Tobin Insights

Who and what will define your life?

2011-04-16T17:35:00.004-04:00

"Unless you change your canvas, today's thoughts will paint your tomorrow."

People will come into our lives, some will stay forever, others will stay for a while and then they will be gone. Some will mentor us and enable us to be all we can be. Others will hurt us and the pain will go deep.

When the hurt comes will your eyes focus back to the past and let the pain remain the center of your life?
or
Will you move beyond the hurt, keeping your eyes focused forward?

“You spend a lifetime learning and an eternity owning your choices.
Make the trip a good one.”

Who and what will define you?

New, Old, Indifferent…

2010-12-28T14:17:00.002-05:00

Over the Christmas holidays I watched several football games and as I watched the different teams, it was easy to spot the teams that had been together a while, the teams that had some seasoned players and some rookies and sadly the teams that were thrown together.

One team I watched had a proven quarterback, however, the receivers and line men were new. The quarterback was getting sacked right and left because the linemen were unable to hold the line. If the quarterback did get a throw off, the receivers were having trouble holding onto the ball. I saw another team that the receivers were in place and open, but the quarterback hesitated too long.

As I watched the different teams play, my thoughts drifted and I began to think how much work teams are like sport teams. Each player/worker has a position and that position comes with duties and responsibilities. If just one player/worker is not functioning well or not being responsible, that player/worker can affect the out come for the entire team.

I watched a team that in the past has been a contender for the Super Bowl several times, but this year their fumbling and frequent missed throws were going to keep them on the sideline. It appeared as if this Team was not communicating. The owner was interviewed and he was behind his players 100%. However, his enthusiasm and support were not enough to carry the team forward to victory.

Another team I watched had lost for years and years, but this year they are headed to the playoffs. I found myself cheering for them even though they are not my home team. I admired their tenacity. The owner did not give up on them and the team did not give up on themselves. For years players on this team came and went but finally the mix became right and the team moved forward.

Companies like sport teams have good years and bad years, however, if the players/workers stay together long enough and they all keep their eyes on the objective, victory will be tasted.

A real sharing and a choice!

2010-10-23T16:06:00.006-04:00

The shift began with the news we had a nurse call off and each of us would be carrying extra patients. The nurse before me left 8 infiltrated IV’s and an open wound that had not been repacked since 11:30 am, plus three other treatments that were not done at all. It was going to be a long night.

A few hours into the shift, I found myself sitting in a pool of urine with my left shoe hardly on and my right knee smeared with feces. I was on a hospital floor with my 82 year old patient, Molly*; my arms were curled around her and I was rocking her back and forth. Molly was crying and I had tears running down my cheeks. I had frightened her when I pulled her off of the bedside commode as I entered the room responding to a code that had been called on her. When I lifted her up her arrhythmic heart beat converted to a normal rhythm. It was a false alarm triggered by her excessive straining. In the rush of everyone entering the room, the bedside commode got knock over and thus the reason Molly and I were sitting in urine. Molly’s tears were from fear, but mine were from exhaustion. This was the third “code” called on my unit and my patients this evening and it was only 8:03pm.

After I got Molly back in bed, I took a minute to change my clothes and as I was in the lounge I thought, "is this what it is going to be like all the time?" Will I ever get comfortable at what I do?" I sat down, cried for a minute, then got back up and went to the unit.

This was my first job as an RN and I was in my eighth (8) week. My orientation was five (5) days long. On the first day, I did paperwork and watched safety videos. The next three (3) days I shadowed another RN. On the last day, I observed activities in the ER. After my orientation, I was assigned to the Med/Surg Unit and given a full load of patients on the first day.

All I ever wanted to be was a nurse but tonight I was wondering if I had chosen the wrong field. I doubted if I had what it took to make it as an RN. At home that evening, I played the shift over and over in my mind. I needed to assess my actions. Why did I respond the way I did? Why did I cry? I tried not to be too hard on myself, but the bottom line was if I did not want a repeat of tonight then I had to make a change. As I reviewed, it came down to one major issue: I doubted my clinical abilities. I was uptight because I was afraid I would not know what to do in an emergency. I had to find away to increase my faith in myself.

I had read a story written by Walter Cronkite where he shared that he learned early on that in order to be a success you needed to be prepared. He said for every story he expected to cover, he thoroughly researched all the available material regarding the event, the background, and the major persons involved. He went on to say he did not design plans or labor-saving machinery that might permit him to skip this essential step to doing his job to the absolute limit of his ability. His motto was: There are no shortcuts to perfection.

“Reading a book is never enough to make a difference in your life. What has the potential to make you better is your response.” John Maxwell

I figured if Walter Cronkite had to keep studying and preparing for his commentaries all of his career, perhaps that is what I was missing. I quit preparing when I finished my nursing boards. The next day I arrived at work a half hour early. I did not clock in because I was there to prepare! I brought with me several index cards and a small notepad, both of which could fit into my uniform pocket. I picked up my assignment and went to the patient kardexes. I searched each kardex for treatments, medications, procedures and unusual occurrences. If I found something I did not know or understand, I went wherever I needed to go to learn what I needed to know to do it right. I wrote procedures step by step on the index cards and then I attached them to the kardexes. If there was a medication that could cause a certain reaction I was not familiar with I wrote that on an index card and attached it to the med sheet. I was getting prepared.

For the next few weeks on my breaks, I wrote signs and symptoms and complications that could occur on the type of patients that were admitted on our unit. On one side of the index cards, I wrote the diagnoses and on the other side I wrote the signs and symptoms and complications. It was a great learning tool. I brought in a recipe box and stored my index cards by diagnoses in the box and put it at the nurse’s station. I started making care plans for the typical diagnosis we admitted, this way when a patient was admitted I could pull one of my pre-made care plans and tweak it to fit the current patient’s condition.

I found by taking these preparatory steps I was reeducating myself and building my belief in my clinical abilities. I was no longer frightened of what a shift might bring; I was now looking forward to each shift as a growth opportunity. What really took me by surprise was in a short period of time, I noticed the other nurses on the unit referring to my index cards and using my pre-made care plans. I was no longer just helping myself; I was now helping my team mates.

Lesson learned:

1. Make a decision - stay or go
2. Look around and take a hard look at what is happening.
3. Ask yourself, what part of this situation do I own? What part can be changed? What part do I have to let go because I do
not have the power to change it?
4. Do something

I had two choices:

I could blame others for my issues – after all the “other” nurses did not do their jobs completely – the “other” nurses did not run to help me and ease my burden – I did not get “enough” of an orientation – it was the hospital’s “fault” etc, etc, etc. - they, they, they, --- in other words I could take the “victim” route

Or

I could come up with solutions and climb over my stumbling blocks to victory. Take ownership and make a difference in my life.

To no surprise, I stayed in Nursing. Did I have other nights that were worst than this one, absolutely. Did I cry again, yes I did! However, my behavior changed and again and again I found solutions and moved on.

“You spend a lifetime learning and an eternity owning your choices. Make the trip a good one.”
(peg tobin)

* Molly is a fictitious name to protect the true patient
** the year is 1985 prior to package care plans and computers at the nurse’s station

What foundaton is your company built on?

2010-08-29T08:04:00.012-04:00

Individuals that build their company on dishonest practices and justify their actions by saying they are "entitled" will bear fruit that is rotten.

As Abraham Lincoln said:

"You can fool all the people some of the time and you can fool some of the people all of the time. But you cannot fool all the people all of the time."

The foolish think the truth will never come out. The wise know better and they know lies beget lies.

Build your foundation on truth and honest practices and you will bear fruit that is sweet and that fruit will become a legacy.

Good happening or bad?

2010-08-14T11:51:00.004-04:00

I spoke with an individual the other day, she is an RN and has worked hard to get where she is today. She has had multiple successes and has earned an outstanding reputation by/of improving facilities and regions. However, she was hurt and wanted to share a situation with me. As she spoke it brought back memories of my own similar experience. This Executive Nurse was brought in to help turn a facility around. During her time at the facility a grave incident occurred. This Executive Nurse got busy developing a QA program to rectify the situation; however, the company she was working for had other plans. They brought someone in with “white-out”! This Executive Nurse refused to use the white out and guess what happened to her?

Does any of this story sound familiar? Does the thought go through your mind, “Really, this stuff still happens?” Do you sit and scratch your head and wonder why the one with the ethics is out looking for a job?

Would you say that things ended badly for this Executive Nurse or good? If we accept this scenario at face value we might say it does not look like it ended well for her. Long hours of hard work and still she was out!

However, had she stayed would she be available to walk through the next open door of opportunity.

It is interesting how things play out in one’s life. It is my belief that your attitude will be the barometer to your altitude. You can either look at the glass half full or half empty. If you believe in yourself, others will believe in you. Present yourself well and let your abilities shine and other organizations will want you.

It states in the scripture that if you are not received well in a town, to shake the dust from your feet and move on. If you are put in a position that does not line up with your ethics then be thankful and move on. Why would you want to work for a company that you cannot support enthusiastically? A grave incident is bad, but what is worst is for the issue not to be fixed and there be another grave incident.

There are lots of great organizations left and I am honored to have the privilege to represent them.

For all of you professionals that have been put in a position to say no, pat yourselves on the back and take pride you got fired. Rejoice! You have been released to take your positive energy to a company where white out does not exist.

By the way, I have read the end of the book and the good do win!

Perspective

2010-06-30T16:36:00.004-04:00

It was a bright sunny autumn day and I was just getting to work, standing at the Nurse’s Station to greet me was Zena, one of our facility residents. She had a big smile on her face and was dressed for the day. As I approached her she said, “Hi, Peggy.” I said hi back and as I did I noticed Zena’s shoes were on the wrong feet. I told Zena she looked really nice and we exchanged some pleasantries about the weather. However, before I walked away, I told Zena she may want to check her shoes because they appear to be on the wrong feet.

Zena looked at me with puzzlement in her eyes. Then she looked at her feet, then back at me, then at her feet again, then finally back at me and stated clearly,

“No those are my feet.”

(the real person's name was changed to protect her privacy)

You

2009-11-27T14:50:00.002-05:00

When the sun is straight up and brightest, the shadow you cast is small.

When the sun is rising or setting, the shadow you cast is long.

When there is brightness in your life, one does not need an extension of themselves.

When the light is dim, you may need an extension to be seen and heard

As you go through life select your friends well for they will be the extension that defines you as your light dims.

Knowledge

2009-09-16T16:47:00.001-04:00

Knowledge is a platform on which one can stand more securely.

Read to a man and you control his knowledge, teach a man to read and he will choose his library.

Thoughts

2009-06-29T16:37:00.003-04:00

Wisdom is learning to listen to the unspoken word!

Darkness will come in one's life, how long it stays is up to you!

Dream loud!

Look a person in the eyes, for their eyes will let you into their heart!

If you give more than you receive, Celebrate!

An honest friend is a saving's account for your emotions!

McDonald Hire

2009-04-02T10:14:00.006-04:00

Time is short, your back is against the wall, you are down one assistant with pregnancy, one with emergency surgery, and one with pneumonia, what are you going to do?

You have tried everything but giving birth to a full grown nurse assistant. Administration tells you agency is not an option. You have to have staff on the floor. Who will care for the residents?

You open your office door, music from “Chariots of Fire” starts playing, a bright light appears over your desk, and the room fills with the fragrance of fresh cut roses … nay... you are dreaming! It is the same old office and the same old smell. Back to reality!

If there was a quick fix, I would package it, sale it and retire to an island without phones.

On your desk sits 4 resumes of candidates that you pushed aside, but now in the “real light” of day, you think they might not be so bad. Their references are good, they have moved around a lot, but they have no charges of abuse, they are not felons, they are certified and “WHAT” they can start right away!!

The past has taught you these types of candidates will be gone in a month or at tops, three. However, today a month is a very….long time. These are what I call “McDonald Hires”, no one wants a steady diet of McDonald’s food, but when you are real hungry that “Quarter Pounder” looks de..li..cious..!

A facility of McDonald Hires would end in disaster just like a steady diet of McDonald’s food. The cholesterol would kill you. Staff that only stay for a month or two would be very unhealthy for the residents! Medication errors would occur, baths would be missed, dressings would not be changed, diets would not be adhered to, etc. Continuity of Care is essential for residents and that can not be attained if staff come and go through a revolving door.

With that said, in times of emergencies, emergency measures must be taken. However, an emergency situation is short lived. The McDonald Hires are only there to give you and the hard working staff a break. Take the break, but know it is short lived. Get strong and then get out there and do what you have to do to develop a pool of interim staff.

When I was a Director of Nursing (I had to walk two miles in the snow to get to work and it was uphill both ways) in the great state of Ohio, there were several nursing homes in a 6 mile radius of where I worked. I invited the DNS’s of these homes to meet with me and discuss developing a pool of interim staff that we could all call on to use during times of shortage. We had to agree to share the on call for this pool, to set the salary the same, to keep the benefits the same, to sign a non recruit and non compete, to serve first called and to have the same job descriptions and requirements.

It took us a while to work through things and a whole bunch of cooperation, but we did it and for the remainder of my time as the DNS (one and half years) in that facility we were able to successfully share a group of staff. We were able to keep the pool staff busy between the 5 facilities.

It really does take stepping outside the box to make things work sometimes.

Remember you can now train volunteers to feed residents, therefore, if you train a few of those to feed and those same volunteers can help escort residents to the dining room, they can serve trays, they can make beds, they can set up the shower room with wash clothes, towels and resident’s clothing and bring the resident to the certified nursing assistants to bathe the resident, etc., etc. These things can help in a pinch and it definitely frees up the nurse and the nursing assistants to do what is required of them. Do not forget to train these volunteers on HIPAA and have them sign off.

McDonald’s anyone?

Written by Peg Tobin

Long Term Care - How to calculate Nursing hours allotted per day per patient/resident (PPD)

2009-03-19T12:34:00.007-04:00

PPD

If you want more staff for your department, better equipment and higher salaries, you as the Nurse Manager have to show that your department is capable of helping produce revenue and that you are a good steward of the funds you are entrusted with to run your department.

Federal Nursing Personnel Staffing Requirements for Long Term Care

F353

Nursing Services

The facility must have sufficient nursing staff to provide nursing and related services to attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care.

Intent §483.30

To assure that sufficient qualified nursing staff are available on a daily basis to meet residents’ needs for nursing care in a manner and in an environment which promotes each resident’s physical, mental and psychosocial well being, thus enhancing their quality of life.

Procedures §483.30

§483.30(a) and (b) are to reviewed during the standard survey whenever quality of care problems have been discovered (see Appendix P, Survey Protocol, Task 4, for further information and Task 5C for the investigative protocol to complete this review). In addition, fully review requirements of nursing services during an extended survey or when a waiver of RN and/or licensed nurse (RN/LPN) staffing has been requested or granted. Except as licensed nursing personnel are specifically required by the regulation (e.g. and RN for 8 consecutive hours a day, 7 days a week), the determination of sufficient staff will be made based on the staff’s ability to provide needed care to residents that enable the to reach their highest practicable physical, mental an psychosocial well being. The ability to meet the requirements of §§483.13, 483.15(a), 483.20, 483.25 and 483.65 determines sufficiency of nurse staffing.

§483.30(a) Sufficient Staff

§483.30(a)(1) The facility must provide services by sufficient numbers of each of the following types of personnel on 1 24-hour basis to provide nursing care to all residents in accordance with resident care plans:

(i) Except when waived under paragraph © of this section, licensed nurses; and

(ii) (ii) other nursing personnel.

§483.30(a)(2) Except when waived under paragraph (c) of this section, the facility must designate a licensed nurse to serve as a charge nurse on each tour of duty.

For interpretive Guidelines and Probes on §483.30(a) see tag F354

PPD is based on an average acuity level of the whole. This level decides the amount of nursing hours allotted per day in the nursing department.

Do you know your PPD?

Do you know on what your acuity level is based?

Have you seen your nursing budget?

Do you know who is inlcuded in the nursing PPD?

How much of the PPD is for Direct Care Nursing?

How many nurses included in your PPD are salaried?

Once you have your direct care PPD, you can figure

the amount of hours allotted each day.

Take the PPD and multiply it times the

number of residents/patients in the facility.

Once you have a PPD it remains the same

until the acuity of the residents/patients

change.

The allotted hours may change on a daily

bases related to a change in the census.

If the census is 80 you multiply it x 3.2

the nursing department will have 256

hours in nursing allotted in 24 hours.

(76 x 3.2 = 243.2, on so on)

With a grand total of 256 hours, you will still

need to break those hours into RN, LPN, Restorative

Nurses, Restorative Aides, Med Aides, CNA's, etc.

To figure the PPD for each discipline you can either

look at the facility budget or:

Take a look at how many RNs are allotted for a certain census.
Then take the number of LPN's and then CNA's.

If you are allotted 3 RN's in a 24-hour time limit, then take how many hours a day they work and divide the census into that amount - 3 x 8 = 24, then divide 24 by the census 80 = .3, thus the PPD for RN's for the day is .3. If you have 6 LPN's in a day, 6 x 8 = 48, then 28 divided by census 80 = .6, thus the PPD for LPN's is .6

If you are not certain what the PPD is for your unit or facility, then you can reverse things and figure the PPD by using the hours you have scheduled nursing staff and divide that number by the census. If you have 280 hours scheduled and the census is 82, then the PPD for nursing will be 280 divided by 82 = 3.41. To figure the PPD per discipline, you would do what you did in the previous paragraph.

Gone

2009-03-17T17:13:00.003-04:00

Try as you may yesterday is gone, never to be revived. May it have shown you:

• Thankfulness is learned by those that forgive.
• Sensitivity is learned by injustices.
• Importance is fleeting.
• Real life heroes have faults.
• Life continues.

Yesterdays build our todays and goals give us our road maps for tomorrow.

Written by: Peg Tobin

Could you hold the flashlight closer?

2009-03-17T09:48:00.004-04:00

Could you hold the flashlight closer?

It is hard to see the light at the end of the tunnel!

By Peg Tobin, RN

MDS+, MDS 2, MDS 3, PPS, Y2K, New Survey Processes, Sentinel Events, etc., etc., etc. Every time you turn around as a Nurse Manager in Long Term Care there is a new compliance or perceived new compliance. Deadlines are set for new procedures and if they are not in place the facility will be monetarily fined by the regulatory agencies. Surveyors may not know what they are inspecting, but the Nurse Manager is supposed to figure it out and have everything in place before the surveyors arrive. And they wonder why nurses do not flock to be managers in Long Term Care?

When I was selected the first time for nursing management, I was excited. Foolish me, I did not know it was merely attrition. I was told there were many perks to being a Director of Nursing Services:

It was easy to lose weight, because you never get to sit long enough to eat a meal.
Bed head was a thing of the past, because your head rarely hit the pillow long enough before the facility was calling you.
Saving money was easier, because you are not home, thus lower utility costs.
Plus you save money on toilet paper because you only have time to go once a day.
No worry about obtaining a cell phone or pager, the facility will be nice enough to provide you with one.
Energy saved on developing relationships with staff, because employees used a revolving door.
You learn how to leap tall bedside commodes with a single bound and save a resident from slipping to the floor.
You learn to multiple-task, like bath a resident, answer the cell phone and handle a physician’s complaint all at one time. You are unstoppable.
You get to learn so many other professions as you hold down your own full time position, such as being a scheduler, cook, housekeeper, admissions coordinator, social worker, you name it and in no time you will know how to do it. And by the way at no extra charge.
The best perk of all they told me was comp time

With these great perks, how could I want to do any other job?

You may think I am slightly nuts, but I would not trade one of those days as a Director of Nursing Services for anything. I know staff came and went, but I appreciated everyone of them for giving it a try. I remember interviewing people and thinking, “They are breathing, they can bend, they are certified, I wonder if they can start in 15 minutes?” Times have been and are going to be hard in the long term care industry and any other health care arena, however, the bottom line is the patients and residents need us.

There is a light at the end of the tunnel. No matter how dim it looks right now, it will get brighter. It has to; the infirmed are not going to go away. We have to survive and we have to learn how to survive.

Complaining has never solved any problems. The squeaky wheel does get the attention, but that does not mean that is a resolution. Solutions and a desire to make things work do solve problems. I have found I can complain about the fact I can no longer fit into a size 8, but if I really want to make it happen I have to change my attitude and behavior.

There are some things I will never change. It is inevitable I will grow older each year until I die. As with growing older, there are also some things we will not be able to change about health care. Learning the difference between what is inevitable and what is changeable is a beginning toward a solution.

Can one person make a difference? Yes, and for each voice you add, hope gets heard louder. You have heard the phrase two heads are better than one, can you imagine what a thousand heads can do? The Health Care Industry needs changes and we Nurse Managers have to get involved. I know it is easy to say, “I am too busy, I really cannot take on one more thing.” I know that is a true statement, but trust me you are going to get busier in the future if you do not take action now.

Nurse Managers need to get involved with other Nurse Managers. It is hard to see different solutions if the only input you receive is from one organization and one facility. Nurse Managers need to share ideas, even if they seem weird. It is for sure the sane ones are not working.

Compliance issues are big, but how important will they appear if we have no staff to implement them?

When we graduated from Nursing School we carried a lighted lamp to represent Florence Nightingale. Florence was a pioneer and she helped establish the nursing field. Like it or not, it is our turn to help establish the professionalism of nursing in health care.

As leaders in our industry, if we stand together and work together, we can make a difference. We can redevelop communication lines among each other and perhaps put a halt to hiring the same bad apple over and over. We must stop being held prisoner by poor workers.

Nurse Managers need to be proactive. If we get out and help lay ground work for the future, we can be ready for tomorrow. Join groups and learn how to write congressman, senators and even the president. Ask them to help change the image of health care. Give these representatives ideas on how they could better represent us. With their help and a change in our image, we will be able to recruit to nursing.

Visit colleges and volunteer to speak to nursing students and introduce them to your chosen industries. There are many types of specialties in nursing and each is rewarding. “Wine and dine” nursing school teachers. Ask these teachers to take a look at where the care industry is headed. Ask for their help. Demonstrate the changes that are taking place in the health care industry and show nurses that hospitals are not the only places graduate nurses can develop technical skills. Today’s sub acute units are what hospitals use to call medical care units a few years ago. Who ever dreamed we would be doing telemetry and dobutamine drips in Long Term Care facilities?

Approach high school counselors and volunteer to have a student interested in health care shadow you for a day.

Improvement starts with action. I am not advocating that Nurse Managers take up a lamp like Florence Nightingale, but it would be nice if each one would agree to help make a difference. Local nurse’s groups are a great place to find other leaders wanting their voices to be heard.

Grab a flashlight and hold it up so other nurse managers can see they are not alone and that you agree the patients and residents are worth standing up for and you can see the light at the end of the tunnel.

One last thing, I have learned it is inevitable I will not fit into a size 8 again.

“If they speak not according to this word, it is because there is no light in them.”

Isaiah 8 v 30 (KJV)