charge nurse dilemma

[cargal]

Hi, I need some views on my capacity as a charge nurse in my LTC facility. I was oriented as charge two months ago. I really feel I have limited experience as a p/t nurse, worked the floor in the hospital skilled unit and assisted living charge.

Here is my dilemma. Have LPN, been there 19 years. Likes to moan she is treated like "an lpeon, but also hides behind her title to avoid anything out of the med pass ordinary. Saturday I was charge, looking forward to a peaceful weekend without all the staff chaos-you know what I mean. Well, there was four CNA call offs that led us to a staffing crisis, which got thrown in my lap. Walked down for a cup of coffee before I got on the phone to call agencies. The list was missing so I had to look up numbers in the phone book, which was outdated, etc. Coming back through the hall, a family member told me her dad was in pain. Same thing happend the day before. Epigastric and back. History kidney stones. Vicodan and demoral IM (for severe pain) ordered. I did a quck look at him, alert and non-diaphoretic. He always has a hard time spitting out words and when he is in pain, this slows him down more. Asked the LPN on his side to give him a pain pill, and started to inform her that he was like this yesterday, I thought it was a kidney stone, has seen him before like this---she interrupted me and said "I'm not giving him a pain pill, he is lethargic." I asked her to get vitals on him and she stomped down the hall. Came back with vitals on a scrap piece of paper and they were way stable. I asked her again to give him a pain pill and she started to inform me that I was the nursing supervisor and it is my job to go down the hall and take care of him. I asked her if he was diaphoretic and she stammered 'no", and I asked her if she could assess him? She got very mad at me. I always check up on residents who are experiencing changes. I did look at him again, and talked to the family and asked them IF I assessed him and felt it was cardiac involvement, which I did not, would they want him sent out, and they said no, make him comfortable. Of course, I charted in depth on all of this. Two and half hours later, I checked on him again, probably the fourth time, he was still in pain, I instructed the LPN to give him IM demoral. He was good for the next 24 hours, when in the am I checked up on him and he stated he had pain just about every day, the same kind, etc. I then instructed the LPN to give him a vicodan during the med pass, which she grudgingly did. The wife called and I explained all my rationale and she stated how glad she was that I was there.

This LPN seems to resent my RN status, I spend a great deal of time passing meds and being charge at the same time when we have a call off or agency is unavailable or just doesn't show. When I am charge and have 2 LPNs I try to get some paperwork done, vitals, help the CNA's and spend alot of time with the agitated to help calm them down or see to their needs. This LPN seems to resent that I have time to do this, and thinks I should do her work instead of asking her to do it. Why can't she assess the resident, as she needs to have knowledge of what's going on on her side. If she disagrees with my instructions, I can see that she has the right to NOT give a pain med, but assess him first then tell me she is uncomfortable with my instructions.

Am I barking up the wrong tree here?

[adrienurse, LPN]

Cargal,

Can I EVER relate to your story. Sounds like my situation 3 years ago when I was the lone RN on nights in a 300 bed PCH. I worked with some LPNs who were very skilled and whose intuitons were as sharp as they come, but I also worked with some who were weak, and very ignorant to the needs of our geriatric patient load.

It's a very tough and draining position to be in. All I can say is document document document. Make sure your managers know exactly what it is you have to put up with and do without.

[nursenoelle]

this is also happening alot the med nurse refusing @ times to admin pain meds. burnout is esp. rampant in LTC facilities . I am soooo tired of hearing why do I have to do that from CNAs to RNs. I hear she just wants to feel good" and things such as this . must be so frustating as a charge. I am an LPN, going to school to be an RN , but if i wa behaving that way i hope that i would be corrected.-- Hang in there

[realmean1]

Write her up, discuss her behavior, attitude with your DON or Admin, bring her in for a conference. I am ususally the only RN on the floor of a 91 bed nsg home, evenings/nights, weekends, whenever. Don't care if she has been there 19 yrs or 1 month, she will keep her same behavior until it is corrected or it will get worst. I push meds, do treatments, calm down families, etc.,but, the main concern is the pt., and SHE caused him to suffer longer than nec.

[cargal]

Thanks for all the support here at allnurses. I have just finished four days in a row. I usually don't work that many, and I have seen alot of things that disturb me. Residents that could be continent that have to lay in bed until rounds are done and they are changed and get up. Residents that are crawling out of bed are moved like sacks of potatos and no one tells the resident what they are doing before they do it. Agency LPNs come in and go for the ativan instead of therapeutic communication. Why not just come back later? Or circle the med as refused instead of going to the ativan. Combative with am care, well I would be too if I had 3 shifts of god who knows who coming in and waking me up to do god who knows what to me. Residents that refuse to get oob but are made to. Loud piercing continuous noise from the security exits going off when maintenence is moving in and out. Loud overhead paging system. Really loud vaccuum from housekeeping.

Most of the residents are depressed and I would be too. Most of the time I can't blame the staff, they are over worked, they work short, and burned out. They work doubles because they get the overtime and bonus-who cares that the residents suffer. As a part timer that has been there less than a year, I feel that I am spitting in the wind. Alot of the staff has been there ten, fifteen years. They are set in their ways. I don't see that they really any longer enjoy working with this population, but it pays more than a minimum wage job. And you know what, I haven't seen a facility yet that doesn't operate like this.

I have followed the thread on med tech passing meds and I will tell you, when I have to pass meds 25 people is just too many. When done correctly it takes almost three hours, not enough time for a break, with every thing else that needs attended to, assessments and just being patient, caring, gently, and observant. But all these problems that I have stated, the state says we are overstaffed! The whole system sucks. I am thinking of applying to hospice to lower my stress level. Is there anyone out there working in ltc that finds they work for a great company and they nurse for the resident, not just for the state survey?

[caliotter3]

cargal

I left the LTC environment (had a little help by getting laid off in a "downsizing" and was involved in an unfortunate situation in the last place). Went to home health care, and quite frankly, will never go back, even though LTC was why I went into nursing in the first place. Less stress, less depression, no dealing with "that kind of co-worker" (I only ever relieve one nurse for one shift per week!), more money per hour for only one client, very little interference from my agency, haven't seen anybody from the state in almost four years, haven't seen my charting quoted in newspaper articles about horrendous nursing homes, haven't been told by anyone lately that my good name is being muddied about the profession, set my own hours, etc. I could go on and on. I think you can get my idea. Why don't you just say good bye to it all? Just because you choose to go to a different area of nursing does not turn you into a bad nurse. I know. I feel a lot better now that I am away from a situation where I could accomplish no good.

Just consider making a change. It might be for the good, like it was for me. I thought getting laid off was the end of the world ('specially while living in my car), but have since found that it was a blessing in disguise. Good luck and God bless.

Cali

[adrienurse, LPN]

One of the problems with LTC nursing is that as rewarding as it can be, a lot of very "weak" nurses seem to settle into positions there.

Can anybody relate to this? I have worked along with some godawful RNs and LPNs who would have been weeded out long ago in more acute settings (read more supervision from the suits) who have been allowed to fester and thrive for years in their positions.

Sorry it that cheeses anybody off, it's amazing some of the things I have seen people get away with.

[cargal]

I had the worst day again. This LPN has decided that she will speak to me only with yes, no and ok. She does what I ask her, but only with a vegetative stare that says she will not rock the boat, not be insubordinate, but she has decided she will be civil and nothing else.

The other LPN today was agency, who decided to take over a half hour break then another break for lunch for over 45 minutes, wouldn't answer my page (was outside) and skirted assignment related duties all day til we got slammed with an admission at 1:50. She left for lunch at 1:30 and didn't return til 2:30 and stated she only went for 1/2 hour. I don't know if I come across as not assertive enough in delegating or asking them to check on things with their residents, or if my expectations are too high (like check on a foley, still problems, recheck, reposition and change prn). I really don't care how long they break as long as they get their work done. I am soo sick of them( the LPNs)telling the aids to tell me when there is a problem like this,when it is duties they should take care of themselves. She actually said "the charge can do it I'm going to lunch, and then was gone almost an hour. I was busy with my charge duties, had a 15 minute lunch so it wasn't like I was not doing anything, and I didn't have time to attend to her residents foley problem (I had troubleshooted twice.) The LPN did state that the resident c/o "soreness from the previous day's foley insertion" This is BS, she just did not want to deal with it. I see them talking to each other , with family members and other staff for long periods of time, each time not assignment related. I can't write them up, we need them, we have mostly agency staffing now. We are continually short staffed and most CNA's work doubles for the overtime and bonus- but you can't get blood from a stone.

I cried after work, the tension is so high. The agency lpn called off for tomorrow-she stated someone was "rude" to her. I don't kmow if she meant me, or another LPN from another unit that called her on her long breaks. I REALLY try to be professional and not rude, I want things to work out. I don't know if she considers the fact that I stated she was gone for a long time as rude, but I really try not to be.

I hate it there now, I can't stand to go back-it's bedlam. I must stess that in no way am I slamming LPNs. It is just this one and now this agency LPN. It seems our facility has one standard of duties for agency and one for regular staff.

Please help!

[ktwlpn, LPN]

Originally posted by adrienurse

One of the problems with LTC nursing is that as rewarding as it can be, a lot of very "weak" nurses seem to settle into positions there.

Can anybody relate to this? I have worked along with some godawful RNs and LPNs who would have been weeded out long ago in more acute settings (read more supervision from the suits) who have been allowed to fester and thrive for years in their positions.

Sorry it that cheeses anybody off, it's amazing some of the things I have seen people get away with.

>>>>>>>>>No excess cheese here-what you have said is very true....It is way too easy for that type of nurse to be counted as a warm body in a facilty with chronic short staffing....

[Nursenan0]

Hi cargal,

I can relate so much to what you are saying.......I left my charge position a week ago! I hired into another LTC facility as an MDS-RN. I love the elderly, I love the charge position but it only took 7 months for me to totally burn out in that position. I would leave after my shift, either in tears or totally disgusted with the whole place. Although I did have probs similar to yours with 1 certain LPN, I was able to reconcile that after just talking to her face to face about the problem. Of course I think this would depend on the 2 personalities involved. All I wanted was to do my job well enough to go home satisfied that things were done right. I wasnt able to that at this facility, so I found one that I could! I do think most facilities have people in charge who think of survey but I also am determined not to become a non-feeling nurse. The elderly need the ones of us who care!

[quackers]

ktwlpn, boy can I every relate to what you say. I have been in nursing a long time and have worked with some really great nurses and some that were just plain terrible, no assessment skills, poor patient relations, lousy bedside manner and they are still working. Some of these nurses were LPNs and some were RNs. There has to be a happy medium somewhere. The nursing crisis has increased the ability of the "godwful nurses" to stay in nursing and work eventhough they are not very good at it. I don't know the answers. One thing I do know is that when I come across a nurse, whether a LPN or RN who is not doing their job, I let it be know by either putting it in writing or having a long heart-to-heart with that person. I will not put my license on the line because of someone elses mistakes and this can happen. These type of nurses are the reason that LTC has such a poor reputation for having bad nursing. Those of us who work in the LTC setting need to take a stand in our facilities and try to weed them out. It takes time but can be done.

[cargal]

Thanks to everyone who has replied here. My job is getting worse. Over the weekend I was charge nurse and minus an LPN so I have to take the floor and pass meds, do assessments, deal with family members, change foleys, do incident reports, etc all the while doing the charge thing for 52 residents. I had some coming and I was sending some out. The LPN on duty( another one) previously would help me if I asked and now she seh balks too. She found a bruise on a resident on her side of the unit and didn't do an incident report- leaving me to do it, etc. I was actually running in the hall at one time. No lunches, no breaks. I am seething mad. I cannot take this kind of stress, nor do I want to. Some people thrive on this kind of environment, but not me. To top it off, the incoming 3-11 RN alludes to "work not being done on my shift" but has 2 LPNs under her for that shift.. I stated she is welcome to try daylight under the conditions that I worked the last two days. I hate confrontation and I don't think I come across very well when I try to discuss these issues with them, and I am so unsure of my managenerial skills, but when I ask someone to do something, shouldn't they try to get to it? The LPN's are doing nothing more than their med pass and they usually will do somethings else on their assigned side of the unit, but I cannot handle my side and do the charge duties too, without their help! I feel that the first episode has snowballed and that LPN has a grudge against me and the attitude is spreading throughout their ranks. I almost cried this weekend on duty.

I must tell you that I try to give my residents much TLC and hands on touch and validation. I also spend a great deal of time with families. This place has alot of dementia- you guys know- and they require alot of time and special touch and care- but I feel most staff doesn't care. I have seen those assigned to residents that are in their w/c acting out just walk right by them repeatedly with NO attempt at validation or TLC, no interventions at all. I have discussed my concerns with my DON who interrupted me to tell me the administrator wants the beds made a certain way- at which point I stated I really didn't care- I care about resident care- which is sorely lacking. Our ADON turned into a suit, does't have a compassionate nursing bone in her body. I try to set by example- but I am pizzing in the wind.

Please advise! Help! I do have applications in other places and also am thinking of going agency to stay out of all the politics.

Also for those interested, I have been taking Validation Therapy Worker classes, which is a communication technique used with the maloriented old-old. I find these techniques to be the most humane way of communicating with the maloriented old. May not always reduce unwanted behaviour,but it is a relationship of trust and gives dignity. See http://www.vfvalidation.org/whatis.html for more information.

Blessings,

[jevans]

Carrie

I really do feel for you:)

I am sure that you have tried these tactic BUT

At the beginning of every shift-

1) determine number of staff +/- number of qualified against number of unqualified to patients

2) determine what you are prepared for your unqualified to do and DELEGATE

staff A you will be responsible for X No of patients I expect you to be responsible for XY and Z

staff B you will be responsible for X No of patients I expect you to be responsible for XY and Z

3) speak to your qualified tell them that you have to achieve XY and Z today so you will need them to do XY and Z

4) half way through the shift bring all your staff together and ask for a reality check Find out exactly what they have achieved and ask them why they have not. Find out if they are struggling and why. Perhaps give them suggestions on how they can improve time management or performance

5) ensure that your qualified have the knowledge and ability to assist you eg in filling out incidnet reports [ if they know take them into an office and find out why they did not]

Finally keep written documentation of any interaction that you have with staff that you think -WHAT?

Carrie please do not hesitate to PM me

j