Monday, November 17, 2008

Another Home Nursing Vent - Sorry

Saturday night our scheduled nurse called off from the shift. So Katharine and I have taken shifts staying awake, but not quite so alert with Elias. This is really the first night we have had to deal with such a problem, but instead of being thankful for this I am actually very irritated. I am always one that looks at the bigger picture and all the potential scenarios before really coming to judgement on anything. I am very patient and as a colleague described me once, "I am the sleeping bear you do not want to wake. All cute warm and fuzzy when asleep, but vicious when awakened." When a bear is sleeping if you poke it lightly, he will simply stir and return to his slumber. Naturally, if you continue to poke the bear the poking becomes stronger as you get more daring. Eventually, you will wake that bear which will be very angry and you my friend are in a world of furry. I am that awakened sleeping bear right now. The reason I am so very frustrated and borderline irate is last night when I spoke to the weekend on call supervisor, my request was if they could not get someone to cover the shift tonight, can we get someone for anytime during the day to make up those hours. That was at 6:30 PM Saturday. She informed me that she would contact me if she had something lined up. We have not heard anything, which means no one is available. Why this is such a problem for me is that we have eight nurses assigned to this case right now, but I still have two nights a week uncovered and I can not get anyone of these nurses to cover make up hours even for a daytime shift? This is a real problem, there is no flexibility or accountability. The agency simply does not get paid, that is what they lose. There is no one to advocate for us, we have to do it ourselves. The state could care less and actually they probably applaud and condone this activity, and why not, less money they have to spend! So who is protecting my rights? The government has made me dependant on them, but have no measures in place to protect my interest, only their pocketbook. Oh sure, we can change agencies, but is the grass really greener on the other side? It seems as though we will encounter these same issues no matter what agency we are with. Our current one is already trying to sub-contract out to another agency and still no leads after 2 weeks. That signals a clue in my mind this is a global problem and that it is better the devil you know. Everyone keeps telling us to be patient, things will work out, it is always like this in the beginning, and on and on. It has been 4 weeks and 4 days since Elias came home. We started working with the agency 2 weeks before that. How long is the beginning? I would think after this amount of time we should be settling in to a routine. At what point does enough become enough? We lost 17 hours this week due to "shift covering" for other nurses and the days we do not have a nurse. Many times the nurse covering could not work the full 10 hours, so we just have to make do? It would be different if it were a one time thing or happened once in a week, but these hours add up. 17 hours is over a day and a half's worth of time allotment. To top all of this off, as if I haven't complained enough, after our meeting Wednesday with the nurse supervisor and our discussion about lack of leads we had two nurses come out for orientations in response. However, I felt like I was being placated by sending them out in such a short response time after I met with them. You see the first one was only for back-up use, which I understood from the onset. The second nurse though was to be for our Tuesday & Thursday opening. She very candidly explained at the very beginning of our time that she had told the nursing agency she would not be able to commit to those specific days due to her other job. So essentially, she would become another back-up nurse. I appreciated her candor and it is a misfortune that she is not available full time for the case. Then again, that would be as luck would have this. I know that my conversation with the agency will not have the same pleasant, patient, and understanding tone they have become accustom too. All I am asking is that they communicate honestly their intentions, problems, concerns, & action plan for our case. Here is a letter I am drafting explaining our thoughts to send to the agency:

Since I had not heard anything from anyone, I suppose that there was not a nurse available to cover Elias’ make-up hours from Saturday. I find this very disturbing and disappointing considering there are 8 nurses assigned to his case, 3 of which are strictly for back-up, and absolutely none of them can even do some day shift work? This is now the 4th day this week we have lost hours without makeup because no one is available, totaling 17 hours. That is more than a day and a half’s worth of allotted time. We have tried to be very patient and understanding through this process, but frankly this has to be resolved and quickly. This is becoming a very frustrating process that everyone keeps reminding us how difficult it is in the beginning. We have been working for 6 weeks now, a little over four of which Elias has been home. Our Supervisor explained to me the issue about Elias being the youngest client and finding nurses with the skill sets and comfort level, but also told the agency would not accept the case unless you thought you could staff it. We have only turned down three nurses completely and for solid reasons, some serious in our opinion. We understand that after those incidents and we placed restrictions on nursing based on that apparently caused some “staffing issues.” However, we loosened those restrictions as of Monday November 10th and still have only seen two nurses for orientations, neither of which it seems would be permanently assigned to the case, only serve as fill-in and back up. Therefore, we will start the week yet again 48 hours away from an unfilled shift that we will scramble to fill for the day, and then repeat the process again in another 48 hours. As for the weekend, well, Saturdays we have actually had our scheduled nurse only 1 of 4 Saturday shifts. I can see a pattern emerging that is not positive. According to your agencies, own employment policies per cancellations (see part d) “If cancellations are frequent or inappropriate, termination of employment may be necessary.” And under employment termination policies part I repeated cancellations and/or lateness. I am not suggestion termination, but it demonstrates that the policies do not seem upheld fully. The issue is I can no longer be confident that my assigned nurse will show once a pattern of unreliability arises. Couple this with the fact I cannot seem to get these hours made up when missed the next day makes it more of an issue to myself. While I will give your agency kudos for this being the first night we have had to go without a nurse, it is the fact that most of the “fill-in” time is not the allotted number of hours. Since we lost a day and a half this week, we feel as though the nurses in your employment have demonstrated an issue of reliability and accountability, which reflects on your agency from the client. Based on the way things were explained to me in the beginning, 2-3 nurses is what you try to staff per case. We have almost tripled that number, yet we have issues staffing and covering? I realize this is a challenging case and outside the box in some ways, however, your agency repeatedly and openly prides itself on “providing quality nursing care while providing the family unit the skills and support necessary to adjust to the daily living demands.” In order to full-fill this mission statement you must ensure you are hiring quality nurses that are as dedicated to that sentence as the agency was when writing it. While I appreciate the need of the nurses to hold other positions outside the agency, working for you is a choice and a privilege. If they are not on board with your mission completely or are over committed, that will cause you to fall short every time. There has to be an understanding of commitment, reliability, and accountability in terms to covering cases. I am certain that many of your clients, such as me, only have home health care because they are required to have it in place for the patient to be home. However, it should not be a luxury to have shifts covered or have them made up, regardless of the shortage. If you do not have the ability to staff, you keep saying you do not take the case. If this were true, then why do we not have enough nurses to fill our allotted time and back up for them? Personally, if you assign a nurse to back up a case and they accept the position you must uphold a policy as if they were scheduled to be there. You should not assign a nurse for this duty on a case if they are committed elsewhere. Moreover, if a back up repeatedly become unavailable when the need arises, that would be grounds for removal from the assignment. To serve as a fill in or back up on a case should be a privilege to earn extra time obviously resulting in extra income because of positive performance and ability. Maybe this privilege, rather than necessity, would motivate your nursing representatives more positively and reflect your commitment to the client. I am aware that I do not understand the ins and outs of your business challenges and day-to-day workings. This is still a business with a cliental that you need to please and satisfy. You have to work on reducing the exposure of breakdowns and faults. When you go to the store for shopping, it does not matter why the line is long you simply want it fixed. It is the businesses responsibility to the customer to improve the way it functions based on the conditions of the environment.

My apologies for crying so long over spilled milk. There is certainly nothing more we can do but grin and bear this. It does help to vent the frustration though.  I did have a very long discussion yesterday with the on call supervisor and she enlightened me on a few things. I am certain today's conversation will be another lengthy debate. I have a feeling I will be learning about the dark side of Home Health Care and it having a lack of oversight. We will continue to update our progress on this frustrating battle. To be honest I'm not sure which has been more frustrating. The G-tube or the Home Nursing!

Finally, today we have three doctor appointments; Pulmonology, Cardiology, & G.I. Hopefully there will be no surprises and only positive changes to Elias regiment. We will bring you an update on how things went as soon as we can!


  1. Whew! I feel for you guys. We have never had home nursing drama like that. Our somehow almost always miracuosly show up. Turns out we are the undependable ones! I would love to be a fly on the wall during those conversations with the supervisor- I'm sure you'll do well. BTW- when we need coverage and the nurse is sick, delayed, etc guess who shows up- THE NURSING SUPERVISOR. You are right, kids like Elias, and Benji, ad many more that we know are only home because nursing agencies take on the committment to staff the case and provide the same level of coverage consistently. Tell the sup. that you'll have a fresh pot of coffee for her waiting when she arrives to fill your uncovered shift!

    Also it might help if you tell each doctor you see that your coverage is sporadic. I think Pulmo. would definately not be happy that your are lacking the needed coverage on a kid with a trach. Sometimes those docs get territorial and will make calls to make sure their territory (i.e. Elias' airway) is covered. We've found this to work for home medical equipment (like our crazy feeding pump that beeps when there is food) and for supplies (no one wants a kid with a neurogenic bladder to run out of catheters). Why not try it with the nursing agency.

  2. Grrrrr.... rant all you want and send that letter!!!

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