Tuesday 24 January 2017

Www Nursing Care Plan

what's going on guys, jon here with nrsng.com.today, i'm excited, it's my turn. heather has been stealing all the camera time andtoday it's my turn to actually come on here and talk to you guys live on facebook live.our topic tonight is going to be ... i'm going to give you guys four tips on how to get ajob in the icu as a new grad. as a lot of you guys know, that's where i started as anew grad. i talk about it all the time because look, i love the icu. that's where i alwayswanted to work, i was able to get a job there starting out and i wouldn't have been ableto survive anywhere else probably. i'm going to give you guys some tips, fourtips. i want you to get a sheet of paper and some notes, and get stuff to be able to takesome notes because i think we're going to

give some good tips here tonight. before weget started, as you guys know, as heather has shown you, we like to give away a freebie,give you something for coming up here early. if you go over to nrsng.com/ivfluids, you'llbe able to get our cheat sheet that goes over, you can see a little bit in here. it goesover different types of crystalloid iv solutions. that nrsng.com/ivfluids. make sure you headover there. it has basically every crystalloid iv solution you're going to use, it talksto you about everything you need to know about that. what we're going to talk about tonight, i'mgoing to give you these four tips and what i wanted to do after that is have a q & aand talk all about icu nursing. any questions

you have about starting in the icu, any questionsyou have about that stuff. one other thing that i want you to do though is if you'reinside your post, i want you to like, comment and share, that'll help get people in here.let's get this going here tonight. if you're on a mobile, you can push like as many timesas you want, i'm okay with that. i can push love, you can also push hate if you just aresick of hearing me, sick of seeing me, or you can just keep on liking that. leave ussome comments. what we're doing tonight is i have my widesandy here. she's going to help with the comments because it's really hard to talk to you andmanage the comments at the same time. one other thing i want to show you ... i lied,two other things i want to show you. this

week we launched a brand new podcast, thispodcast is the nursing mnemonics podcast, and it is hosted by kati kleber. she's workingwith us here at nrsng.com. this podcast has ranked as high as it was the number one podcastin all medical podcast in itunes for a little bit. if you go over itunes you can go to ourblog, and you can search on the podcast there, and you can find that. lastly, we're going to be doing this new seriescalled nursing shorts. me and heather are going to get our kids together. heather hasa three year old named harper, and i have my son taz, he's just turned five, and we'regoing to do the series where we have them give you nursing tips. we're not going tolet them say whatever they want to or anything

like that, but we're going to have them sharewith you some other things. i want to show you where we're going with that. let's get rolling on today's topic. we'regoing to talk four biggest things that you can do as a new grad to get a job in icu.if you have any questions, any comments, any complaints or anything while i'm talking,just go ahead and post them below and we'll try to answer them as quick as we can to makesure we get you guys some answers. the first thing i want to share with you is there'sthree search engines that you need to use to find a job in icu. they are google, indeedand allnurses. if you go to google.com, obviously everyone knows about google.com. go to google,and the first thing that i want you to do

is i want you to understand how hospitalscall new nurse job. the way they're going to call them is there'sgoing to be new grad rn, it's going to be new nurse residency, nurse internship, nurseresidency program and nurse graduate program. those are five ways that hospitals will mostoften call these new grad jobs. in the dallas area there's three trauma 1 hospitals, andeach of those hospitals get about 800 applicants for these job, so it's really important youfind out when these jobs are out and you find out how to apply to them. the best thing you can do first of all isgoing to google and typing in those keywords. if you do that ... i just did it here. letme show you my desktop really quick. if you

type that in, new grad rn icu residency, itbrings up jobs from indeed, it brings up jobs from vanderbilt, from penn, from wisconsin.you find all these jobs really quickly by just typing that in there. once you have those,you can also take those same keywords, those new nurse residency, new grad rn position,nurse internship, take all of those and head over to indeed. it's indeed.com, and typethose same keywords in there. you can filter it down by location, so you can filter downby texas, by dallas, by a zip code. what that'll do is it'll bring up all these hospitals thatoffer new grad residency programs. once you have that, you can go to those hospitalsand find out when they offered them, when you're supposed to apply and things like that.what you would do is take your piece of paper

and you write down all those places. you headover to allnurses.com, everybody knows allnurses.com. you head over there and you type in the internshipfor the hospital. let's say it's duke. you find out about a residency at duke. you goover to allnurses, and you get into the forums, and you find out what they hospital specificallyis asking for. question. yes. will hospitals be interested in nursingstudents who are two semesters from graduating? that is a great question. the question is,will be hospitals be interested in nurses that are two semesters away from graduation?that is a hard question. what i would do if you have not graduated yet, is i would waituntil your last semester before you really

even worry about this. i let myself worryabout this like three semesters from graduating, i've seen nurses do that before, is they wait... they start applying and they start worrying about getting a job before they even havetheir license. to give you a quick answer to that question,most hospitals won't even blink an eye at you until you already have your license, untilyou pass the nclex. they really want to make sure you have that license in hand so thatthey know you're ready to walk on the floor and get going. however, it is possible, andi think it's plausible and it's doable to apply for jobs, start applying for jobs duringyour last semester especially for this residency type jobs. you can [spine 00:07:46] theseplaces that are doing these residencies, and

you apply ahead of time because they usuallystart posting those four to six months before they expect you to start. if you apply to that job and with them knowingthat you're going to graduate, you have a graduation date, and then by the time youstart you're going to have your nclex done out of the way and you'll have your license.those are the key words i want you to search. that's the biggest thing, is understandinghow hospitals look for those things. the next thing i want to talk about, i'm going to popthis up here, is references and connections. a lot of people overlook this. nursing isa small world. there's three to five million nurses in the us, and that's a lot, but whenyou think about it nursing really is a small

world. one more question. yes. from tori. what's a good reasonable startingsalary should we accept from job offers? tori, where do you live? i don't know if thiswill probably too delayed to find out where you live. that's going to depend a lot onwhere you live and whether or not there's unions where you live, and what your shiftand staff would be in, and with differentials. with that said, i think low end, the lowesti would personally take ... texas pays pretty low honestly. starting rate, lowest i wouldbook like $23. people in california and new york and stuff ... why are you laughing atthat?

north carolina. i can give you a direct advise on that. iwas offered a position at duke university hospital in their icu after i graduated school.what duke offered four years ago or so was $21 an hour, so it's pretty low. maybe ifkati's watching, kati kleber, if she's watching she can maybe bump in there and say what sheactually makes in that area of the country. duke offered about $21 an hour with differentials.the way it usually works is you get raises every six months. the way my job works is it started prettylow, it's $23 an hour which is low for a lot of places in the country, but then what theydid is the first six months was $1 raise,

the next six months was $1. you got a $1 raiseevery six months for the first two years, and then you also got your performance reviewraises which came out to â¢50 to $1 more an hour. differentials, so differentials is whereit's at. i actually have a blog post. if you go on our blog, i have a blog post about howmuch i made my first year of nursing. my base salary was $23 an hour, it wasn't much, butin my first year i was able to make just a little over $70,000 a year because i bookedmyself out on weekends. usually you'll make a differential for working weekends. wherei worked, it's $6 extra an hour just for working weekends. for me it's a no brainer, i work friday, saturday,sunday. you get differential for working nights

which is an additional $3 or $4 and hour,and then you get differential for ... you get time and half if it's under staff, soi'm always in there when it's under staff. you could make a lot of extra money like that.that's probably a very vague answer to your question. in oregon i know i have a friendwho just started up in washington state. she's making $35 and hour on day shift. i wouldsay out in north carolina, i wouldn't expect, especially from the larger university hospitalsmore than probably $25 an hour or so. yes, another question. yes, from jill. if someone wants to land inicu someday, is it wise to start at a trauma level 3 hospital?

let me clarify the question. say the questionone more time. if someone wants to land in icu someday, isit wise to start at a trauma level 3 hospital? trauma level 3 as you know is the lowest levelof trauma. here's what i think. if you want to work in icu at a trauma 1 hospital, inthe big city, something like that someday, i'd personally don't think it matters whatlevel of trauma icu you started. if you do want to go to crna school or nurse practitionerschool, it's going to be much more difficult for you to get into one of those programsif you're not in a trauma 1, maybe trauma 2. most crna programs require you to have trauma1 experience. as far as managers looking for

people in icu, it can be hard to find experiencedicu nurse, so even if the experience is from a trauma 3, trauma 2, you should be able toget a job in a trauma 1 hospital without much difficulty. if you get an opportunity topstart in a trauma 3 icu and that's what you want to do, i would take over that over trauma1 med-surg in my opinion. references and connections. let's go backto this really quick. if more questions, you guys bring them in, i want to answer as indepth as i possibly can. biggest thing i want to tell you with this is get connections frompeople that are going to sway decisions of the decision makers, of the managers. lookfor people like the dean of your program. i had a lot of meetings with the dean of myprograms. when i say that i don't mean that

they were necessarily good meetings. i hada lot of frustrations in nursing school like i do now with nursing overall. i had a lot of meetings with the dean of myprogram, but even with that, they saw in me that i was motivated, i was driven, i wantedto create change in nursing. she, even with all that, she still left a great review forme and a great reference letter for me. you want to look for people like deans of yourcollege, college nursing program professors, clinical instructors, physician that you mayhave built a connection with. look for those people as much as you can. number three here, your resume. i want toflip over to this really quick. let me just

show you this. here's an example of what anursing resume should look like. this comes from csu, california state university, chico.what i want to show that's a little bit different here on a nursing resume is that the verytop of it you should be putting your clinical experience. especially if you're looking fora job in icu, if you were able to rotate through an icu or be in an icu for any amount of time,for any reason, put that on top and show them that you're not just interested in icu, likeyou've actually seen it, you've seen what's going on. that should be the very top of yourresume. where people might not have experience as a cna or a tech or anything like that,you at least have your nursing practicum hours, and put those in order of ... if it's icuput it up there on top.

another question. from john. i'm having a touch time decidingwhether to apply to the department where i worked as an er tech or applying elsewhere.i know i'll have a job there but i'm afraid they'll assume i don't need as much trainingas other new grads. i'm really torn. that's a great question. that's a hard questionto answer. i mean you're right, that you would be probably a shoe in to the job, but i cansee the concern, i think that's a valid concern. that's one thing i was going to talk abouttoo is that the most important thing that i think you need to do when you're lookingfor an icu position or an ed position, or or position, one of these specialized areas,is start in a place that has extensive training.

you're going to learn everything you needto know through that training and through time. i would express that if you have a goodrelationship with your manager here is what i would suggest. is i would express that concern to the managerand let them know very upfront and from the beginning like, "i really want to work hereand you know that i'm doing a good job and i'm a great tech here, and i'm going to dothat as a nurse too. i'm going to be the best nurse you have, but i'm concerned. you know,what i'm doing as a tech isn't what i'm going to be doing as a nurse, and i want to makesure that we bridge that knowledge gap with a good preceptor and a good everything."

that might be a leg up you have on peoplethat applied for jobs there too, is you can let your manager know specifically like iwant this nurse as my preceptor. i want this nurse to be the one who trains me, and i wantto have just as long as training as everybody else. if you like the hospital, if you likethe people, that almost matters more than anything else. if you want to work ed andyou want to be there, i would just have a real sit down with the manager and see howyou feel after that conversation. from sarah. i have spoken with my hospital'sccu manger and she has agreed to let me shadow on my own time. i'm out for the summer anddo not start back third semester until the fall. i plan on shadowing as much as she willlet me. is this something i should add on

my resume? absolutely. definitely. the question is, she'sbeen allowed to shadow in an icu, at a critical care unit and she's asking if she should putthat on her resume. i would 100% put that on your resume. let me just flip over to thisscreen again. here's another example of a resume. i wouldput that at the very top here, where you have all your practicum hours. practicum hoursare essential in here, i would put that just below that and i would add up every singlehour that you're there, because what's that showing and that's something else i was goingto talk about too. what's that showing is you're driven outside of school, like thisis you doing clinical hours that you're not

getting paid for, you're not required to do,but you're just doing because you have a passion for nursing. managers want that. i've been in on hiring with nurses, i've playeda role in hiring new grads. what they want is they want people that are passionate andthat care about what they're doing, because that's someone they're going to feel comfortablewith when they have to go home and they're not on the floor. if you're absolutely passionateabout that and they can see that, i would throw that all over my resume and i wouldmention that. it's not paid experience, this is just you just wanting to be a nurse. putthat all over the resume. from joe. should i include any leadershippositions i held during my clinical rotations,

like for community, i was the leader for myclinical group and we organized a community healthcare? yes. the fact that you did leadership experienceand that you organized a health fair, that's awesome. another thing managers and hiringpeople are looking for, they're looking for ... this might sound weird maybe, but it canbe hard for managers to find the right people to move in to charge nurse positions and preceptorpositions. i know everybody that's part of this nrsng family, they're hearing that andlike, "what?" i know you guys are motivated, you guys are driven, you guys are part ofthis nrsng family and group because you're the driven people in nursing, but there'sa lot of nurses out there that are doing this

because it pays the bills and that's all. the fact that you have that leadership experienceand that you have that organizing experience of leading a team, i would throw that allover there. let me switch back to this again. you can see here, this resume here shows anexample of additional nursing courses, so this person obviously went to trauma or somethinglike that because they showed like, "hey, like i'm really driven with trauma and everythinglike that." anytime you don't have nursing or healthcare related work experience, i wouldbe beefing up the resume with everything else that is nursing related. the manager doesn'tcare about your job at cvs necessarily, they just want to know that you've had job andyou can hold a job. they'll love to see that

type of experience. from amy. we were instructed to put our servicelearning volunteer experience in the spot you had highlight it for clinical locations.would i put clinical experience first and then volunteer info, would that work? these are examples from ... this one fromhere is from linfield college. i would say if it's healthcare related volunteer experiencei would put it above it because, again, that kind of step outside of it all, and then puttingyour clinical experience maybe below that. i wish i had it here and i can't find it rightnow, baylor university healthcare system, big healthcare system here in texas, theyactually published what they want their resume

to look like, and i copied their resume specificallywhen i applied for my job, but it was something to this effect. yes, i would put volunteerexperience, i would put it up there as high as you can for sure. from marissa. i just got done with my secondsemester and a lot of my colleagues are interning. i see the word extern thrown around abouta lot on the job sites. is it possible to do both, an extern and an intern position? go ahead and read it one more time. i just got done with my second semester anda lot of my colleagues are interning. i see the word extern thrown around about a loton the job sites. is it possible to do both,

an intern and an extern? i don't know how to answer that question specificallybecause i'm not entire sure what the difference is going to be between the two. i'm tryingto remember back to those days. i'm sorry because i tried to remember what those were.is extern after you've finished everything? i can't remember what the difference is betweenthe two, but where possible ... number one, i would focus on your grades and creatingthose networks that are going to help you. i've been able to get three people or morejobs in my icu just because i knew them and they worked hard, and my manager knew thati worked hard so she trusted my judgement skills.

i would focus first of all on your grades,making sure your grades are good to get you where you want to go. if you want to be acrna, you want to be whatever, focus on that. number two i'd focus on connections. buildingthose connections, building up where you want to be and then i would focus on those otherthings. if it's possible, yes, throw as much healthcare experiences as you can, and thereare internship, externship job, whatever it is. we can throw the next two together. shaun.with the resume, would you add past work history, and if you're a medical assistant first beforebecoming a nurse? another one is, would it be a good idea to mention all my tech experiencein my resume and other experience in other

experience section? yes. there's really two ways to organize workexperience. the first way would be chronologically: i worked at cvs, i worked at mcdonald's, iworked at the hospital. or you can do by most relevant experience. when we're talking nursingjobs, i don't think it would hurt to organize by most relevant. just let your manager knowthat i wanted to organize by most relevant so you know what's going on. the only healthcareexperience i really had before becoming a nurse was working as a transporter for radiologydepartment. i put that up there that i had the chance to talk to these patients, andsee these procedures and do these things. i was comfortable in the healthcare environment.i put the other jobs that i had, and unfortunately,

a lot of those jobs weren't very long, theydidn't last very ling, they weren't very great jobs for healthcare. let me go down to number five here, is besociable. if you get the chance to get in front of a nursing manager and present yourcase, they invite you in for an interview. remember like i said in dallas, we'd get anywherefrom 400 to 800 applications for one job. if you get that chance to be what the managerand sitting down with them, be sociable. try not to be nervous, and i know that's reallyhard. right now i'm sweating bullets, i'm nervous talking to you guys because i can'tsee you. try to convey confidence and really learn a lot about the hospital.

the reason i'm saying that is because if youget the chance to be in front of them, they already want you and they just want to seethat they can work with you. outside of experience, if you don't have that experience, if yourgrades aren't what you wish they were, if you don't have whatever else it is, at leastbe sociable so they can make that connection with you and say, "okay, yes. you know jon,somebody that i could see myself working with." from liliana. will you be discussing interviewstrategies tonight? yes. what do you want to know? we can talkabout a few interview strategies. the biggest thing that i'm going to tell you is that goin there with confidence. the first thing you need to do before you even show up toan interview, and this applies with any job

but especially with healthcare, is get onthe hospital's website and look for their mission statement. every hospital is goingto have a mission statement listed on their website. go there, learn that mission statement, andthen get as much information about the unit that you can. what types of patients are theregoing to be? when i applied for neuro icu job, i honestly had no clue what i was goingto be seeing. i was like, "i don't know, seizures and stuff or gunshots?" i don't even know.i tried to learn as much of those procedures, and i tried to find out about the manager,i tried to find out about the hospital. have a nice portfolio like this and have your questionsalready written out that you're going to ask.

have 10 questions written out that you wantto discuss. what's the schedule like? how long will mu internship last? make them asbroad and as specific as you can think of. how many patients do we normally see in ayear? ask them business type questions too, they want to know that you're going to beinvolved. how long does the average nurse stay here in the department? that's what i'mgoing to tell you to do before you even show up to the interview. always dress in a suit or business attire,very professionally. i'm going to tell you guys again, you would be surprised how manypeople show up in khakis and a polo for a nursing interview. we work in scrubs so itfeels weird dressing up, but get yourself

a really nice suit, be really well groomed,and show up to that interview with confidence. you're going to be terrified. i promise you'regoing to be terrified, but show up with confidence and try to treat them as much like a professionalfriend as you can. sit there, cross your legs, have your questions ready, and be okay braggingabout yourself a little bit. when those questions come up about your biggeststrength, be honest. there's people that just said, "you know i was the leader of a communityhealth group and we organized this health fair that had this much attendance. and iwant to bring that same organization and that same drive, and that same leadership to thisjob. where i see myself going is i want to learn everything i can during this internship,and then i want to get my feet under me as

a new nurse, and then i want to start preceptingand teaching and sharing what i've learned." i would say be confident in yourself, be okaybragging about yourself a little bit, and then talk about the other person. if you canget the other person talking, they won't even realize that that's an interview. if you canask them about their family, "so why did you become a nurse? what are you doing here?"that's what's always helped me a lot in job interviews is get them talking. like i said,if you've gotten to the interview, you've already made it through the screening roundwith hr, you've already made it through the manager's first pass at your resume, you'vemade it to the hiring committee's pass at the resume. at this point you really justneed to show them that you're going to be

a good person to work with. from juzette. what do you recommend for someonewith limited work experience but a large number of clinical hours. limited work experience, large number of clinicalhours. build on that. show them that you're a clinical master. one advantage i kind ofhad maybe, maybe it wasn't an advantage, i don't know, is that when i got my first nursingjob i was 29 or 30 years old, so i had some work experience, but most of the people thatwere starting with me were 24, 23, just out of college. they didn't really had the workexperience either and a lot of them didn't have any healthcare experience either.

what they did have was that clinical experiencelike you're talking about. even if it's not paid clinical experience, show them that you'remotivated within the healthcare area. even if you don't have that broad reach of clinicalexperience, at least show them that you're focused on this job, that this is want youalways ... that's an advantage you would have over someone like me. i was 30 years old andi'm finally settling down at nursing. it's like, "how long is this guy gonna last?"the advantage of maybe you have of not having a lot of that work experience is letting peopleknow, "look, i'm driven in this profession, this is what i've always wanted to do, andthis where i'm going to stay. i wanted to get here as fast as i could, and that's whyi didn't waste time with other jobs." you

can maybe word it like that. would it be appropriate in the interview tobring up salaries? how would you bring it up in the most respectable way? when is the good time to bring up salaries?this is something that i probably stressed out more than i needed to about. here is thedownside with rn salaries is that they are pretty much set. if you're a brand new grad,i don't know if you're a brand new grad, you can let us know in the comments. if you'rea brand new grad you have almost no negotiation room. they have a published rate that theygive new grads, and you almost don't even need to talk about it because what'll happenlike what happened with the duke job.

they sent me a paperwork and it says hereis your salary, here is what you're going to make, here is when you're going to makemore money. if you're coming from a different hospital, you have a couple years of experience,this is the time that you can start discussing salary. sandy, you can correct me if i'm wrong,she's had many more jobs in hospitals than i have, i wouldn't probably even bring itup in the first interview. yes, i don't. i would've come back ... after they know theywant you. don't worry about being tacky in that first interview, just let it go, don'teven talk about it. leave that first interview with them wanting you. they're going to wantyou, and when they come back with the phone

call ... salary is really something you'lldiscuss with the hr anyway. am i right? yes. they'll bring it up a lot of times. hr will be the people that are going to talksalary not the manager. when they come back with the offer and say, "whoa" ... becausesandy has done this few times. they come back with an offer and she says, "that's severaldollars less than i was making before. we got to come up." they'll come up and they'lleventually get to a place you meet at, but interview really isn't the place to do that.interview is a way for them to see if they like you, and for you to see if it's a goodfit for you. did that answer the question? nursing salaries have ranges. usually brandnew grad there's a very narrow range, and

as you get more experience the range grows,but a lot of times people jump ships at hospitals because after that first year you can moregoing somewhere else. that's the recommendation i would have there. let me go back to this again. a lot of peopleare asking things that you would put on resumes. couple things that i would put on resume iswhat people want to see. they want to see your history of hard work. it doesn't necessarilyhave to be a long history of a lot of work but a history hard work, history of dedication.one of the guys that i was able to get a job at my icu, he had had a job at a clothingstore for six or eight years, so nothing related to healthcare but it showed like, this kidcan stick with folding shirts all the time.

you need skills. it doesn't have to be relatedto nursing or healthcare, but unique things. some other things i would add on there. ifyou're a member of student nurse association, throw it on there. if you went above and beyondand you got your acls, throw on there. you should have your bls already. did you createa club or group? did you do any research projects or research papers? we were required to doa research paper. obviously for my bsn, i put it on there, i was like, "dude i've writtenthese research papers. i'm motivated in this area." how many hands on hours do you havein an icu? how can i build myself up during an interviewfor a medical position when i've only worked in psyche substance abuse?

that's awesome. the fact that you've workedin something so unique ... if i was a hiring manager or if you came to me and telling methat you had that experience and you're looking at icu, or trauma, or ed ... sandy workedicu too. a lot of your patients are going to be substance abuse patients and psych patients.you'll be surprised how many eds and icus are kind of psych wards in some ways. justin your specific case, that's freaking awesome experience. i would talk about that, that about specificpatients you've worked with and how it applies to calming down patients in a hospital, becausethat's what nurses end up doing a lot of times, is keeping patients calm and explaining thingsto family members. in your specific case having

that psych substance abuse experience, i woulddefinitely tie that back into nursing. what we do as nurses, is we bring calm in the mostturbulent times in people's lives, and i would build that up as much as you can for sure.definitely, that's awesome experience. if you guys haven't yet, you can like, commentand share this little segue here. if you could just want to comment and tag a friend or somethingthat has questions about jobs and job searches. let me tell you specifically exactly whati did when i applied for my job. what i did is i typed in google. i did all of those thingsthat i've showed you guys, and i was able to ... let me bring it up. i'd made a liston this post on the blog about how i did it. if you guys want to find this post on theblog you can actually type new grad rn icu

residency, apparently this post comes up atnumber five. it's 4 no fail tips to get a spot in the icu. what i did is i typed in all those words,did all of those things that i've already talked about with you. doing those tricksi was able to get, like i said, interviews at duke, baylor, university of arkansas medicalcenter, methodist dallas icu and multiple smaller icus, eds and ors. i wasn't a phenomenalstudent, i didn't go to a top tier school by any means, trust me, and heather couldattest to that. my gpa was good, it was decent. what i focused on on finding the right jobsat the right times. what actually did is i typed in google, i typed in nurse recruiterdallas texas, and somehow i found this list

of 50 recruiters, the email addresses forevery recruiter basically in every hospital in dallas, then i just spammed them. i said, "my name is jon." i bragged aboutmyself a little bit. i said, "i'm graduating now, this is the experience that i have, thisis what i want to do. think i'd be a great asset to your floor. do you have any new gradpositions available?" i got a couple of people hit me back and let me know when they weregoing to do things. for example, baylor has a facebook page. if anybody is interestedin baylor, fantastic healthcare system. sandy has worked for them for several years. baylor has a facebook page for their new gradpositions. you get on there and the recruiter

there will post everything. when it's due,remind you, so awesome group to be a part of. what i got is i got an email back specificallyfrom one recruiter, and this is weeks before i graduate, so very, very close to being done.she got me on the phone and she talked to me about when everything was due. i sent everything,did everything, went to the interview, i was confident. showed confidence. i was sweating,i was dying, but then i got the job there. taylor wants to know what happened to thebeard. taylor, none of your business man. sandy makesme shave it every now and then, and i was trying to look nice for everybody tonight.i usually shave about every two weeks. from trisha. taking one step back. i'm ina competitive bsn nursing program, i want

to be chosen for the critical care fellowshipat my local hospital. what type of things i can put on my resume to set me apart fromthe rest. read just the first part again, sorry. i don'thave the question in front of me. i'm in a competitive bsn nursing program andi want to be chosen for the critical care fellowship at my local hospital. what was her name? trisha. trisha, thanks for asking. everybody is unique,and that sound really whatever, but everybody is unique. everybody has something uniqueabout them. i never noticed this more than

when i talked to my sister who's an iron man,triathlete, boston marathoner. she's led teams of one of the top orthopedic hospitals inthe country, and then she sends me a resume to look at and it's like, "hi, my name istammy. i want to job." i'm like, "what about being at the number one orthopedic hospitalin the country?" "oh yeah, there's that." that is healthcare experience, but what i'msaying is what is unique about you? what makes you the person that they want to hire? itdoesn't have to be healthcare stuff. it can be anything. were you a leader of some organizationor some group during college even if it's not healthcare related. what are those uniquefew things about you that make you stand out, that show that you're a leader, that showyou're dedicated, that show you're hungry

for knowledge. that's what managers reallywant. are you going to come to this job everyday? are you going to work your butt off? are yougoing to continually be learning in this field? that's really what they want to know. let'stalk about some specifics. other things you could do is you could goand get acls certified. you can become acls without ... that's advanced cardiac life support.it's a two day course, you can take it on your own for probably $100 or so, $200. whatit does is it puts you in that position with one of the things done that you will haveto have done anyway. you can get those certifications, make sure your bls is up to date. what aresome other really good tips. network with everybody on facebook that you know, everyfriend that you have that is a nurse, ask

them if there's positions because sometimeswhat's going to set you apart is honestly, it comes down to having connections. firstof all, exhaust all of those connections in a good [kosher 00:38:53] way and then alsoreach out and try to find any tiny things you can do. leigh. i would like to be certified and iwant to know how long should i wait once i graduate nursing school? certified for what? let's talk about whatwe might be talking about certification. if you're talking about just taking your licensure,i did some research on this, made a post somewhere and i can't remember where the post is onthe blog. the average time for successful

nclex takers is 45 days after graduation.if you wait much beyond 45 days, your success rate of passing nclex actually starts to decline.if you ... cc. critical care? you cannot become ccrn untilyou have 1800 hours which comes out about two years. i took mine on the date of that1800 hours, and i was able to get my 1800 faster because i busted it, you can ask sandy,she's here. there were a couple of months there where i just wasn't home because i wasworking every extra shift i could, because i wanted to be that knowledgeable nurse, thatnurse that people could go to. number one and number two, i didn't want to feel highand dry if a code happened or something happened,

i don't want to be the nurse that was likesinking back in the shadows because i didn't know what to do, i want to be exposed everythingi could. you have to get those 1800 hours first, thenyou have to apply for the test. it's really easy to apply for, and then you have to takethe test. two books i would recommend after you pass nclex and starting out in icu, firstbook is the icu book by dr. marino. this is an old version, you can see i spilled somesoda or something. i think a soda exploded in my car one time when i was in the parkinggarage here in dallas. you can get this older version for $8 on amazon.awesome book, way over my head but awesome. the second book that's much lower level, easierto understand is pass ccrn by robin dennison.

has tons of charts, and graphs, and things.as you guys know, that's the way i learned, and i have them all here. you can subscribeto the american journal critical care medicine and become an aacn member, that's like $70a year, and you get this magazine so you can start learning a ton. the only reason i'msaying do all those things is because if you do all those things when it comes time totake that test, you're not going to be freaking out preparing for it. next question. jenny. i've volunteered at a local hospitalfor two years to collect hours for nursing school application. now that i'm in nursingschool i'm considering going back there and

volunteer for a few hours a week. would thatvolunteering at the hospital on top of my clinical hours [there 00:41:42] set me apartand help me get a job? yes. if you're planning to apply at the samehospital you're volunteering at and doing your clinical hours at, yes, go for it. ifit's going to stress you to the max of not being able to complete your work, i wouldn'tforce it, i wouldn't push it. if you can get those hours and do well on your school workand everything like that, maybe just do the minimum. get on as many floors as you can,meet as many managers as you can, buddy up with as many nurses as you can. not to be sleazy, not to be [selzy 00:42:13],not to be scummy or anything like that, but

just to meet the people that you need to know,that's going to make the transition much better. if you can do it get in there, especiallyif it's the hospital that you're going to be applying at. i know heather shared herstory, heather here with nrsng shared her story. she got a job at the hospital thatwe all went to school at, and it was because she knew the people. sarah. how intimidating was it for you beginningin icu? i was pissing bricks, as short answer. it'sterrifying. it's absolutely, 100% terrifying. i will tell you that after several years experience,some nights it's absolutely, 100% terrifying. that's probably true on any floor. now thati have you sufficiently scared, let me tell

you why that's a good thing. when you workin a hospital, when you work in ed, in icu, in or specifically, you literally have people'slives in your hands. one mistake and you can kill someone, and that death is on you. havingthat and respecting that is very terrifying. there are nurses, and i know you guys aren'tthose nurses, trust me, i know that 100%. there are nurses that honestly don't see itthat way, don't care about it that much. the fact that you're asking how scared it is showsthat you're one of those that cares, and that gives a damn, and that's important, that'sso important. i did a podcast recently. if on the blog, there's a post ... maybe sandy,you can find it. there's a post that talked about why should be terrified for your firstnursing job. i did a podcast and a blog about

it because you need to be terrified becauseof what's happening. it's going to be terrifying, it's going to be scary, but that's okay. when i got my first job i had never met mypreceptor, i had been up to the floor a couple times but it was night shift, it was my firsttime to ever work overnight in my entire life so i brought like a 12 pack of mountain dew.it just so happens that the hospital was about 30 miles away and it was downtown trafficto get there. i showed up late, never met my preceptor, never had a real patient onmy own, and i was freaking out. there was no way i was going to survive this shift.what my preceptor did, i love my preceptor vanessa.

she could see that i was really flusteredand i was freaking out. i wanted to get there early, look at my patients, learn like youdo in clinical in school, but that didn't happen. she took me aside, she took me overby the break room i remember i just clocked in at the phones, she took me aside and shesaid, "look jon, take a minute, relax, and then we'll go hit this hard, all right? there'splenty of time to learn." it is terrifying, it is so terrifying. what happens as a new nurse is that everyoneknows this, okay? if you're lucky enough to get into a hospital that has good nurses,good managers, good preceptors, they understand this and they're here to help you. that'swhat we're doing here too, is we're here to

lift you up and to be that support under you.no one expects you to know everything, no one's going to leave you on your own duringyour first shifts, and if they do you need to report that, you need to get out of thatenvironment. no one's going to put you in an unsafe situation. vanessa was like a little bird on my shoulderfor the first 13 weeks, and she started to distance more and more as she saw me beingmore comfortable. as that happens and as you become more confident, you're going to bemore comfortable. no one's going to put you in a situation where you're going to havethat life in your hands, and they're going to put you in a situation to fail. while youshould be scared, while it is terrifying and

scary, you're going to be supported and you'regoing to be okay. natasha. i'm dedicated to continuing withmy rn critical care is my dream. as an lpn status, what steps would you take to worktowards getting experience and more knowledge for the ccu besides course work? what preparedyou? i've had no prior medical experience. thisis something that i see in myself and a lot of people is that we want to icu and so wespend a lot of time in school trying to read books like this that we just don't understandand don't get. those books are good and they're awesome when it's time for those books. rightnow when you're in school and you're preparing ... you're in your lpn program going for abridge i assume. right now it's time to be

doing that and to be focusing on that anddoing the best that you can at that. when the time comes to be in icu your learningdoesn't stop. you don't get that icu job, you don't walk through that door that firstday, and you're done. the learning continues forever. what i would say honestly ... this probablyisn't the answer you want or the answer that you're looking for, but what i would honestlysay is focus on doing the best that you can in the stage that you're in. if opportunityarises to float to icu or to do some tech work or to do some lpn work in icu, pass medsor whatever it is, take that opportunity and do that, but don't get worried about thesethings until it's time.

i read this book at work, i read this wholebook at work. when there was a minute i would open the book and i would read it, and someof the nurses make fun of me. they were on facebook, or shopping or planning their nextvacation, but what i was doing is i was preparing, i was continuing to learn. that's probablynot the answer you want, sorry, but i would say is what matters most in every stage oflife, is this stage of life. doing the best that you can then to prepare for the nextone. mindy. how often are nursing diagnosis usedout in the real world? are they more specific to certain departments like the icu? do you want to be honest? don't tell yournursing professor i said this. they aren't

used. when you do your nursing charting, thewhole charting like epic and mckesson and all these programs have nursing charting builtin to them to where you have to do a diagnosis, and write your interventions and do all thatstuff. that all happens but it's all clicking boxes. it's like in impaired skin integrity,and then you're intervention is i'm going to turn q two hours, i'm going to make surethey're getting nutrition. some of that stuff really helps, the problem is you usually don'thave time to do that until the very end of your shift. at the end of your shift you're charting you'relike, "oh yeah, i probably should have ... i probably could have thought about that a littlebit more during the shift." i will say though

however, and you can share to your nursingprofessors this portion. nursing diagnosis are important now to learn some of the interventionsthat are possible for patients with different issues. like the skin care people, the woundcare nurses, those interventions and those things that relate to impaired skin integritymatter a ton. what matters in school is learning how totalk to patients, how to think critically. you see a patient who's immobile, you hada stroke and now they're not moving anymore, your mind has to start thinking impaired skinintegrity, and you have to start thinking when is this patient going to start eating?when are going to turn this patient? are we putting aleve on the bony prominences? stufflike that. nursing care plans matter, but

how often do we write them out? we don't,ever. we usually click boxes. couple of people have noted that it keepsfreezing. i'm not sure why that's going on. sorry guys. that's really annoying. i don'tknow if it is still freezing, sorry. looks like it's still freezing. any other questions? yes, there's another one, it's a long one.cathy. i was a none traditional student and just graduated from ku with my bsn. i completedmy [inaudible 00:50:38] in the nicu. during this experience i had developed a passionfor neonatal icu. finding a graduate nurse position in this area is proving difficultfor me. during interviews for other opportunities my nicu experience comes up. how would i relatemy nicu experiences to these job opportunities

such as med-surg, progressive care units oreven or pacu, and especially on handling the differences in patient care loads? the question is how to get the nicu positionor how to ... how to relate that experience to other jobs,to med-surg, pacu. getting a job as a new nurse in the nicu ... firstof all, we'll just answer that part. i think that's going to be almost impossible. buttransitioning from adult icu to nicu is much more possible. i've seen multiple people i'veworked with be able to make that transition. they always wanted to work nicu but they startedat adult icu and then move into nicu. don't give up on becoming a nicu nurse, i wouldsay give it a year in adult icu. let's talk

about the other side of the question. if youhave that experience in nicu as doing tech work or whatever it is, that would be so valuablewith the adult population because you understand patient loads. there's nicu babies that are one to one, alot of nicu babies are one to one, so you understand giving full attention to a patientthat's very sick, you understand dealing with incredibly complex family dynamic. i'd focuson those family dynamics. i would say something to this effect like, "i know how hard it isto work with family members in very stressful situations, and i know how to help [aleve00:52:19] that and make that better." i would say something like that, "and then i understandfocusing care on one patient."

next question. how many months was your orientation? is this still choppy? yes. someone said mine isn't freezing nowbut the video is about a minute behind the audio. sorry guys. i mean everything looks good fromour internet on this side, it's playing fine but i can see that it's very choppy. i don'tknow what to do. if the video's a minutes behind i can just take my face off and wecan ... i can look at stuff here. the question is, how long was my orientation. at my hospital,the orientation was 13 weeks, and i was lucky, as i said, a really good manager, a reallygood preceptor.

the way that it worked with us is if fiveweeks in you realize you need more time, they give you more time. if 13 weeks in they realizeyou need more time, they give you more time. what happens is [this 00:53:42] continuallyevaluated to see, "okay, are we needing more time because this is something that can befixed and be taught? or is this something that maybe a different floor is better forthem?" in the icu where i work there is three icus, the medical, surgical and neuro. therewere people that would move between the icus throughout internship trying to find the betterfit. there were some that ended up going to med-surg and loved it, were happy, very happy.there were others that decided nursing wasn't right or the hospital wasn't right.

long answer short, usually icu internshipsare about three to four months. or internships, operating room internships can be as longas six months. ed internships is also about three to four months. i would look for aninternship even med-surg if you're doing med-surg, i would look for an internship that's at leastfour to six weeks just because there's so much to get comfortable with and so much tolearn. i would really try to spend that much time getting to know it. any other questions? no, not right now. sorry about the video, that's really frustrating.i hope i was able to answer some of your questions.

i know there's a ton more we could've talkabout and i would love to talk about. if you guys have more questions, you know you canalways hit us up at nrsng.com and you can always find us on social media, nrsng, nrsngcom.i want to know what you guys are struggling with the most. that's what we're here for.i'm frustrated with all the junk there is out there for nursing students, and i wantto make this journey easier, better, more doable for you. anything we can do to make that better, pleaselet us know. if this video was helpful, let us know, give us a like, give us a comment,hit us up on social media, share with a friend. i'm going to put this video up on youtubeand over on the blog. if this was helpful,

please share with a friends, let us know,let's grow this family bigger. we're here for you, we want to see you succeed, and happynursing.

Writing Nursing Care Plans

hello, i'm norman swan. welcome to this programon general-practice nursing. practice nursing presentsgreat opportunities and alternativesfor primary health care. there are health workforce shortagesand they continue to cause concern. many see nurses as criticalto a sustainable workforce committed to high-qualityand safe health care. there's been little acknowledgementof the skill nurses need to work in general practice,

and little formal educationto support practice nursing. tonight, we'll discuss the professionalissues in practice nursing - models of practice, training, educationand indemnity. if you're watching on your computer, you can type questionsdirectly to the studio. just click on the live talk tabon the web page you're looking at. that means we can ask you questions. here's one to get you going: as usual, there are a number of usefulresources available

on the rural health educationfoundation's website: now let's meet our panel. dr brian bowringhas been a rural general practitioner for more than 24 yearsin george town, tasmania, a small industrial-rural communitywith a 15-bed, acute-care hospital, located about an hour northof launceston. - welcome.- thank you. brian has been chair of the gp northrural workforce support in tasmania and tasmanian representative

on the australian rural workforceagencies group. julianne badenochis a registered nurse and midwife and has been a general-practice nursefor 12 years and works in a rural general practice onthe yorke peninsula in south australia. - welcome, julianne.- thank you. julianne has been a board director of the australian practice nursesassociation since 2004. julie porritt is a registered nurseand midwife with a mastersin health services management.

- welcome, julie.- thanks, norman. julie has extensive experiencein the health industry and hospital and primary care, and has held the role of principaladvisor for nursing in general practice with the australian general practicenetwork for seven years. she has recently taken up a roleas program manager for nursing in general practicewith general practice nsw. lynne walker is a registered nurseand midwife. lynne is also the subject coordinatorfor the post-graduate diploma

in primary-care nursing in the department of general practiceat the university of melbourne. - welcome, lynne.- thank you. lynne has worked in general practicefor ten years as a practice nurse, and was president of the australianpractice nurses association from 2001 to 2007, and is currently undertakingher masters of nursing leadership. welcome to you all. how many nurses are we talking aboutin australia, julianne?

in australia, we believe there arebetween 6,000 to 8,000, potentially more throughout australia. the agpn have done studies on that. norman: julie? yes, just over 8,000 was our last count. we're just doing a national censusat the moment. we know that 60% of practicesemploy one or more nurses. what's the pattern of practice?is it mostly rural practice? it's about 80% in ruraland only about 40% in metro.

have you looked at why the 40%don't have nurses? we recently did some workthrough the network. we asked practices that don'temploy a nurse why they weren't. we had just over 2,000 responses. the most common reason,particularly for urban practices, not to employ a nurse is the fact that they can't accessthe practice incentive program payment for employing a nurse. so they want to, but money is an issue?

even thoughwe know the business case is strong, even without the incentive payment, the fact that these practicescan't get the payment acts as a disincentive for them. it's almost a mindset for them - we can't go down that track,we don't get that payment. lynne, is it the same demographicpattern as general nursing - an ageing workforce?with all due respect to our panel. - we're all ageing, as you would know.- speak for yourself.

so, i would say, yes, it is. that's probably something to sayfor the entire health workforce. the age of gps, they're ageing as well. so, yes, in answer to your question. to what extent are nurses trainedfor practice nursing? there are two groups of nurseswho work in general practice - enrolled nurses, or division 2,as they're now known in victoria. they have a shorter training course. they would probably cover about 15%of the nursing workforce

in general practice. the other 85% would be division-1nurses, or registered nurses, who have a three-year training programas a basic. to what extent have they beenspecifically trained for the tasks? as doctors find out,they're not particularly well trained for general practicewhen they graduate. you can't imagine that nursesare any different. up until probably the last few years, there's been very littlepost-graduate education

for nursesto enter into general practice. they're probably not as well trainedas we'd like them to be. there are some courses aroundwhich some nurses are able to access, but there's a range of reasonswhy they don't. most are hospital-trainedthat go into general practice. how many post-graduate training schemesare there like yours? i would saymost of the larger universities now offer some sort of training. norman:what sort of things do you teach?

how to stand up to generalpractitioners, give them a hard time? 'get off my back.' strangely enough, gps don'tsend their nurses in for that one. we tend to teach them things likechronic-disease management, immunisation, taking pap tests, commonchronic conditions, nursing leadership. they are some subjects on offer. do you find people get confused betweenpractice nurses and nurse practitioners? people get confused all the time.nurses do as well. certainly gps get very confused.

there's a clear distinctionbetween the two. practice nurses are nurses employedin a general practice. nurse practitioners are nurses who havea minimum standard of education of a masters level and have a narrow butdetailed knowledge of a certain area. and competency - what are practicenurses out there doing, julianne? roles vary, particularly betweenregional and rural centres. i would say they're jacks and jillsof all trades and masters of many. some practices focus moreon clinical practices and tasks. increasingly, the roles of practicenurses are becoming more specialised

with more of a focus towardschronic-disease management, preventative healthand database searching and looking for peoplethat are underserviced, trying to find those and bring them in. i know that the agpn have done somerecent studies on that, haven't you? the australian general practice network in partnership withthe australian national university were funded through the australianprimary health care research institute to look at a three-year research project

looking at those factors that impact onthe role of nurses in general practice. through that study,we were able to identify that there were six key rolesfor nurses in general practice. that patient-carer rolethat julianne was just talking about is a very important partof what nurses do, but it's only a small partof what nurses bring to the practice. they also bring a problem-solving role. nurses are very proactive at looking at and anticipatingwhat might go wrong in a practice

and putting systems in placeto make sure things don't go wrong. they're organisers.they look after the quality systems. gps in our study readily identified that they divested a quality roleto their nurses because nurses do it better. nurses have a big role in education, educating not only the patientsbut the whole practice team - medical students, gp registrars, nursingstudents and even the gps themselves. nurses are what we callan agent of connectivity.

it's the nurses that actually linkthe team within the practice, but importantly,link that practice with its community. it's the nurse that builds relationships with other health organisationswithin the community. you've had a look at it as well, brian. we had a look in our practicewhat tasks the nurses were doing. the lower-end tasksof simple clinical practice, such as ecgs, pathology testing,point-of-care testing, were very important for us.

the higher-end and higher-level rolesthat we've been talking about with independence and autonomy is something that's difficultin general practice. the paradigm that i worked withwhen i first started practice was - we've always had practice nursesand they've always done clinical tasks and have been there to help. in those days,there wasn't this emphasis on competencies and scope of practice, it was an arrangement between the gpand the nurses.

supervision was by the gp. now the situation is thatsupervision of nurses is by nurses. they have to demonstrate to nursesthat they have the competencies. that seems to me quite logical. if we had a registrar in the practice, i wouldn't want them doing thingsthey didn't feel competent about. they'd have to demonstrate to methat they were competent. i would need to understandwhat my registrar could do. it's very important that, as gpswe do work with the nurses

and understandwhat their competencies are. we will then be able to seegreater roles for our nurses. your questions have come in,where you're located. let's get your answers to that. metropolitan - 36% of you. 10% regional. over half of you in rural and nobody from remote tonight.we usually have a few. that gives you an idea at leastwho's watching via the web.

let's ask the second question. we'd be interested to knowwhether your practice employs practice nurses: give us your answers to that question, and we'll come back to it. commenting on salary and wagesbeing considerably less than state-employed health nurses,lynne? there's no question that the salarythat's paid to practice nurses is well below the salary paid

to those nursesworking in acute and private sectors. norman:why is that? isn't there an award? there is an award. it's quite complicated. some of them are state awards. the awards and the industrial issues have probably been likea lot of other things, where they're focused onthe acute sector. the awards that are currentfor nurses working general practice

are not as up-to-date. it's a different system. it's a privatesystem, so it's quite different. a comment, julianne, about enrollednurses being put in rn nursing positions and practices,and being outside their comfort zone. yes, unfortunately,that still is happening. that's a big problem for those nurses working outsideof their scope of practice. it's very important that gpsand practice managers understand enrolled nurses must be supervisedby a nurse.

they cannot, due to legislation,be supervised by a gp. they must be supervised bya registered nurse. that does vary a littlebetween the states. it can be direct or indirect. in certain states,there have to be protocols in place so that it's well understood. a question, julie -is there an opportunity for clinical nurse consultantsin general practice networking some supervisionthat you might have in hospital?

there's room for advanced rolesfor nurses in general practice. many nurses are working at a level that we would describe as a clinicalnurse consultant level in a hospital. there is certainly a career pathwayfor nurses in general practice from the beginning practitionerthrough to more advanced roles, then through to nurse practitionerif that's what nurses choose to do. norman:but you don't necessarily get paid more? yes, the issue is thatthere isn't a pay structure. one of the elements that's differentfor nurses in general practice

to other settings is,because it is a business environment, nurses need to negotiatefor a higher wage. some have been very successfulin doing that. but it's not somethingthat is second nature to nurses. we're used to being employedwhere there is a set award so we don't have to negotiate,we can see what that award is. an online question - 'do you think current tertiary-educationprograms for nurses is adequate?' existing nursing courses?

probably not. as we've seen, the role has expandedhugely in the past five to ten years. the education providers haven't reallybeen able to keep up with offering what's required to do that role. there's not a lot of incentive for education providersto invest in education, given that the practice-nursingworkforce is quite small in comparison toother nursing specialties. it's expensiveto invest in those programs.

there has been an increase in them and a lot of education done throughdivision networks and short courses. but at a post-graduate level, there still needs to bequite a lot of work done. fabian mccannfrom the kanahooka pharmacy asks, 'is there an industry databaseto search for nurses appropriate for gp clinic positions?'julie or julianne, do you know? the australian practice nursesassociation certainly has on its website a dedicated area where businessescan put in an advertisement

for a practice nurse. there's information on that website about general-practice nursing,which is useful. there's not a list of nurses for hire? many divisions of general practicemaintain databases of nurses interested inworking in general practice. the other programthat has just been introduced, because it was recognisedthere was a gap in providing an entry-level programfor nurses

that may be very experienced nursesin other sectors but not necessarilyfamiliar with general practice, there is now a national,entry-level program, a clinical-orientation programfor nurses interested inworking in general practice. which is another question online -'how easy or common is it for a nursefrom another area of practice, for example, emergency department, totransition to practice nursing?' lynne? the emergency departmentis probably one of the areas

that would streamline more easilyinto general practice. norman: if you'd beena cardiac intensive-care nurse, this might be hard. it might have different challenges, but most of uscame from the acute sector and we're all still aliveand talking about it, so it can be done. a lot depends onyour goals and objectives and the type of practicethat you will be employed in. if i were going for a job todayin general practice,

the questions i'd be askingas a potential employee would be around the role, and what is itthat's required for that practice. brian, tell me how money flows.what's the business model? certainly, norman. the majority of the workthat nurses in our practice would do would be procedural itemsunder the supervision of the gp. asking a nurse to do an ecgwould attract a medicare item. a substantial amount of the moniesthat nurses would earn would be evaluating immunisation,wound dressings.

all these thingsnow have medicare item numbers. some practiceshave nurses doing pap smears. that again attractsa medicare item number. there's some intangibles... you don't get rich on it,you or the nurse. there are some intangiblesthat are really hard to measure. how much do our nursescontribute financially to things likechronic-disease care plans? our practice is an industrial/ruralpractice in a mining/processing area.

how much do they contributeto the non-medicare dollars that we earn by doing health surveillance medicals,and that's substantial. the bottom line is, though,that besides income coming in, there's costs going out,and that varies from state to state. part of the $77,000 cost deficit thereis due to things like, our practice is big enoughthat it cops payroll tax. we would certainly say thatthat money is well-spent. we couldn't do without our nurses. they're indispensableto the way we practise.

we really need to befreeing up more of our time by having nurses do more. do you find your practicemore enjoyable? incredibly, and it's a team. it's not this vision some gps would havewhere it's a competitive thing. the nurses have been lookingafter a wound for several visits, we go in and consult with the nurse. it's a team consultationabout what the best method of managing the next few visits will be.

nine times out of ten,they'll suggest a dressing method and we'll think, fine. negotiate slightly, but it's a team,collaborative arrangement. i think that will be sharedby most members of the panel. i think that study julie referred to showed that only 21% of the rolewas clinical work. a big chunk of what nurses dois not funded by the mbs. are many gps charging for their nurses'time in a non-reimbursable way? do we know that?

i don't know if we collected figures, but we know anecdotally thatthat's not a common thing. some practices do chargefor nursing services. i was interested inbrian's business modelling because certainly agpn and other organisations have done the modellingaround the business case for nurses. generally,it shows a profit, not a deficit. it's just aboutwhat's included in those figures. i was interested in that modelbecause i hadn't seen that before.

norman: you can get on a treadmill. if what you're looking for from nurses is time with patientsand their families, and identifying problems and so on, being fee-for-service, thattask orientation could be frustrating. it's very frustrating. the general-practice nurse populationis a highly skilled population. unfortunately they're a bit bound upin a task-orientated funding mechanism. but for the general-practicenurse population out there,

every encounter they havewith their patient is another opportunityto help that patient in a holistic way. it's the way we work. funding doesn't reward us in any waywith that. when brian was talking abouthis funding model, what isn't countedis things we're doing behind the scenes. in attendance for wound management,we're talking about the whole patient. we're working out what's happening athome, do they need a medication review. can i say too, i don't know whetheryou took this into consideration, brian,

it's also the time you're saving the gp. it's not only the income generated,it's what the gp is able to do. if you weighed it up,would it increase revenue generation? no, that's quite difficult. how can we, in this simplistic model,quantify the controls the nurses bring? in accreditation,it's around the clinical standards, and nurses are largelyin control of that. what value do you place on that? that's an important point.

we shouldn't just talk aboutthe business model. it is not only the business model, it'sthe fact, and research tells us this, that having a nurse employed in generalpractice improves chronic-disease care, improves quality, reduces waiting times,all of those things. to what extent do gps get it that nurses are relatively independentpractitioners, that they're not to be supervisedby doctors? autonomous practitioners? there are many very successfulgp practice-nurse teams.

a lot of whether they get it or not, some of it is tied up withthe culture of the practice, whether they are able to work as a team. there's a whole body of work thatdivisions of general practice are doing, and need to do more of -sharing the successful models out there, having people come from other areas,even, and talk in divisions. i've heard of quite a bitof division training, but it's an important aspectof gps' learning - from peers,and nurses learning from peers.

do practice managersget practice nurses? in other words, do they understandwhat's needed in terms of management? sometimes not. i've met somevery switched-on practice managers who knew exactly whattheir nurses were capable of, but i don't think that would beas widespread as we would like. practices are big business now. they need to be managedvery efficiently. i would think knowingwhat all of your staff are able to do, what their strengths and weaknesses are,

would be fundamental to managementof any practice. there's probably more work to doin that area. some more questions - 'whilst there's a lot of material aroundfor educating nurses, particularly on the internet,that's hard to access for remote nurses who often don't have doctors presentall the time.' any suggestions how remote nursesworking in general practice can access educational materials? there's a lot of education onlinethat's free.

they're claiming that, in a remote area,that's not as easy as you'd think. i guess it comes with challenges. some education providersrun distance courses if they can't access the internet. julianne, you work in rural areas. it's not an issue for us in our region. we have very good it access. most of the organisations that do runthese programs, if you contact them, they're able to get these programsout to you by disk or whatever it takes.

especially through the apna, if they ring in,we can find ways to avail those nurses. the divisions are very supportive. it can be quite expensive. i know the modelthat rural and remote gps use is often just leaving the areaand going to a course. there's several very good courses. the nurses network runs an annual course and the conference and exhibitionruns two courses a year.

just go and get it all in one package. lynne, how is competencyscope of practice measured? how does an individual nurse knowwhat his or her scope of practice is, what their competencies are if we're talking abouta relatively informal sector? when you say, informal sector, scope of practice and competenciesis not something new for nurses. - it dates back to their training.norman: sure. it's an individual assessmenta nurse makes on their own practice.

it's not that hard for a nurseto determine their own competency. there are certain questionsyou would ask yourself. the regulatory authorities havedone a lot of work providing frameworks for decision-making,so that there's a process to work out - am i competent to do this? yes or no. it's really not an issue for nurses. they are clear, usually,about their own scopes of practice. there are specific competency standardsfor nurses that work in general practice.

it is relatively easy for a nurseto look at those competency standards. norman: if a gp wants to look at them,where would they find them? they're available on theaustralian nursing federation website. part of the package developedaround those competency standards was a lot of informationfor gps to assist them, and practice managers,to understand the competency standards and how they might use them. i must admit that in doing some readingaround this program, i came across them. i knew they were there, but it wasthe first time i'd had a look at them.

this is the culture that needs to changewithin general practitioners' minds, that this is somethingwe do informally ourselves. we wouldn't do a procedurewe didn't feel competent to do. nurses, it's a different situation. we need to understand this needfor competencies and scope of practice. it's vital that gps start embracing thisand looking into it and working with their nursesto understand how you can move forward. 'nurses are involved inquality and safety and the medical benefits scheduledoesn't reimburse for this.

isn't it valued by the practice and gps? it's certainly valued by the gps. without the quality, there's noaccreditation and without accreditation, there's certainly financial implicationsto the practice. i know that's not the universal model, but in the practicesthat have practice nurses, i would say it's virtually universal. they are in charge of the clinicalquality and sterilisation procedures. it's... it's...that's their responsibility.

julianne, is there a role forpractice nurses to prescribe medication, for example,in chronic-disease management? there's certainly not a role for general-practice nursesto prescribe medication. it is becoming on the forefrontof the role of nurse practitioners, but it's not within the scopeof practice for general-practice nurses. it's interesting, norman,that one of the things that changed the role for nursesin general practice in the uk was the fact that they instituteda post-graduate program for all nurses

so that they could prescribe. there was a lot of quality systemsput in place around that. the world didn't come to an end and patients werenone the worse for wear. for the nurse in general practice, beingable to see a number of presentations that they could treat adequatelyby prescribing a medication certainly has been a big boon and has really changed the waynurses are working. there's a rolefor general-practice nurses generally

to be discussing medicationswith their clients as part of their holistic care. that's just around quality useof medicine, which is very importantfor all health professionals. lynne, what's the most out-there roleyou've seen for practice nurses? it might be out-there for australia, butnot if you're living in another country where the role has beenmore clearly defined for many years. there's very good examplesof nurses running clinics, hiv medicine,looking after patients with hiv.

there's lots of examples nursesrunning well-women, antenatal clinics, looking after pregnant women. julianne: lifestyle.- lots of lifestyle counselling. there's a very good programin western australia, the street doctor program, where nursesand sometimes a gp as well take a van out to the streetand treat people that are homeless. there's certainly outreach worknurses do, going into child-care centresand immunising, taking work out of the practiceand into the community.

there's a number of examples of that. this is the end of the general-practicenursing that needs to expand. unless something dramatically changeswith workforce, the workforce isn't going to be there,and who's going to suffer? community. closing books in doctors' surgeriesis not an answer. there's got to be another wayof working cooperatively, not substituting,but work is done differently. nurses can fill a lot of that role. let's go to our first case study.

jackie is 50 years old. she smokes 30 cigarettes a day and comes to see the gp because she's got pain in her chest when she lifts heavy objects or goes upstairs. her mother died of a heart attack. she's not had palpitations, but has shortness of breath and a pain in her chest.

what's the role of the practice nurse here, brian? this may be seen in two ways. the person might not identify that they've got chest painat the front desk. if they did in our practice, the reception staff would automaticallyescort that person to a wheelchair, or if they were more able,straight to the practice nurse, who would do observations, an ecg.

norman: you've got protocols?- protocols, what to do. the monitor, the defibrillator would bethere, ready and waiting if needed. the doctor would be informedthe patient was there. the nurse might say, in a coupleof minutes the ecg will be done, but can you come soon? if they were in the waiting roomand informed the doctor, there might be more history taken beforehanding over to the practice nurse, but that would be soon, because you needthe test to decide what's going on. that's an exampleof a non-reimbursable activity?

the ecg is done not by mewhile i'm doing something else. the... (speaks indistinctly) ..that'sdone is purely a cost to the practice. if this was a less acute situation,there could be an educational role - in the ideal setting,education about smoking and risk factors this person hascould well be done by the practice nurse if this was a more chronic setting. it would definitely be done. as i said previously,every encounter with a patient is another opportunityto do lifestyle modification

or just seekinga bit of background information. while i'm doing an ecg on a patient,or any registered or enrolled nurse, we'll be seeking more information to seeif there's some way we can help them. if this is not a crisisat this point in time if we're doing this diagnostically, you would be havinga very good chat with them. let's say they have stable angina andthey get put on statins or beta-blockers or whatever elseto control their symptoms. do you have an ongoing rolein your practice with a woman like this?

i would encourage themto come back to the nurses for a chronic-disease management role. we would talk at that first encounterabout the value of setting up something along the linesof a general-practice management plan and booking a further appointmentfor that. let's take the answerto your previous question: does your practice employpractice nurses? 81% of you said yes. 10% no.

none of you are considering it. and 10% say you never would.i wonder why. we might ask that on another occasion. i'm just looking for the next question. it's interesting that those 10% whonever would are watching this program. they must have some interestin practice nursing. norman: they might be practice nurses. brian: that's very encouraging. there's an interesting question here -

'is there evidencethat nurses doing pap smears are better at itthan general practitioners?' there's certainly evidencethat nurse-taken blood pressure is more accurate thangp-taken blood pressure. there certainly is some evidence,norman. every year, the victorian cervicalscreening registry publishes a report on pap tests done in that state. for the last three or four years,it's clearly showed that the quality of the pap testwith the endocervical component

in those test taken by nursesexceeds that of those taken by gps. the numbers of paps takenis increasing as well. so there is some indication thatthat would be the case. it's an area wherethere is significant need. i don't believe that the government'sfunding model for greater incentives for the more overdue the lady isin having the pap smear is done a lot. so, another paradigm or wayfor addressing that problem. you certainly need it, and offering pap smearswith practice nurses may be something.

they're not doing it for some reason. is it, they don't want to do itwith the doctor? that same report shows that womenwho access nurses for that reason are usually the underscreened groupwho are difficult to engage with. and that... um... it's gone out of my head,what i was going to say. speaking generallyfor general practitioners, i might be shouted down by the gps. a lot of gps don't want to lose controlof this very important role they've had.

it's a way of relating very closelywith that patient. the build-up with that patient,they feel they'll lose if they hand over this test. women don't like men doing it to them. there's a percentage that preferthe male practitioner and a percentage that don't. the thing we have to remember is, as with most of the servicesthat nurses offer in general practices, it actually offers a choiceto the patient.

it's not about telling patientsthey can or can't see a person, it's about offering them a choice. if it's the right person they see,it's the right patient for the right provider of the serviceat the right time. i understand the data is that you don't need to ask the questionanymore about patient preference, or that patients are satisfiedwhen they see the nurse, normally. but when they're offered that option,what are the data here? julie, did you allude to this?

i don't know that we've looked at thatdata. some practices may have done that. there was research done a few years agofor consumers. the outcome was, practice nurseswere very acceptable to patients, but they did point outthat it needed to be a team and that they needed to be reassured that the doctors and nurseswere working together, that it wasn't one replacing the other. also, that patients still had accessto the gp whenever they needed it. practice nurses,that's one thing they do very well,

is triage patients,so that those most in need of care get it when they need it. i think... sorry. the other element thatthat research showed is that patients identified there would be some thingsthey would rather ask the nurse about. in my experience, whilst i'm nota credentialed pap-smear provider any longer -i've gone on to greener pastures. norman: you broke your stick, did you?

something like that. i do know that clientsthat came to see me for a pap smear, very many of themcame for another reason. it wasn't the pap smearthat brought them. norman: it was their ticket of entry.- that's right. there is certainly that role. this is the point wherethe gp conversation starts. it could be about time,it could be about gender. but separating itis even more important.

they're coming alongwith a problem they want to discuss and figuring the way they canget a longer appointment is to book a pap smear. then you do the well-woman check and don't do a particularly good jobon the problem they want to raise. it gets rushed. we have to differentiate that nursesperforming a lot of these roles, like for the pap providers, it's the underscreened womenand the normal woman.

often they do have other problems, butour services are targeted to well women. there's a lot of screeningwhich happens in general practice, and there's going to be more screeningas we move into that prevention mode. there's no reason why nurses can'tbe involved in screening practices, rather than diagnosticand ongoing management. there's a lot of patient educationneeded. what we haven't touched on hereare indigenous patients and the role of the practice nurse here, when you've got a non-aboriginal,mainstream general practice

with practice nurses, how does that playout with indigenous patients? julianne? as it is, general practice does havea fairly high indigenous clientele. we do have onevery fabulous practice nurse who certainly has a focus onindigenous clients. they are increasinglycoming into our fold. it's been fabulous. there's a lotof preventative-health messages. is this woman an aboriginal person? no, she isn't.married to a local cop, actually. female, white.she is doing some great work.

i think this is a rolethat's certainly going forward. that may have something to do withthe fact, we also know from researchthat patients perceive that nurses would have more timefor them than the gp - the gp is busy,better not waste the gp's time. a nurse mightgo a bit more slowly with me, give me time to actually ask the thingsi want to ask. the apna recentlyundertook a trial consumer survey. one of the thingsthat came out of it was,

the consumer was very satisfiedwith practice nurses. it was about the timeand the easy access. in particular, the 18- to 35-year-oldswere very satisfied. we're not sure what that was about, but we think this related to easy accessand provision of information. for those of you who saidyou won't consider having one or you don't have a practice nurse,the question is, if you don't have a practice nurse, what are the reasons?:

let's see what your reasons are. while we're doing that,let's go to our next case study. diane is a 46-year-old mother who works part-time. she's made an appointment to see her practice nurse for a regular pap smear. the practice nurse takes diane's pap smear, but during the consult, measures blood pressure

and diane's bp is 140/95. she's got a bmi of 28.she's only slightly overweight. she has no history of hyperglycaemia, however her fatherdoes have type-2 diabetes. but the practice nurse feelsdiane is at risk. what should and does the practice nursedo in this situation? i think it's probablya very common scenario, really. what the practice nurse will dois have a consultation to address what the patient came in for

and have a general discussionabout lifestyle issues and refer her back to the gp. she obviously needs some screeningand addressing of the hypertension, so i would thinkshe'd be sent back to the gp for a work-up of the problemsthat have been identified. some surgeries would do a random sugarthere and then. i didn't hear.i must have been daydreaming. did you sayyou'd do the diabetes risk assessment? that's something i would do.

it's a great opportunity. for me,the lights are coming on straightaway. i'm very much an average practice nurse,and the lights are coming on. she scores 7 for being 46 years of ageand having a family history. that immediately puts her at risk. i would be asking herto do the ausdrisk tool herself and ensuring that she comes backto see her gp and have a fasting blood-glucose levelat some point. i'd be touching base about diabetes,et cetera,

finding out what her knowledge base is. all this can be done very quicklyin that one consult. there would be very fewhospital-based nurses who would even knowabout the ausdrisk tool. this is really a toolfor general practice. how do nurses learnabout that sort of thing? that's wherethe new orientation program comes in. nurses can nurse in any environment. they're delivering nursing care.that doesn't change.

what's differentabout general practice is, it's a different environment to work in. there are those things about medicare and various epc itemsand things like that only pertinent to general practice. there's probably a million and oneexamples we could quote of patients going into hospitaland coming out with problems that weren't addressedwhen they were there because medical and nursing staff,for a variety of reasons,

weren't able to touch on. i think that's just a symptomof our system. the fact that these patients can accessthat kind of care in general practice is very valuable for the community. of course, this woman doesn't qualifyfor an epc item. not at this point,but she's highly likely to. that's the key rolefor the practice nurse - ensuring that this person hasthe level of care they need over the 12 months to make surethey have optimal diabetic care.

i think you've touched ona important point, norman. the models of fundingfor general practice need to change if general-practice teams are going tobe able to deliver the best care. as lynne said, the best person. salaried care delinked from piece rates. yeah, that's exactly right.a blended payment system. another important point is the capacityof the nurses to pick up problems. there's huge opportunityfor nurses to pick up issues which can then be addressed,and that's not funded either.

do you conduct teaching sessionsin your practice, mutual learning or things like that? we have regular clinical meetingswhere practice issues are discussed. we have registrars. nurses are welcometo come to those meetings, depending on the topic. but i wouldn't saythat we'd have meetings that had a sectionthat was specifically nurse-orientated. something to think about. one of things we found from theaustralian general practice nurse study

was that those practiceswhere there is good teamwork and autonomy for the nurses, they're the practices that have regularteam meetings and clinical meetings between the gps and the nursesand allied health professionals. it's part of the third standardsof general practice, that there be clinical meetings attended by all health professionalsproviding clinical care. as you said, there's certainly evidence. on reflection, i've probablyundersold ourselves a little bit.

meetings are attended. norman:it's getting better all the time, brian. digging myself out of the hole. our next case study is this general practice which has no female gp, has employed a nurse who's undergone education in women's and sexual health. the nurse has established

a well-woman's clinic, and marketed to women in her area identified as underscreened. the practice has agreed on a policy for the patients that the nurse will target cervical-cancer screening, pathways for referral and billing of patients. she will have an appointment system

using mbs item numbers. there may be an out-of-pocket expense in line with practice policy for some patients. is that what's happeningin the real world? yes, it is. increasingly. it's part of the processthat we need to go through, to educate patientsthat sometimes there will be a cost,

and that seeing the nurse for a servicethat is comparable to the gp is actually not a cheaper service. it's as good as, and therefore it willcost as much money as with the gp. before we go on,there's a comment from anne callum from gp partners in queensland - 'this 46-year-old lady should qualify for the 45- to 49-year-old health checkmedicare item.' yes, but she still needs to see the gp. that was the differential.

what's the journeythat practice has to take to get to this pointwith this well-woman's clinic, julianne? it needs to be absolutelya team effort. there needs to be protocols, as stated here,in place before we even get started. the consensus needs to be, this is where we want goand this is how we're going to do it. the nurse needs to be credentialedand confident in her role and that she has a great relationshipwith everybody in the team,

including her practice managerand all the other nurses. the funding doesn't necessarily reflect the work that will be donealong the way. it is about more choice. is there a professional-indemnity issuehere? no, i don't think so. it's just important for the practiceto let their medical insurer know that the nurse would be doing that. otherwise, there's not an implication.

you could probably summarise itby saying that, whenever you introduce a servicelike this into a practice, there needs to be a general agreementand culture within the practice that it will work in a certain way,there will be a team, this is how it will work, we're all clear about our roleand responsibilities. there's a clear referral pathway,there's a clear billing procedure. the receptionists knowwhat the billing procedure is, so everybody is crystal-clearon how the system works.

a comment from leanne kotz,moonta medical centre. 'i'm a practice nurse, and believewe are a vital part of the gp team and should be paid the equivalentto hospital nurses and not a much lower award rate.' feeding backinto our earlier discussion. there's no reason why not.they're just as competent. it's just the historical evolutionof the system. - tomorrow, when you get to tasmania...- i'll have a revolver in my hand. nurses in the practice we work atcertainly are. thank you, leanne.

i'm sure i'll be shouted down -it's not the only attraction - but the hours of work probably are why a lot of nurses opt outof the higher-paying hospital work for a more nine-to-five-type,regular practice. we've done a bit of work around that. there are a number of reasons. the so-called family-friendly hoursare only one. there are elements aroundpatient continuity. nurses love that as well,just like gps do.

it's something they don't getin the acute sector. it's also the scope of practice,the variability of role. julianne: holistic care.- the holistic care. let me take the question we had earlier,then i'll come back to the point. if you don't have a practicenurse, what are the reasons? 100% said cost. the sample was lowgiven that almost all of you did have practice nurses, butthose of you who answered, it was the cost.

let me go to the next question, 'causewe're getting to the end of the program. this is to the nurses watching: it would be interesting to hearthat question. i interrupted you, lynne. i was going to sayon the subject of payment, if we think about howthe corporate world works, there's incentives for people to workto capacity, to have through-put. we don't seem to have that culturein general practice. i would suggest that when briangoes back to his practice tomorrow,

he might think about paying his nursesa percentage of the pip income for the outcomes payments.i don 't really understand why... that's fine, and it gives people payment and goes along with the systemat the moment, but the reality is, don't we want to getbetter health outcomes out of this, and that you're just playingthe fee-for-service game? the reality is, that's how we work. if we talk about rewardand incentivising and getting nurses to stayin general practice,

which is probably becominganother problem, their retention, maybe if they're paid more,the attraction will be higher. the pay-for-performance systemthat they have in the uk, where it doesn't matter who does thework, the income comes to the practice, is maybe something we need to look at inaustralia to better reward the teams. the health reform commissionhas made statements along that regard. if general-practice nursingis to go forward, that's something that needsto be addressed, this model of payment. julie from wuchopperenoutreach health service asks,

'do you see a role forchild-health nursing in general practice extending beyond providing immunisationsand funded by medicare?' there's no reason whyany primary-care nurse couldn't be situated general practice,whether it be a child-health nurse, immunisation nurse,occupational health and safety. the only barrier we have at this pointis how they're funded. the actualworking together as part of a team and looking after the communityand public health is a great idea. do we know about churn -

what sort of turnover there isof general-practice nurses? we don't collect statistics nationallyabout the level of turnover. we do know anecdotally that nurses havecome into general practice and left. sometimes that's beenbecause they haven't been supported, another reason why we've introduceda standard orientation program, so they do have some supportto learn that role. but no, we don't have national figuresto do work around that. that's somethingthat could be looked at. some work we have seen through apna

is that the turnover is often related todissatisfaction in not being able to workat their full scope of practice. how much do you have to learnabout teamwork? doctors are not very good at it,usually. not generally. in rural practice, gps are much morelikely to be team-orientated. they just have to be. they have to work with ambulanceofficers, paramedics, hospital staff. so they probably do thismuch more easily.

i think in our practicethat's been the case to an extent. the ability to go onand develop protocols that enable the higher-scope-of-practicetype of nursing to happen is the difficult step. if we are going to make inroadsinto primary care, this is where it's going to be,not in general practice. to have a good team, you have towork at it, a bit like a marriage. you have to want it to work, and you have to invest timeand education and all those things.

i don't think general practice does thatvery well at all. it's something that has to changein undergraduate programs too, not just for doctors, for nursesand for allied health professionals - that there is moreinterprofessional learning and instruction aroundworking as a team, because i think you do need to learnto have that skill. it isn't second nature. how often is the practice nurse marriedto the gp? do we know that figure? we've got more important thingsto think about.

it could affect the dynamicin the practice. it does. lots of practice managersare actually the wives of gps. i don't think we should go there. we're on wobbly ground. i understand. this is an important concept. practice management maybe hasa few more years' earlier development, but it's a developing art as well. practices now would havevisiting dieticians. if they've got good efficiencyin the practice,

they would probably haveallied-health services visiting. let's go to the answer to your question: and the answer is mostly no. lynne: well, isn't that interesting?brian: i'm not surprised. an underutilised group of people. absolutely. here's a handy one for our last questionfrom one of our online viewers - 'as an ambitious nurse, why wouldi go into general-practice nursing?' here's your elevator pitch,as they say in america.

it's actually a fabulous job. it's a job which createsa lot of opportunities, a role you can make very interesting,and you can do it exceptionally well. patients love it.there are lots of reasons to go into it. just because it's not perfectthe way it is doesn't mean we should stop trying,and take opportunities when they arise. there is a new dimensionin primary-health care and i think practice nursesare really at the forefront of that. we've had seven yearsof really good groundwork

in providing the frameworkthat they need to really move on from here. with federal-government initiativesaround supporting more primary care, practice nursesjust need to seize the day. - julianne?- i love that - 'seize the day.' it is the best job on earth. norman: really?- absolutely. i'm very passionate about that. the only thing i've ever donethat was better was delivering a baby.

it is a very highly skilled workforceout there just waiting to graband run with the potential. there's no other job in nursingwhere you get to see the whole patient - you get to see your outcomesin the long-term, you get to see the impact on the familyand in the community. i'd recommend any nurse worth their saltgiving a good look at it. norman: brian?- observing from the outside, it is the long-term relationship that practice nurses developwith patients and families.

we've all talked about it. julie: and the team.- working as a team. thank you all very much indeed. let's hope we have a better-utilisedpractice-nurse workforce the next time we do a program on it. i hope you've enjoyed this programon general-practice nursing. if you're interested in obtaining moreinformation about issues raised, there are resources on the rural healtheducation foundation's website: don't forget to completeand send in your evaluation forms

and register for cpd pointsby completing the attendance sheet. i'm norman swan.from all of us, bye for now. captions bycaptioning and subtitling international funded by the australian governmentdepartment of families, housing, community servicesand indigenous affairs�