New Grad Needing Advice

[iaejd]

So I'm a new grad that's had a job for about 2.5 months now in a for-profit LTC. I've got really low job satisfaction right now and could use some information on what is normal for LTCs.

Some of the things that are making my life difficult:

* There are never supplies - tracheostomy care kits, ziploc bags for ice, medications are never there (especially frustrating since I work weekends and pharmacy only makes one delivery early into the weekend and then it's like "oh, pull from the e-kit" and then the e-kit is out)

* People no call/no show or call out with little notice ALL THE TIME

* The majority of the CNAs/CMAs don't do their jobs - I get VS that are incorrect more often than correct (think O2 sat of 60, BP of 199/110) - and there's a whole 'nother problem: nurses were expected to pay for and use their own vs equipment when I first started (thankfully this has gotten fixed but I am scared it will become the norm again when the new equipment breaks)

* I spend a lot of time doing the CNA's jobs because of the above (retaking VS, answering call lights - and partly I think the facility really has the patient to CNA ratios too low so even the ones who are good can't get everything done)

* Because of the staffing shortage none of the above is ever effectively addressed by management

* I have 30 patients, at least two of which are getting multiple nebs a day, BS & insulins, treatments (2-5/day), all prn meds (and residents that use them all the time), a res that constantly tears holes in her colostomy bag (once a shift), all of which would be manageable except for the above reasons and that I always have falls. At one point I had 6 sets of active neuro sheets.

* The culture is not one of politeness - I have been hung up on by my NP when I called to clarify orders, CNAs have screamed at me and my med aide is openly hostile.

I've gotten a LOT better at time management, but at this point I really feel that the requirements (all the charting, med pass, treatments, nebs, dining hall duty that takes an hour and a half) are unrealistic. On top of them I'm having to do some intensive managing of my CNAs because very few of them get along with each other (There's been a lot of situations where a resident puts their call light on, and the CNA on the hall tells me "That's not my resident. So-and-so should have done it before she went on break. I guess they'll have to wait"). I'm trying to educate myself on how to do this constructively but I'm new and young and not good at it yet. Overall, I'm providing the best care I can and I feel that I'm letting my residents down. I can't see myself getting a job anywhere besides a LTC - I don't think my skills are good enough for the independent work of home health/hospice, and the new grad programs at hospitals are insanely competitive.

Are all these problems above unusual or are they endemic to LTCs?

[amoLucia]

Normally I attribute a post like yours to what I call 'newbie-itis'. LTC is terribly tough esp for new graduate staff. But for some reason, your situation has a ring of more to it than usual. That your place is for-profit suggests some issues. But some other issues are not unusual for many places.

Your pt load/assignment is typical of many, many places. A nurse on the day shift at a NH down the street prob has the same kind of assignment. As I'm sure you've read along on AN, the med pass, tx, charting, nebs and glucometers are quite a lot. But not unusual. Such is the state of LTC today A/E/B all the other posters here on AN. What makes things tough is staffing and that's not likely to change. Increased staffing numbers for nurses and ancillary staff most seriously could be improved everywhere. So all that seems to be unchangeable GIVEN factors to me at this time.

What I'm not sure about is how admin is addressing the problems. Are the NC/NS staff being written up? If there is a union, a progressive disciplinary process MAY be being implemented unknown to you.

Who is responsible for supplies? Does that person KNOW what's needed? Is there some procedure to charge out supplies that nurses are NOT following? That's a disciplinary problem if not being done. Maybe it's an education thing ... if there's a procedure that you don't know to know how to, then you need to find out. Question - when you use a #16 catheter from the supply closet, how do you get it replaced?

When equip breaks, is it tagged and is maint alerted? Or the supply person? How can they be expected to know?

The same for the E-box. I'm sure your pharmacy has a replacement P&P. Do you follow it? I bet during your orientation, you may not have been told about it. Am I right?!?

You didn't mention it, but what about your CRASH CART? Who is responsible to check it off? Personally, I have major thing about unstocked or cannibalized CRASH CARTS. (O2 tanks and suction machines esp.)

If you think staff are making mistakes with VS, let the Staff Devel person know. Only just don't pick one person out. Let SD know it's multiple staff.

Request (not just ask) the staff person to retake the VS. If they balk, you need to ask them FLAT OUT - ARE YOU REFUSING? Otherwise that's insubordination and should be written up. But you're a newbie and I doubt you'd want to get involved in writing up staff. It's a PIA to do the paperwork, but the staff person needs to know you mean business, and it provides admin with a paper trail for disciplinary action (esp if there's a union). This could be something to bring up with your DON. I'll bet she/he will say for you to do it - at least you know you have that authority if nothing else. And when you feel brave enough to, you can do so.

Just curious - are many of your peer staff are relatively new staff? And how long was your orientation? Is there inservice so you know how to ... ?

Oh, and we had a rule - an instant write-up for "IT''S NOT MY PT". (Look back at my REFUSING paragraph.)

Your place has a lot of problems, but I don't think it may be all mgt's fault. And just know, you can't fix everything at one time. Where is your HN/UM in all this?

My suggestion - start just finding about how to replace supplies and fix things. But just as you need to know, so do others. I found staff telling other staff often was the most effective means to get info out. Get your SD and HN on board.

PS - Just a thought for your colostomy pt - have you guys tried some kind of abdominal binder/support? They can be applied loosely.

Good luck and hang in there. You seem to care and want to help. You can make change.

[ProudMom511]

At least you have a med aid...

[Nola009]

Sounds bad... I don't think these environments are the norm, but I've heard about quite a few that are like this! Where do you work, so I can make sure I stay away from this place?!

[misstrinad]

Run. Honestly my facility has issues and so do most others. But in my opinion it sounds Like your are being set up to fail. The work load is normal for ltc, however the combination of everything else sounds like a poorly managed toxic environment. I would start looking for another job

[workinmomRN2012, BSN]

I've worked in a place where some (not all) of the CNA's acted like you should be happy that they even came to work that day. Aides got 30 minutes for lunch and on one particular evening I noticed that one aid did not return from dinner until 50 minutes later, when I questioned her she said "I come back when I'm done eating". I reported this to the DON and the person was spoken to. Another aid continuously used her phone in the hallways, patients rooms, dining room while feeding residents. There were so many negative behaviors happening and I kept a running tab of what I saw and reported it all to the DON. She would always talk the same individuals involved, nothing changed. Which includes not showing up for work, no call, no anything. The bottom line was that this facility needed the workers even if they only worked at half steam. I found that this environment was very conducive to learning a lot of skills, not just clinical. Stay, get experience, and keep applying for other jobs.