the best paid hospital system, by average, in the region.

I know of no hospitals except possibly pediatrics in town that pays for specialties, such as critical care.

********************

I went to work for a private company that offered a salary based on my years as a nurse. I left my base AND my night differential behind and am still ahead.

Most surprisingly to me, my organization has clinical measurements for GOOD PATIENT OUTCOMES, and the employees at my hospital ARE PAID BONUSES WHEN PATIENTS DO WELL CLINICALLY. How cool is that?

Nurses at my new company are sometimes embarrassed about this when they talk about it in my orientation, feeling like we shouldn't be so happy about our bonuses.

Why

the

hell

not?

If our patients are clinically doing BETTER, and are FEELING BETTER, are able to lead fuller and healthier lives, that means we are DOING OUR JOBS WELL. How exactly is it wrong for us to get a bonus for a job fantastically done? Is the only thing motivating me money? Of course not. I'm a nurse for chrissakes. If I wanted money, I'd have gone to be a specialty surgeon. I want my patients to do better because I like them. But that my company pays me a bonus for doing a good job means that I am MUCH happier doing my good work for that company rather than some schmuck hospital Scrooge that's gonna nickel and dime my overtime on Christmas.

What could be better? Heck, yes, that makes me likely to stay working as a nurse five years from now. Not only that, but likely to work as a nurse working for this company. Essentially, if my patients get better, I make more money. But I make a good salary no matter what (because patients are patients, and my company appears to understand that concept, too.) What a thunderingly win-win wonderful idea.

***************

Why do I tell you all these things? Because it's the most normal thing in the world to want to do good work in your community, be a leader in your world and promote the health and well being of others. And also want good food on your table for your own family, gas in your tank, money to vacation, and some socked away to retire upon, much less all that you owe paid off.

So that's my big idea: Talk (mindfully) about your salary. And for god's sake, when you go shopping for your next job....remember that YOU are shopping, and get a good deal for yourself.

Don't simply buy in.

Be an educated consumer instead.

Retooling.

Long time, no post. I know. In the remote possibility that somebody out there is still paying attention, I'm going to explain my hiatus.

I left the ICU at MyHospital. I am now retooling to be an acute dialysis RN.

Much of the reason I couldn't blog was because first of all, I was negotiating a new job. Other reasons I couldn't blog:

Lots of hospitals have ICUs, and calling MyHospital MyHospital and changing a handful of details about patients was easy enough to be HIPAA compliant and protect everybody's privacy. There are a lot of ESRD patients on dialysis....but few dialysis companies. And I need to rethink and be more cautious in my tale-telling than I had been before. I'm really very excited about the new digs, though, and I can't wait to tell stories. I just need to probably change many more details than I had to protect everybody, and there's likely stuff I can't talk about at all.

Also, as I was leaving MyHospital, several large nails were pummeled into the coffin that contained my decision to leave there. Two reasons had me spitting bullets angry. One was a patient story wherein I feel that a physician should have been shot. Not because of any malpractice or negligence on his part, but because he'd flunked Compassion 101 in med school. It's a story every ICU nurse out there can tell about a patient 100 times over. At MyHospital, working with this physician and his group is regarded as an honor....a crowning moment in your nursing career...when you can be A Heart Nurse. But after this patient, I don't want to work with that man.

And finally, there were some management problems that I may be able to talk about now with fewer expletives. I've skirted around that issue in this blog before, and have finally had to drop off discussing it. I had a direct conflict with upper management over a patient safety issue. There isn't a nurse out there who's going to think cutting staff AFTER a sentinel event and subsequent Visit From The State is a good idea. Sane people do not think this way. MyHospital does. I had taken care of the patient, and I sent an angry (though expletive-less) email over some people's heads. I was hauled into the principal's office over "my way of communicating." I was told I offended people by suggesting that "anybody had forgotten the patient's name". (Which I dropped repeatedly in the email, lest they forget that a woman died and she has a name and it is Insert-Name-Here.

See? Me and my rude communicating. So I've got a lot to get caught up on. Been a busy two months.

So I'll be checkin back in more often.