I think my nurses are on the verge of mutiny!

chrisrn24 · Nov 19, 2013

I have a lot of thoughts - if I can get on my computer later I will post.

NurseGuyBri · Nov 19, 2013

Thanks. It seems I have thoughts too, but for some reason something just isn't clicking yet. I'll be looking forward to it.

chrisrn24 · Nov 20, 2013

I'm a floor nurse in LTC. I know nothing about budget, etc. so this may be totally out of reach and this is just a spillage of random thoughts from my mind. Maybe food for thought?

First I guess I would talk to nurses and have them tell you their biggest concern, and work from there.

EHR - what are you using? Is it the system that is slow? Is it your wifi? If you could figure out what is slow and present it to corporate, you may have a case. If you can show that nurses are taking longer due to the EHR, and thus accumulating overtime and what not, might give corporate a boot in the butt to get moving on a new EHR.

Long med passes - not sure what state you're in, but some LTCs in my area use med techs. We don't but I know other facilities do. Could that help free up a nurse to do more actual nursing skills, like IVs and PEGs and wound dressing changes? I have many residents who are typically "easy" pill passes.

Do you utilize charge nurses? Could you have a desk nurse who could do these things when crises occur? We are lucky that our system is nice, and that at least on my shift, we have good teamwork. It's just a quick couple of clicks and the face sheet is printed, MAR printed, progress notes printed. If you have a charge, you could relay the situation and have the charge print the paperwork, meet EMS and relay the situation, while the nurse gets back to med pass.

If your residents are truly long term, can you work with MDs to get rid of unnecessary meds? There is another good post in this subforum about a new QI to decrease meds for the elderly. I think this would probably be a good place to start, considering your budget.

Were you the one who said your med pass is like staggered? 0800/0900, etc. Could you change the times to more generalized? Like AM PASS/PM PASS/HS PASS. Gives nurses more leeway.

Also, you need patients but thoroughly vet potential admits before you admit them.

As far as training - do you have a formal system? I think my work has a system where you shadow for a shift, then start to dive in and learn skills, you are reevaluated, etc.

This probably isn't much help but again, maybe some food for thought.

VANurse2010 · Nov 20, 2013

30 is only a "doable" ratio if the residents are ICF and not skilled. The ideal for skilled in my experience is

That said, I think chrisRN has some good suggestions regarding the EHR. Also, I agree that it may be helpful to have a desk nurse even if it meant the remaining nurses taking on a couple more patients.

LTCNS, LPN · Nov 21, 2013

ChrisRN had some really great suggestions. In adding to those suggestions, have you thought about asking if it is within the budget to hire a unit clerk? A unit clerk would be a great way to free up some of the floor nurses' time.

mellster, LPN · Nov 25, 2013

Please don't leave since you seem to really care, and we need nursing administration like you. Nursing administration at my old job just kept throwing more and more work at us and had an it's too bad attitude. We really need people in long term care that care about things and want to make a difference. Unfortunately, reimbursements have gone down and often the money is not there to take care of our elderly. It is a very sad situation. The acuity of the residents (who should be called patients now since alot of them are short term stay) has gone up, but nothing ever seems to be done to get staffing at a reasonable level. State surveyers are more worried about nitpicking then about good care. Medicare and medicaid services needs to increase their reimbursements and make rules that these increases go to patient care only and not into the pockets of a facility CEO, COO, etc. My last job the CEOs expense account was way more then I make in a year. It is sad how a government in a country as advanced as ours cares so little about our elderly that they can't take measures to make sure they get good care. More than 20 patients to one nurse is ridiculous in any setting. I guess the only thing that we can do as nurses is to make sure we do our best to take care of our patients and give them the attention they deserve. I don't have any suggestions that haven't already been given. Please hang in there though. You sound like one of the better DONs.

RNlove17 · Nov 25, 2013

This sounds a lot like the first unit I started on as an RN - I quit within 4 months. For all the reasons I'm sure many of your nurses are quitting, and really because it was unsafe for the patients, unsafe for my license, and I was burnt out. I actually still work per diem there on occasion and HATE it (about to go on maternity leave from my FT job, will look for a new PD job because I don't want to go back at all. Nothing has changed there). I think it is AWESOME that you are actually acknowledging the issues and trying to find solutions. It really does sound like you have a decent management team because a lot would/don't care about these issues and just throw it back on the clinical staff. What kind of support do they have on the floor? Are you utilizing GOOD charges and nurse supervisors, ones that will actually HELP the staff nurses - calling MDs, helping with wound care, draw/send labs, take care of all new admit issues, etc? Or are they ones that just sit around telling the floor nurse to do it all herself? When I worked that unit, having a helpful charge/supervisor made a world of difference (of course all the good ones ended up quitting tho!)

ttt4271 · Nov 30, 2013

How big is your nursing home? Ratio of ICF to Skilled? Are there different roles you could transition your "good, slow" nurses to? I have one RN who residents complained about constantly when she started as a charge nurse (waking residents up for HS meds because she just couldn't get it done...) She is now our Restorative nurse and does great in that role. Still a little slow with charting but it doesn't hurt in that role...

HeyHeyitsMaay · Dec 2, 2013

Your facility and this issue sounds identical to mine. I reduced the issue to the typical 30:1 patent nurse ratio we're used to seeing in skilled nursing vs. the higher than ever acuity of the skilled patients we're accepting. CMS and state rules for nursing/patient care are extremely difficult if not impossible to meet with the complicated acuity levels we're admitting. I transitioned a CNA from the floor to unit clerk who also helps out on the floor when needed. This has helped TREMENDOUSLY in the past year as far as freeing up our nurses for ensuring that assessments and documentation are performed correctly and to completion. I tried to use a nurse in that role but she was quickly taken advantage of to the detriment of patient care.

Having amazing unit managers and a great ADON it's still extremely difficult for our nurses to keep up - even with the utilization of medication aides to pass meds.

One thing I do is new graduates start out on night shift, not on days. They're allowed to transition to day shift after they've demonstrated competency where they're at, and then they work half shifts during the day while we monitor their ability to keep up with that as well before they can go to FT days.

In the end it's reimbursement rates that are the crux of the problem. Lower reimbursement rates forcing SNF's to accept higher acuity to earn revenue - and refusing to alter the model of care that's been in place since the beginning of time. LTC/SNF facilities are a rough place to be right now.

Long Term Care Columnist / Guide · Dec 2, 2013

As with everything else in LTC, when you can't get funding for more staff, you have to work smarter with the staff you have. At my facility, the nurse/patient ratios are fairly high, but we use med techs for PO meds, fingersticks and non-invasive treatments, and we have an ancillary nurse who does all of the admissions and/or functions as a med aide, treatment nurse, and fill-in for breaks. It's still pretty wild for the charge nurses and the acuity is high on both SNF and ICF wings, but many of our nurses have been there for a decade or more, and even the CNAs tend to stay for years. Pay is average, but people tend to stay for the positive morale and the leadership provided by our administrative team. :)

As DON, you set the tone for the entire nursing department. It sounds to me like you are a very good one and that you care deeply about your staff. You've received some really good advice here. Wishing you the very best!

SleeepyRN · Dec 5, 2013

I don't have any real advice, but I come from a background having worked in a small family owned company before nursing. We were worked to the bone. What kept us going with the little we had to work with was the show of appreciation from the owners. It made all the difference in the world hearing at the beginning of the day and end of the day "Thank you, and thank you for bearing with us during this difficult financial time." The appreciation was heartfelt. It didn't solve our problems, but it made working way more bearable. I don't recall hearing a Thank You once from my previous DONs. Let your TEAM know you understand the pressure they are under and that you are on their side and doing everything you can possibly do to help them. And THANK them for all they do under such pressure and thank them frequently. I know I am the type of person who will go above and beyond for someone when I know it is appreciated. Heck, we nurses do it when we aren't appreciated. But it also makes us more likely to look for another job. I feel kind of heart broken reading your post. Mostly because I don't know what the solution is, or where to begin, and this seems to be a common problem. We have such a surplus of nurses looking for work, all while LTC facilities only hire 1 nurse for every 30-40 residents. I worked at a SNF for only a few months. I absolutely loved the work. Even the charting and entering MD orders. BUT I had way too many patients, especially for a new grad. I remember thinking "Wow, what awesome care we could provide if this floor had just 1 more nurse." Anyway, I'm looking to get back into LTC, and this post saddens me, reminding me of the conditions I'll be returning to. Thank YOU for being a caring DON.