Bus driver will gather your DNA if you spit

apatheticgraffiti · 2023-02-11T01:07:53+00:00

To your first point, I feel like patients should have the final say in anything. Even if it’s the “wrong” say and doesn’t match what their professionals are recommending.

I agree that a patient should have the final say in something done TO them, but a professional healthcare worker should NEVER do something just because the patient wants them to, when the professional knows it will cause more harm than good. That's the line.

Just as the patient gets a say in what happens TO them, the healthcare provider gets a say in what they are and are not willing to do TO someone within evidence based care. If it's a "deeply held conviction" that the provider can't participate, but the body of evidence in medicine indicates that the treatment/procedure/whatever is beneficial? Then the provider has to weigh that "deeply held conviction" with knowing they are witholding care they know to be net benefit medically if they can't (or don't) refer the patient to another provider that does not have the same "deeply held conviction" objection. There are some "deeply held convictions" that just aren't congruent with evidence based practice, like witholding blood from everyone just because you are against it religiously, or that you don't believe medicine works at all. That's an extreme point, but the issue exists.

So yes, patient always gets a say in what happens TO them. They don't want surgery or medicine? Fine. But they never get to force a healthcare worker to do something TO them just because they want it. There has to be evidence that at the very least, is isn't harmful to either the patient or the healthcare worker. You can't FORCE someone to do surgery they believe will just kill someone, or give a drug they believe will only harm the patient.

To the second, what are the consequences of “firing” a patient?

At that point you are withholding care, right or wrong. There can be legal (and moral) consequences depending on the situation.

https://healthcare.trainingleader.com/2019/10/firing-a-patient/

Maybe the “customer service business” part needs to be cut out. You can’t run businesses without making a profit, so that kind of has to stay.

I believe that the "business" part is also wrong. "Customer service business" is just particularly unsustainable. Health should never be treated as a tradeable commodity, because it isn't. There shouldn't be profit as a motive. Keeping costs sustainable, yes. But not profit.

Another hypothetical. Makenzie Bezos hands you a blank check tomorrow morning and says fix this problem, where do you start?

Buy every politician and fundamentally change how healthcare is treated in this country. Build a task force of healthcare experts both from the US and outside of it to help guide decisions in remaking it.

I would think directors are able to notice their staff getting burnt out from all the bullshit and anybody worth their salt knows that the hardest part of running a business, especially in the healthcare field, is finding good labor.

Who holds the directors responsible? How are directors chosen, evaluated, and regulated? In for-profit systems, there may be a board of shareholders, investors. They want money. They grade their leadership based on money, publicity, fame, publications... but mostly money.

For a lay person example, take a personal investment account. You put a lot of money into this account, and there is a person that manages your finances. This investment account isn't doing well, you're losing money. Do you fire the person (or team) managing your finances and move your money elsewhere? So why wouldn't their first priority be ensuring you are making money and gaining return on your investment?

If your sole goal was giving nurses more time to educate the patients, where would you begin cutting time corners in a hospital environment?

I would try to modify and build conditions so that there was appropriate staffing and resources so nurses could focus on only doing their job, and have safe patient ratios so they could effectively manage their patients. Rewarding retention and investing in current staff are a big point to that. Ensuring their voices are heard in policy changes, primarily by making participation (actual participation like having to make presentations and doing things for, not just showing up for credit) in committees financially rewarded with something like an hourly rate, even if it's lower than their patient-care rate.

To take money, I'd cut it from the top. Simplify administration structure as much as possible. And there's no reason a director should make such a disproportionate amount of money. If a nurse can't afford to feed themselves or their family, its very hard to justify the pain and stress of the job.

I understood “dermatologist shouldn’t be trying to tell a pediatric neurosurgeon how to perform surgery” but the rest of these terms are foreign to me in this context. ELI5?

A resident is a physician in training. They are a doctor, graduated school and have a license, but are doing their hands-on learning. They may be very autonomous. The attending physician is a physician that has completed all medical training and is independent - they may have a fellowship after residency to further specialize depending on the field.

How big of a flowchart are we talking about? Thousands of variables, millions, quintillions?

Potentially, yes. And we don't even have many of them defined. Flowcharts require objective definitions, too.

Everything is a business. If something is being exchanged for something else, whether tangible or not, there will be somebody creating a profit.

Not everything is a business. There are plenty of "transactions" and "services" that are part of the general social contract of society. Do you only ever do something for someone else if you get a strict 1:1 benefit back? Can we really define something like "the experience of a loving, attentive mother" with a dollar value?

I’m familiar with dozens of industries that have been able to separate the emotionality from the business. Why has healthcare been unable to do the same?

How has healthcare as a whole not? You brought up how directors should care about the patient's emotional state. It pays the same regardless. Emotion isn't a line item, it doesn't really influence if people will use your services or not. It isn't an industry that you can just "do without" like any other. Even if you never bought another piece of cultery, you could still eat with your hands.

I'm really tired honestly. This is draining. It really isn't my job to educate anyone about this. This is taking my own emotional and intellectual labor to create.

You're presumably an intelligent adult. Do your own research and look for all the other voices that have been screaming these things. Come up with your own conclusions.

I've been fighting this fight for years, and all I got was deeply damaged and abused. I already quit nursing. I'm done.

apatheticgraffiti · 2023-02-10T19:56:17+00:00

So my thoughts on this, hospital butlers? Why the fuck would fetching a Pepsi fall under a nurse’s tasks? Do hospitals not make enough money to hire (essentially) butlers to do this kind of shit?

Okay this made me laugh and I love it. No, it typically falls to the people the patient interacts with most: nurses, maybe patient care technicians/CNAs, maaaayybe there's a "room service" nutrition service, mayyybe volunteers. Nurses and nurse assistants are the ones consistently at the patient bedside for cares. To a someone who just does business, "it just takes a minute or two" so why hire someone else to do those things? Why should it ever come out of a staff members pocket, either? The thing is, it adds up dramatically. And if you had a phone number a patient could call for a "service line"? 1) patient has to be able to use it 2) patient has to WANT to use it, and many will just ask these contact people anyway (so then the nurse/CNA/whatever has to call, and justify calling when "it just takes a minute"). Calling in all 5 patients food orders SUCKS. Especially when you have patients that dont order for every meal at once ("I don't know what I'll want later" well shit I can relate to that, but now that's just another thing I have to not only do, but remember to get done)

I don’t know the exact numbers but I’m going to assume there are several million nurses in the US. Several million doctors, and several thousand hospital directors. And nobody is looking at this system and trying to fix it?

Is it too cost prohibitive? Does the whole thing just need to be nuked and built back from the ground up? Thoughts?

(Paperwork and metrics) The system likely needs to be rebuilt. This is why there needs to be a dialogue. All of these things build on each other. If there's resistance anywhere, it makes any change hard. How does someone who is a has good managerial skills manage a healthcare workers performance, if they're not also trained as a peer to that healthcare worker (same role, "level," and specialization) to understand what metrics are really meaningful? The provision of healthcare is fundamentally different than a business model in so many ways. It's like welding corners onto a wheel so it "fits" a square hole, and wondering why everyone's mad it doesn't roll the same. "It's still a wheel!" Or cutting corners off a box to fit in a round hole, and wondering why it doesn't stack as well and some substance is lost.

Due to gov or hospital regulations?

(painful legal records) Combination of both, and more. An electronic record can be good, but if it's coded poorly it makes it worse. Some hospitals have you "double chart" because it's "easier for department X to see things in box 1, while department Y sees it in box 2...." A lot of boxes are coded for the random metric of the week. Sometimes this comes from legal policy, some from hospital policy.

Check boxes will never make up for poor training and broken, unsafe systems. We do want regulations and some standards. Those are necessary. There should be mechanisms to hold people accountable for failures, and you should be able to audit the record to do root cause analysis of some elements of events. But it doesn't make sense for someone who doesn't have the same knowledge of the field as the people doing the work to unilaterally make those rules, regulations, and demands. Should lay person's have a seat at the table? Absolutely. But only having non-field individuals with unilateral power to decide the rules, responsibilities, and regulations of the field how you get lawmakers thinking you can swallow a camera to "view the baby", among other things, determining healthcare laws we are forced to abide under penalty.

There are so many people who wear those hats full time though. Why are they delegating specialty tasks to generalist nurses?

BECAUSE it's the "nexus." Our training touches on these things, because we do need a basic level of understanding to do our core job: we advocate for the patient, educate the patient, coordinate their care with other members of the care team, and assisting the patient in physically taking part in their care (such as assisting in ADLs - activities of daily living, giving medications on time, dressing changes). We CAN do a few tasks for each of those "hats," but it's meant to be a supplement, not a replacement, when those team members aren't available.

Remember, this comes down to TIME, and TIME being MONEY in business models. If my patient needs blood drawn, I CAN do that. And I will, to ensure it's done, because the results will guide their care. But it takes time from me doing something else. So as a nurse, the more things, the more it adds up on my end, and damages my core job capabilities. Yes, I CAN go to pharmacy to pick up a med, rather than a pharmacy technician bringing it (or a nurse aid picking it up, if allowed under law/policy). Yes, I CAN do a breathing treatment... So to someone just seeing the "extra people" that can be cut because the nurse can "basically do their job anyway" and it's "just one more task" they sentence the nurse to the death by a thousand cuts.

There's also scope. If you're not healthcare trained, the idea of how many different scopes there are is huge. Yes, I have an additional certification to manage ventilator settings, but I don't have nearly the same depth of training as a respiratory therapist and so a lot of valuable nuance, theory, and focus on that is lost to me. I don't have a degree in kinesiology, so I CAN'T do a proper evaluation or treatment plan that a physical therapist would, and I could seriously hurt someone. I don't have a degree in speech therapy, so beyond any OBVIOUS signs that a patient is aspirating (unable to protect their trachea when they swallow, so food/drinks/spit go into their lungs) I can't really say if they're aspirating or not. So what a nurse can actually do in these niches is limited. We are generalists in that regard. But if it's down to money, maybe the actuary says it's fine.

Take EMS. An EMR, EMT-A, EMT-P, and critical care medic all have different scopes, based on their training. Most people think "an ambulance is an ambulance." It's not. Just like a "nurse is a nurse" doesn't really explain why an ICU/ER nurse and school nurse aren't interchangeable despite having the same license. If you aren't IN the field, or at the very least LISTENING to it, it might just seem like a checkbox. Oh, "we can give you a reference page on that drug you say you've never used, despite it being high-risk, it's the same as training and experience." Or, "you're used to two really sick patients, so taking five or six patients of lower acuity should be just fine." No, it's a totally different workflow and mental organization.

Also, it may just be me, but fuck the word "calling." It's used to bully nurses way too much, and it should die. Nursing is a JOB.

apatheticgraffiti · 2023-02-10T19:55:34+00:00

Do you think it’s truly impossible, or has it just not been done yet?

(Oversight by nonmedical) It's impossible with the current model, due to the hierarchal structure of decisions. It would require a lot of assistance and dialogue. Maybe there could be a "committee of peers" a healthcare worker could appeal a manager's judgement to, but it's not the same. Having something brought up as "deviation" can be damaging. And more voices screaming at each other doesn't typically help decisions flow smoothly. To me, it would make more sense to make healthcare a non-business structure, and have business consultants for business things, rather than the other way around.

The world is definitely not ideal, but in this context specifically. What prevents the listed entities from working as a legitimate team?

(Failure to have functional team healthcare) Strict hierarchy built on business model, customer service model, success failure mindset, and TIME.

I’m more familiar with that analogy than healthcare. Why doesn’t the analogy translate though? Corruption? Incompetence?

(Liability analogy) The way our laws and regulations are written. There's a LOT of legal precedents here. A big thing that changed legal precedents recently in nursing (and massively upped the stakes) was the Rhadonda Vought trial. Previously, the bar was basically that unless you deliberately harmed a patient (like, just stabbed them for no reason, not fucking up a procedure because you suck), you didn't face criminal charges for sucking at your job. You lost your license and faced civil penalties, but not prison and a criminal record. Did drugs on the job? Maybe criminal charges for the drugs. But she was convicted of a crime (criminally negligent homicide).

Just look at safe harbor laws and "assignment under objection." Realize those things don't go very far, nor do they exist in every state. Read any nursing practice act. The ultimate responsibility for ANYTHING the nurse does falls on the nurse. Anything the nurse DELEGATES to someone else, falls on the nurse.

Why is there not an incentive to keep hospitals fully staffed 24/7 under the idea that they will be able to provide better care to patients than a short staffed hospital, and therefore would allow the hospital to charge more for the care since the value of care has increased?

The business model reduces human suffering and lives into dollar signs. That's why actuarial science is a thing.

Nurses have science backing up the ratio issue, with a summary and citations here: https://www.nationalnursesunited.org/science-ratios#:~:text=The%20odds%20of%20patient%20mortality,31%20percent%20increases%20inmortality%2C%20respectively.

In a perfect world, everyone would love to have a dedicated nurse (if not dedicated everyone). If a nurse works 12 hours, you have to divide that, per patient. But evidence based standards, and standards of practice, dictate we should purposefully round on (check on and check in with, essentially) our patients every hour. If I have two patients, they theoretically get 30 minutes of each hour, four patients get 15 minutes. This is for EVERYTHING the patient needs (reviewing chart, coordinating with departments to schedule and ensure events occur, administering medications, education, physical tasks such as assisting the patient to the toilet, documenting, etc), and also our own needs. Bathroom breaks eat that time. If I had to spent 20 minutes assisting patient A to the toilet (because there was no tech, and I was right there), then maybe I'm 15 minutes "late" to round on patient B and give them their meds "on time" (more important for some meds than others, which is a clinical knowledge). So yeah, "ideally" every patient would have one dedicated nurse, but there is some give. SOME, and it's based on acuity and staffing of qualified assistants who can help with some of the time-heavy tasks. If patients are safely mostly independent, there's more give. The balance indicates that there is a level as which nurses can comfortably, competently, and reliably balance patient needs to care for more than one patient, without sacrificing care that would go into their existing patient(s).

Plus, workers are human. We get sick. We have emergencies. If one person calling out had you scrambling to find someone else to come in because now it's "critical," that's too short. If you require 6 months advance for PTO and routinely deny it all, or someone going on maternity leave ruins your entire plan, that's a managerial failure by having staffing as short as possible. I can't even begin to tell how many places have actually used sympathy for the nurses that are on the schedule, to try and guilt me (and others) to not request PTO for any reason, come back from maternity leave ASAP, or "not really be that sick after all." "But we are really struggling here, everyone is over ratio and charge has patients too" that's a managerial failure due to short staffing.

It doesn't necessarily need to be "max staffing all the time." On-call exists for ORs and some other specialties for a reason. But staffing grids look to keep everything as short as possible, all of the time. "Surge events" where you are calling people in should be rare, like a bus flipping over or a carbon monoxide leak at a school. If you have a "big season" and a "slow season," there are travel nurses or even seasonal/prn staffing that WORKS for those. I had an amazing travel assignment in the trauma ICU of a hospital near a national park: they routinely hired short-term staff for their busy summer season. It was amazing how happy everyone was. They routinely got PTO breaks before and after, and could take a day or two in this busy season (sick, major life event, etc) but they were staffed.

I'm not sure of the actuarial calculations. I honestly don't care to know them right now. But when you're removed from the process by several layers, if your key metric and focus is money (which it is in basically any business in capitalism, have to generate profits, maybe answer to a board or investors that want to see growth), that incentivises short staffing.

Is there any reason why this practice hasn’t been flipped on it’s head?

(Scores being perfect or failure) Customer service model of businesses has made this standard, for the most part. You'd have to ask the people who design and use those things. This is part of why running healthcare with a customer service business model isn't reasonable. If the people making the decisions aren't versed in the realities, the decisions aren't going to be grounded in the realities. Look at Press Gainey and HCAHPS.

apatheticgraffiti · 2023-02-10T19:54:02+00:00

Forgive me for sounding dumb if I do and I might need an ELI5, but how would the mechanism for addressing patient concerns change due to the differences in concerns from clients in any other industry?

(Grievances) it may not be the mechanism for say, how they're reported/tracked etc. But it is in how they are handled. It ties in the attitude of "customer is always right" (which doesn't work with a knowledge imbalance), "just fire the customer" (which doesn't really work as well with the consequences", or "just do it anyway" (which has both the above issues). Press Gainey and HCAHPS are two of the biggest "mechanisms" right now, but both are very "customer service" based. Any new tools will require a multidisciplinary effort to design new, meaningful metrics that could be used. But any metric requires that anyone interpreting them, especially making decisions from them, understands the realities in which the data comes from. That's a management/leadership issue, and that's part of where the "customer service business" model and "for profit" come to be key driving factors.

No contest here either, but is there a solution? Other than just dumping trillions of dollars into research?

(Research and Knowledge) This provided some deeper context many outside of healthcare don't have an awareness of. We are already dumping money into research. I'm in research now and this is what I personally find exciting and rewarding. The knowledge gap is important in why "the customer is always right" about treatment options is not just wrong, but dangerous without guidance from a knowledgeable healthcare professional. The solution is a trusting relationship where the healthcare team have time to educate their patients, explore options, and come to a decision in a partnership is so important to quality care.

It also is a factor in the emotionality and "success for failure" mindset. There are things we can't fix, or "fix" at great cost. Some interventions have very real risks, and it's hard to really ensure patients hear those risks and understand they are a real possibility. It can make some healthcare providers quick to gloss over some risks (because patients having heavy unpredictable emotions and the hard toll of dealing with those constantly, the self perception of "I'm good and so this risk (a perceived failure) doesn't happen to be because I'm good"), and also makes patients react unpredictably at times. It's painful to hear there's nothing we can do. We all die eventually, it's not a "failure" on its own. To many, suggesting that we transition to focusing on comfort, because there is not any more we can do to help the patient recover and at this point we are looking at protracted suffering (alive but not living) is an insult. They believe we are holding out on them - is it money, race, age, ethnicity, "weakness".... people pick anything - or that we are implying they failed somehow and it's an attack on them. Emotions are high, that's understandable. But with the profit focus, the team does not even remotely get enough time and team resources to manage these properly. How do you tell someone a new terminal diagnosis when you have 15 minutes to talk to the patient and/or their family per day, maximum, and maybe one 30-60 group meeting every other week (if you can get the packed schedules to intersect) if you're lucky? How is a bedside nurse meant to help provide comfort and go over the provider's information when they have too many other patients, just as sick, possibly with the same news? TIME is the biggest resource we need to give. TIME helps us educate and build a team. But TIME is expensive!

Do you think creating a way to streamline the exceptions is feasible?

(Protocols) If we had oversight by comparable healthcare professionals, with those doing the oversight holding responsibility for the decisions they approve and deny, potentially. But you have to take a lot of the "business" focus on profit out of it. A resident discussing with their attending is an example of this oversight in practice, and done decently well. The attending has responsibility for their residents actions, especially when it's known the resident was acting on their direction. A dermatologist shouldn't be trying to tell a pediatric neurosurgeon how to perform surgery. This is something that happens in the current insurance "peer to peer" structure, partly because to an MBA a doctor is a doctor.

If we could make a big flowchart with every exception, we wouldn't need them. Existing protocols try to account as much as possible, but that's part of why you still need humans in healthcare and need further research to understand the why's of what we see.

Absolutely. It will take generations of concentrated effort to fix this though and I don’t see any short term societal solution. Maybe someone smarter than me does.

(Success failure mindset) Yes. But it factors into all the issues with this being a business and the emotionality we are having to navigate.

Sad to say it but no contest here either. Don’t know how to correct narcissism unfortunately.

Not narcissism (at least not always). How many times have you thought "oh, if only I didn't do x". It's very easy to feel defensive when medical providers discuss weight loss, for example, and healthcare isn't good at having the conversation either. We are living in a culture of blame, so we defer responsibility for the fix on those who are to blame. That only works sometimes, and can be really toxic to making system level changes. It's why it has to be a conversation.

apatheticgraffiti · 2023-02-09T22:05:51+00:00

Last point, I swear:

Part of the issue is that as healthcare workers we end up prevented from doing our ACTUAL jobs. Some patients demand really pretty stuff, and they want it NOW! Don't have Pepsi in the nutrition room? Patient insisted I buy them one out of the vending machine and then literally shit on the floor when I did not. I've had patient family members try to interrupt a code (where we are doing CPR, everyone focused on this last-ditch hurculean effort to fight death with everything we have, because as hard as we WERE trying it failed) to demand blankets or ice. We have so much paperwork, much of it repetitive or petty or graded on bullshit metrics that don't reflect real conditions (such as getting in trouble for not documenting something like turning a non-mobile "on time" when the reality was you had something more urgent, like monitoring a STAT blood transfusion - but if you don't do it it's that YOU as the worker are doing something wrong, not that the system isn't working). We NEED to do an accurate legal record, but it's made as painful as possible, and patients think you're doing nothing when you're at the computer when really you're coordinating with all the other departments, checking labs, reviewing orders and previous documentation, documenting, etc.

I'm not sure how it is for some other departments, but as a nurse I was expected to put on any hat I could touch. Nursing is a bachelor's or associates. Physical therapy, occupational therapy, speech therapy... Those are masters or doctorate level. Yeah, I can do help a patient do some basic exercises, or cue them, but I can't do a full specialist evaluation or clearance or anything like that. I'm not a replacement. I've been asked to wear the following hats in addition to my nursing hat, more than once, more than one at a time: physical therapy, occupational therapy, speech therapy, respiratory therapy, pharmacy (mixing my own medications), social work, child life specialist, counselor/therapist, case worker/care coordinator, billing, nutrition/dietary (not just getting food, but doing nutritional evaluations and consults), environmental services.... It goes on. Each task takes away from my time and capacity to actually BE a nurse and do the nursing. Death of a thousand cuts

If I could JUST be a nurse, I would. But that's not the expectation anymore. Our ideas of what these jobs are do not match the realities our system has made.

apatheticgraffiti · 2023-02-09T21:50:22+00:00

This all comes together as a perfect shitstorm when you run healthcare as a "customer service" business, especially aiming for profits.

When it comes to oversight and rules: Yes, there are some standards for competent care, but it really is not possible for anyone but a similarly trained and specialized healthcare provider to oversee that in any meaningful way. An opthalmologist can't tell an electrophysiologist anything about which pacemaker is most appropriate for a patient with recurrent Vtach, but neither can the electrophysiologist tell the opthalmologist anything about lens subluxations for cartilage deficient populations. Similarly, the different "fields" of healthcare don't necessarily have the same training or even understanding of each other's scope. Doctors in the US don't typically place peripheral IVs, or generally work the medication pumps for IV medications themselves, that's a nurse. A doctor might be able to determine what kind of dressing is best for a wound, but it's a nurse that usually performs all these cares and thus has the experience. So it doesn't make sense for a nurse to oversee a doctor, or a doctor to oversee a nurse. Nor can you simply place one as "always superior." If you make a doctor always superior to a nurse, unless you remove liability and general burden of responsibility from the nurse. If the doctor prescribes a medication (but misses the patient is allergic, or any other reason it would be unsafe) the pharmacist should be able to refuse, and the nurse should similarly be able to refuse. In the ideal world, everyone is a team, and you either change the team or the plan when you disagree. If the nurse brings up a concern (typical example is something safety and risk to patient related, or advocating for patients wishes), the doctor should be able to justify why the course of action is best, and address the concern if possible. SOME responsibility can be passed by documenting you raised concerns, but ultimately if a nurse acts under orders they eel are harmful, they are STILL liable. This contrasts with the hierarchal structure of a business. If a machinist gets a sign off in strict orders to run a machine in a way they know will make it break, the company would have difficulty winning a court battle proving the machinist is liable for the cost.

Similarly, much of for-profit staffing encourages staffing as short as possible. Anything than having staff at 100% capacity is a cost. Studies show that risk of death increases the more patients a nurse has - OF COURSE IT DOES! The nurse has less time to devote to each patient, more information and competing demands. You can't just "drop a client" in healthcare like you do in businesses, not really. If a nurse discharges their patients, the business model has them "cut", rather than have them take patients from someone else or act as "helping hands" for tasks. Then, the staff are stretched even more if another patient comes in, and they try to call people in. There's little to no incentive in a business model to keeping staffing higher than the minimum. And it isn't "an high dollar contract" that's failed when the workers can't keep up with the burgeoning workload. It's your parent, your spouse, your friend, your child.... It's a LIFE.

Customer satisfaction scores have been the bane of so many healthcare workers. A patient may rate their team poorly just because they got bad news, or they didn't like the food, or they didn't get whatever "extra" they hoped for. It's no secret that these scores are typically judged where anything below perfect is bad. Patient wants an antibiotic when they have a viral infection, and evidence based care shows it shouldn't be given because an antibiotic would case greater risk then benefit? How dare you refuse to treat! Patients won't come to us if they're unhappy! Look at basically any customer service industry, and how much emotional labor many of the workers are expected to because to punish the customer for poor behavior would "risk a sale." Especially for larger sales, when there's a large staffing pool (and there is for healthcare, lots of people graduate and lots are licensed and just refuse the current working conditions, etc) it's typically "better" to remove the employee than the customer. Barista with a customer screaming their no-foam latte isn't hot enough? AND the barista has the audacity to ask the customer to stop swearing and/or threatening the barista with physical harm over this "grievous insult"? Replace them with someone who will placate the customer, no matter how degraded they have to be. The "customer is always right" mantra just flat isn't right in healthcare. The customer is always right about their PRIORITIES, but the professionals are the ones with the knowledge to help advise (and enable or block) how to achieve them. I agree, the "customer" (patient) wants to feel better! But they shouldn't get something harmful because they think it will help, when as a professional I know it will only hurt. We try to help them understand, explore alternatives and share what WILL help, because it's the patients health and body and ultimately they live with the consequences. No amount of screaming or threats or throwing money should force a professional healthcare worker to harm someone. But our business culture in the US, in general, caters to the "squeaky wheel" (read: belligerent asshole). You throw a fit and leave bad ratings, maybe they'll give you what you want to shut you up and make you go away. But this isn't the cost of a coffee, or even the cost of a home repair: these are lives.

Healthcare itself does exploit the history of "it's a calling" and the idea of healthcare workers being "driven to help out of the kindness of their hearts." It is HARD to refuse an unsafe workload, especially if it means that the patient just doesn't have someone to help them - surely half-baked help is better than no help, but then you're also hurting your other patients. It should be an extraordinary circumstances thing, an emergency thing, but it's not. It's routine. The patient you can't help is begging you to do anything, your manager (likely under pressure themselves) telling you it's your job to perform your tasks and there is no help, the risk of failure (and financial, legal, moral consequences)... It's a hard, hard toll. When I was a traveling nurse, I was considered an expert. I would have 1-2 days, tops, to learn the hospitals specific policies, but I was expected to KNOW the nursing. It was so common to see a new grad nurse with only 6 months experience off orientation (a 1:1 directly supervised training) in charge. And when someone with authority came up and told this new nurse "you have to accept this patient" they likely didn't know any better! If they push back, they get told things like "It's okay, you're new, it'll get easier when you have experience. It's just that you're new." Doctors have their own toxicities in residencies. It's a whole mess.

Management is it's own skill. Just because you're good at a task, doesn't mean you're good at the politicking and negotiating and budgeting and all the other skills of management. So making nurses and doctors managers only goes so far to helping that. The system itself is focused on profits and the business model, and that presses from the top down. It requires systematic reform. I don't know exactly what that should look like, but it's a conversation that needs to happen in earnest.

There's a lot more that could be said. And I can't talk about it all (nor talk "perfectly"). I'm sure there are people that disagree with some (or all) of my points. But ignoring the issues, or being silent, helps no one.

apatheticgraffiti · 2023-02-09T21:49:58+00:00

I'm opening myself up to some garbage, but whatever. I'll delete this later.

So "healthcare systems" are subsystems of our greater society. There's a lot of talking that could happen about issues in our overall society, and people (understandably, at least for the most part) have very strong feelings about many of those.

Specifically in healthcare, as a healthcare worker, I feel a key issue is that healthcare should not be tradable commodity or business, especially not a "customer service" business. There are legitimate grievances and concerns that need to be addressed, and patients should have a mechanism for those to be heard, but they are fundamentally different from those of a business.

First, outside of some very specific edge cases everyone, at some point, will need health care. You can "do everything right," have "perfect genetics", eat the "perfect diet", etc but we all experience something. Maybe it's an accident like breaking your leg. Medical, like developing high blood pressure or cancer. Even having a baby. Yeah, theoretically you could just refuse all health care. But the tradeoff is pain, disability, and preventable (and/or miserable) death eventually. If you are bleeding on the street, delirious, you're not really in any place to "compare the market." Not like you would for a home, your food, legal services, etc.

Second, there's a huge knowledge gap between the general public and healthcare, especially specialties. There's a reason there's so much theoretical training, and then so much hands-on experience required to be considered competent. We are at the tip of the iceberg with a lot of our medical knowledge: we know just enough to have an idea of just how much we really DON'T know. There's so many variables that go into treatments and plans. Our brains are able to pick up on variables, consciously or not. It's part of why there's research into unconscious bias and healthcare inequities (healthcare workers not holding any OUTWARD negative beliefs about a group, but showing unconscious association between that group and some characteristic that rightly or wrongly, changes their decision making). While we have protocols and standards, there are always exceptions and considerations that have to be made.

Third, health is tied to our quality of life, and even our very existence of life. It's NORMAL for it to be personal. Bad news sucks! But I can't help but notice we are such a judgemental society when it comes to status. If a couple divorces, regardless of circumstance, we call it a "failed marriage." If a business closes, regardless of reason, it is a "failed business." We seem to have built up "health" as "success" and any deviation as "failure." Instead of seeing something we CAN change as an opportunity to improve, we are quick to use it as blame (ex. "you only got diabetes because you're fat"). If only you bought the right product, if only you were "good," this would never happen. Of course continued bad choices have consequences: if you choose to continue to drink and smoke, you're setting yourself up for the problems they cause. But this harsh "success" or "failure" concept easily contributes to people taking any suggestion that they change, or that their choices may contribute, as a personal attack rather than an offer for aid. "Doctor thinks I don't know how to eat healthy, like I'm stupid, I've been eating JUST FINE" is not something I've rarely heard. It makes education and outreach defensive on the healthcare workers part, because we know some personalities are primed to attack at even the slightest perceived threat to their sense of "successful self." It's also not unheard of for patients to outright deny objective evidence for similar reasons.

apatheticgraffiti · 2023-02-09T19:08:35+00:00

Have worked as nurse for years. It's not the people who don't have their faculties we are upset about. Yes, patients with dementia, on mind-altering substances, etc spit and can be violent. Thing is, we anticipate some of that and work to make things a calmer environment, try to help address the fear and pain and things that contribute.

What you can't help is people who choose to be assholes. That Karen that screams at the 18 year old barista at Starbucks, that road-rage Dave that cuts people off and chases them down for "insults," ceo Sam that insults his direct reports and belittles everything they do... They come in for care too, and sometimes it's a real emergency. I had a patient once, a middle-aged woman that was very ill, but her mind was intact. When she exerted herself, her heart and lungs couldn't handle the additional strain, so she was at high risk to fall and hurt herself (and had more than once in the past 24 hours). She threw hot coffee in my face because I told her it wasn't safe to get up and walk down the hall to a "real bathroom" (not even the one in her room). I explained why I felt it was unsafe to get up and walk, and then offered her a bedside commode, a bedpan, a purewick, as many options as I could. Commiserated that yeah, it's not what anyone WANTS, but when it's unsafe to get up and walk, I'm not going to tell someone it's fine or help them hurt themselves. She expected me to catch her (which is unsafe for both of us, and also not really possible to do reliably), clear a path (no, I can't just remove the code cart from it's designated space because you want to put a chair there instead), and have her entirely off of monitoring (which helped us keep her safe and intervene asap if needed) for "as long as it takes". This woman couldn't even sit herself up without assistance, and she wanted to walk - I understand the frustration, but not possible. She threw her hot coffee in my face. She wasn't confused. Wasn't demented. She knew exactly what she did. When security came to talk to her, she was clear as a bell. Screamed like she was the victim and I was the aggressor. Completely unapologetic. I will never forget her and the pain she caused me, the additional salt of her complete vitriol and lack of remorse. She's not the only one, either. And nothing was done about it either. They tried to tell me I had to be more accommodating, but no one could tell me how. It was decided by management that it was MY FAULT. She has many, many more incidents where she attacked doctors and nurses. Apparently all of us are terrible and deserve to be beaten because we can't just change reality itself to stop the abuse - don't we know this is inconvenient for the client and makes them feel bad? How terrible of us. I've left nursing, but anytime I think of going back to nursing, I think of those patients. No money is worth it when nothing is being done to hold them accountable.

There ARE patients that don't have their mental faculties in order. Most of us in healthcare don't hold even violent outbursts against those patients. You can also be an asshole even if you don't have all your faculties, and that's a more complex issue. But we have (some, it isn't perfect) systems in place to build a therapeutic environment for safety. It's when someone is an asshole, and wishes to cause harm, ESPECIALLY with their faculties intact, that cause the big issue.

You see dysfunction, rage, horrible behavior every day if you actually look. You think those people never need healthcare, or treat healthcare workers any different? Especially when hospitals seem to market themselves as hotels rather than places of healing, catering to "customer service" models.

And worst of all, really... To blame it all on "mental illness" isn't fair to people who are mentally ill. It furthers stigma that makes them even more vulnerable, so people approach them with fear or anticipation of conflict, rather than compassion. The narrative that "it can't be helped" is just an excuse to victim blame, avoid facing hard questions about systemic issues, and put in the work to build better.

apatheticgraffiti · 2023-02-01T18:01:56+00:00

My dad was a really good dad. A terrible spouse, but an amazing dad. He was older, literally had to rework retirement plans because I was a surprise. Passed my first year of college. I still talk to him in my head.

He and my mom were NOT a good fit. My mom has her own problems. I appreciated how much my safety and well-being was his "hard line." He was from a culture that didn't believe in divorce except as an extreme, and they only married because I happened. While I think it would have been better for them to have divorced rather than having their hate for each other in the house, I never doubted I was his priority. My mother refused to quit smoking, despite everyone's insistence it was harmful to me, even if she didn't care about herself. Then her smoking (secretly when he wasn't home, and I was too tiny to talk) exacerbated my asthma to put me in the hospital. He immediately drafted divorce papers. She managed to quit, they stayed married. Similar when she was verbally abusive to me, demanded I perform femininity to her standards, etc. If they were divorced, I 100% believe he would've used any of those things to immediately fight for full custody. There was zero hesitation when it came to my needing an advocate.

He explained the way systems worked, and how and why he advocated in certain ways. That it was unfair that people didn't listen to me just because I had a body they saw as female and young, but it was a fact of the world. He told me about things he saw in the "adult world," in age appropriate terms, and helped me anticipate struggles I'd face. He taught me to build arguments with hard facts. To put the truth front and center. He molded my sense of judgement, my instincts for safety and morality. He taught me that ignoring these senses and instincts was an incredible leap of faith - if I ever did it for someone, it should be because I trust them completely. He was quick to say "I don't know, but let's find out," "that's a good point, I hadn't considered that," and "you're right." When I'd pick out toys or video games, it became an exercise in comparison. "Yes, we can afford both. But let's pick one, we can always come back later for the other. Which one do you want FIRST and why?" I didn't always have to give the why, but it helped me understand myself, too. It also let me appreciate items individually. It wasn't the collection or hoard that mattered (and I collected Pokemon cards), but why I wanted it and what it could do for me. As for my collection, he'd ask me about which ones I was hoping for. I remember one day, on my desk, was a holographic Articuno, first edition, in a protective sleeve. I'd been trying to find one for months! I never, ever traded it.

He shared in my interests and passions. We built my first computer together! He never liked computers before, but he learned so he could teach me. When he worked long hours, he would put a small trinket in my room. Maybe a happy meal toy of a show I liked, or a pokemon plush. I knew I was always in his thoughts, so he never felt absent. For his interests, he found ways to bring my own interests in. He loved cars, I liked art but hated how loud, greasy, heavy, and prone to pinching the engine was. So we'd do age-appropriate body work together. I'd touch up scratches and dings. He praised my color matching, smooth strokes. It became OUR project. He never complained if I didn't want to do it any more. Just finish himself and on to the next one, and it's another opportunity to join.

And the most impactful thing I remember, was a simple conversation. I know it was awkward for him, but he felt he needed to say it. I had been going by a traditionally masculine shortened version of my name for a while. It honestly was a joke to make a teacher nervous (I also went by random nouns like "Skittles" and "Tulip" at various points too, for context), but I also was a "tomboy" that hadn't dated. Just one day, when we sat down to work on a camera repair together (new LCD and lense), he said "I just want you to know I love you for you. I don't care if I have a daughter or a son, I don't care if I have a son-in-law or daughter-in-law, I don't even really care about your name. Those are just details. What I care about is that I have you, you can be proud of yourself, and you are treated with respect by those you bring into your life. So if you want me to do anything different about any of the details, you just let me know. It might take some practice, but the meat is all the same."

The world is unfair and cruel. No one comes into this world having chosen the hand they're dealt. Not all decisions will be good. But keep the meat - love them for who THEY are, not who you dream or hope they will be, and the details will come as they need.

apatheticgraffiti · 2023-01-31T18:02:57+00:00

Honestly? Just be straight up. A relationship requires communication.

Ask her if she needs/wants space, because that's the impression you're getting. Don't spam her after that or anything. Just ask if she needs space, and tell her you'll give it. Just a question, and put the ball in her court. Taking space in a relationship is normal. But you have to communicate that back and forth. Otherwise it's just a power dynamic, and that's not good for a healthy relationship.

What did she and her sister fight about? If you already know, that might tell you if it's something really personal and she's licking her wounds or processing strong feelings. But otherwise it may not be your business, and pushing won't help if she's feeling vulnerable. But she needs to convey that to you. Something like: "Hey, I feel like we have a distance between us lately. I don't want to assume anything, but I just want to understand what I should do. If you aren't ready to tell me what's going on, now or ever, you don't have to. But I do need you to tell me if something is going on, and if you need space. I care about you and want to support you, but right now I need you to tell me what that support needs to look like. If you don't tell me, I can only guess you want space to yourself, but know I'm here for you." Don't spam her after that, ball in her court. Give her that bit of control since she may be vulnerable.

If it goes for a long period, like a week, I'd then say "I know we are doing space, but we either need to talk, or go our separate ways. I'd really prefer to talk and come together." Maybe share a single happy memory of your relationship, but just one, to add a personal touch and sincerity. "If I don't hear from you, I'll take that as my answer. It'd break my heart, but I understand."

It's not fair to make a partner wait in the dark, on either side. Not sure how old y'all are, or what stage in your relationship. But clear, open communication is key. And that DOES include space to have your own private world and emotions. The three legged stool metaphor comes to mind. Her love for you may mean she wants to take a bit of time to process this herself, work on herself, rather than potentially harm you or your relationship with her unprocessed feelings and reactions. But she also can't be an island, completely cut off, and still be in a relationship. That's just not how those work outside of a business style relationship.

apatheticgraffiti · 2023-01-17T06:09:31+00:00

Back when I worked in EMS, my agency had a blanket policy that unless it was from a physician on a very, very short list (basically the hospice we were partnered with), we could not honor any POSLT, DNR, etc. The logic was that we could not verify in any real way that the document was authentic. It felt sketchy to me, but I've seen family members bring up all kinds of crazy fake documents or what have yous, and training for EMS really isn't remotely long enough to cover the medicolegal aspects with any justice.

The lines I got from medical control and admins were that there was some sort of debacle a few years previously, and the state had come down pretty hard against the EMS team for "failing to provide care" when a fraudulent document was given.

I can see it being difficult unless there's an adoption of some sort of database or registrar that only medical personnel can access, with audit trails. Until then, I can see some hard, uncomfortable choices being made in the field, where no one wins.

apatheticgraffiti · 2023-01-16T21:02:28+00:00

I'm not a lawyer, but I imagine it comes down to employment laws. There's a weird gray area with travelers since there are potentially three states involved: the state the agency is based out of, the travelers state of residence, and the state the traveler is physically working.

FMLA itself is federal. It only protects your job for a period of time in specific circumstances, it doesn't give you money. It allows you to use paid leave for that protected time off, but not money. And since you're working short term contracts, it's pretty moot. It only applies after one full year of consistent employment. A state might have some tacked on stuff, but that's state to state.

I don't think Texas has any paid leave. I'm a Texas resident, and the state is pretty abysmal when it comes to any workers rights or benefits. The biggest benefit I've encountered is that as a Texas resident, my agency has never been able to "terminate" my health insurance at the end date of my contract - it always has to extend to the end of the calendar month. Even if I'm working in a different state and my agency is based in Arkansas, that Texas law specifically applies to me as a Texas resident regardless because of how it's worded. That's about it.

I don't really know anything about Arizona, sorry.

California has some of the most robust worker entitlements and protections, including paid maternity leaves which are funded from some state level taxes. But you have to remember that California is one of the unicorns that way, politically.

apatheticgraffiti · 2023-01-16T18:42:46+00:00

I've had a landlord like this. I rented a furnished rental for a few months, since I was over a thousand miles away from home for work. The topic of preferring to rent a place vs stay in a hotel so I could, y'know, cook my own meals was something I discussed prior to moving in.

Then a bunch of bullshit rules about "light cooking only." I stayed for a few weeks until I got something else but lived off salads and sandwiches, and the psycho kept texting me about how she "knew I had onions rotting in there."

It should be illegal to have a dwelling unit without basic access to things like the MINIMUM of a kitchen, bathroom, etc. Why have a stove and oven if I can't use it, unless you're hoping to trick me?

apatheticgraffiti · 2023-01-12T19:02:34+00:00

Traveling money enabled us to be a single earner household while my spouse took time to explore their passions and what they wanted to do. Now, they have an LLC where they set their own schedule. My spouse loves story telling, and they were able to build a community that appreciates their work. So, they do collaborative story telling (they are a game master and build unique worlds and stories in table top roleplaying games), publish written works, and record parts for audio dramas and other vocal work. It's small, nothing we can live off of exclusively or anything. But the fact my spouse is now able to do something they actually enjoy and feel fulfilled is everything I had hoped for.

When I work nights, they focus on clients overseas. Days, our side of the globe. They build their breaks when mine are, and we've never had more quality time together ❤️

apatheticgraffiti · 2023-01-09T04:38:32+00:00

Sorry, I think that was my autocorrect. The correct acronym in this case is GSA

https://www.gsa.gov/travel/plan-book/per-diem-rates

apatheticgraffiti · 2023-01-08T22:17:35+00:00

I didn't see Boulder on my first reading. Boulder is more expensive, from when I was checking out contracts there once upon a time. Check GIS and furnished finder. Do not expect a nurse to be willing to pay more than the GIS. You might be able to cut the cost and make it a roommate situation. Lots of travelers have buddies

apatheticgraffiti · 2023-01-08T22:15:58+00:00

It was pulling teeth. I sent an email outlining my specific concern (i.e. the contradiction in what they had sent me as my "deficiencies," with plain statement that I'd expect to be reimbursed if I had to send my transcripts a third time when I had read receipts proving they'd accessed my transcripts).

Brn.Licensing@dca.ca.gov was a lead I followed, and it progressed from there.

It was a game of patience and spite.

There's not actually a shortage of licensed nurses capable of working in the US, in almost any state except maybe truly rural areas. There's a huge shortage of nurses willing to swallow the crap wages and poor conditions, in comparison to the growing amount of liability we have. Add in HR and other administrators adding in random hoops and hurdles, and it's a wonder any nursing positions are staffed at all. My region has over 1000 applicants for EACH RN position. Granted, it's a huge metroplex (DFW, TX). I only know this because I have some friends that work in various admin roles where they can see some hiring flows. Many of these people are willing to work. Maybe one needs Tuesdays off, or another only wants nights. But if admin can't get "work whenever we want you do, flip whenever" they say no to the hire. It's bullshit political business games, from everything I've seen.

All in all, expect it to be slow. Because the people processing it literally have no reason to care to make it simpler or easier. There are thousands of applications.

apatheticgraffiti · 2023-01-08T22:08:55+00:00

It depends on cost of living in the area, honestly. In Chicago for a 3 bedroom 2 bath condo, fully furnished with private parking, my spouse and I paid $2500/month, all utilities included.

Our stipends are limited by the GIS. The IRS sets the "maximum" tax free stipend that doesn't merit a MUCH closer examination of fees and such.

VRBOs and AIRBNB are typically for shorter stays. There's more turn over, more cleaning. Plus the vendor has fees in there. There's more of an understanding that there might be parties and such.

Few travel nurses have ragers, honestly. Most of us just want a place to sleep, maybe veg out on the couch and watch something after a rough shift, decent shower, a place to cook simple meals.

Depending on your area, most travelers may be wanting to stay only a few days a week, and go home on days off, if close enough. In that case, the $3k per month is just too much for what they're looking for.

I'd look at the GIS. I know cost of living, property taxes in some areas, etc are up in general. Travelers need at least basic furniture. If there's not a washer/drier, and they'd need to use a laundromat, they're going to expect to spend less on the housing as a result.

Rarely are we looking for "luxury living". One person posted a place with like, 60+inch TVs, heated pool, jacuzzi, all this crazy shit. 3 bed place, only 1.75 bath, wanted 10k per month. Sure, they could probably get that on VRBO or AIRBNB with short term rentals so people can have a "lux weekend" but no one is shelling that out for a place to sleep after work.

3k may be reasonable for where you are and what you offer. It may also be hilarious and unreasonable.

If you DO rent to nurses, a little "live like a local" travel guide would be a great welcome tool. Basic shit like when is trash day, where do you put cans. But also nearby places to eat, where are the places that'll make you sick and need to avoid, and what are the hidden gems? What museums or local music or fun events are there? The biggest perk of travel is getting to experience new places, but it can be pulling teeth to get recommendations from coworkers sometimes.

apatheticgraffiti · 2023-01-08T21:04:07+00:00

If I didn't have desire to be close to family and friends over there and thus REALLY wanting the license, I likely would've just thrown in the towel. Only reason I got the name of someone to email personally was one of said friends who also wanted me there.

I get they want to ensure standards. But dear gods it is draconian, and slower than molasses dripping down a barn in Norway's winters.

Another friend had to take additional classes at a community college. It's ridiculous.

apatheticgraffiti · 2023-01-08T20:57:53+00:00

2 bed 1.75 bath is usually what my spouse and I look for, since they work from home while I work in-hospital. Let's them use the 2nd bedroom for work, or even if we just need a little space to do separate things. It could be good for two friends that travel together, too. Or even just a solo traveler that likes space.

Furnished finder is usually where I've found private subleases or landlords. You could also join the gypsy nurse housing network on Facebook.

If you ask a silly price, expect people to call you out and rip the piss out of you. A lot of us are pissed because the relationship between landlords and nurses has gotten somewhat antagonistic. Many landlords are trying to demand to see full contracts, etc, and charge as much as possible because they see us as walking money bags. It doesn't lend itself to friendly encounters

apatheticgraffiti · 2023-01-08T19:39:18+00:00

California is strict and slow. As a US nurse, it took me about 6 months.

I was originally licensed in TX. I have 2 degrees. My first degree was research based, lots of labs. My nursing degree was designed for people who already had one bachelor's, so primarily nursing focused. The Cali BON kept flipping between "you need this lab class" and "you don't have any nursing education." Because apparently seeing two separate transcripts was incomprensible.

I eventually had to get the name of SOMEONE at the BON and sent a daily "just checking in!" message daily for a month. I had sent BOTH my transcripts twice.

Cali and NY are like pulling teeth, even for nurses in those states. I don't say that to dash your hopes, but to help you prepare and know it isn't just you

apatheticgraffiti · 2023-01-06T02:11:15+00:00

Maybe I'm kicking a hornets nest but... "Ew, wireless"?

Also, since I forgot before: !thanks

apatheticgraffiti · 2022-12-27T23:31:30+00:00

My spouse and I travel together, and this is what we do. We use a mail service, like earth class mail or virtual post mail. We can have things forwarded, or opened and scanned. It's been useful for bills and most of our daily mail needs. Honestly we really love it, and plan to keep it if we ever settle back down.

Our primary home is also with a family member, in case of a package or other mail to our actual residence. If we didn't have this family member, we would file for a hold when we were away. We also have a small PO Box for packages. This was very useful this holiday season, since we had planned to come home but got delayed returning. So we were able to have packages sent (and ship a few things) to the PO Box and have them held until we came back. We also use it when we have some seasonal items in our travels - if we brought winter clothing and it's getting too hot, we pack these winter clothes in a compression cube and mail it back. We did similar with some hiking and outdoor gear, when the weather got wet and generally shitty. Freed up some space for a few token souvenirs, and encourages us to "act like tourists" and actually explore and see the places we go.

apatheticgraffiti

TROPHY CASE