martinalpn 4,994 Views
Joined Apr 24, '11.
Posts: 137 (50% Liked)
Exactly right, the elephant is in the room because nobody wants to do anything about it. Safety will increase with better and APPROPRIATE ratios (Ex. ICU RN's have 2 patients, but do not give me the two sickest patients, both on life support with pressures in the crapper while on multiple pressors, family issues, etc., which giving the other nurse 1 ICU patient who is on no pressors or life support and being downgraded in an hour) I recently improved our safety in our unit by not scheduling people for mandatory overtime anymore. Management breathing down my neck because we did not have enough staff on the unit and I bargained with people to work overtime in exchange for future time off and the schedule they wanted. Well that went on for about 6 months and they still hadn't even hired anybody or interviewed! I stopped doing the overtime and people of course were not coming in when staffing calling about extra shifts because of burn out or wanting personal time off. We had to start turning patients away because of not enough staff. Well, guess what there went $$ out of the door and sure enough, new staff members hired the next week. You must acknowledge the elephant yourself and do something about it!
The moment that healthcare started referring to patients as "clients" is to understand how modern healthcare is evolving. Its about dollars and how quickly you can get them in and out the door. Look at bundled payments that rolled out for CMS. You get a set amount that covers X surgery and stay. Typically total joints stayed around 2 days, now they are pushing for them to be done as outpatients with < 24 hours in the hospital. I never did an evidence search to see if this was effective but from the experience side, its not really a great idea for the patient or nursing. What it is good for is making money. The shorter the stay, the more money kept in the coffers. I really dislike where healthcare is heading but its not up to me, were just pawns in a much larger game dictated by insurance and health laws.
I was just on a case for work and let me tell you, if myself and the other nurses had only charted by exception we would have been up that proverbial creek. Our charting was raked over the coals. We were all consistent in what we saw but slight differences in verbiage is what they went after. BE Consistent! And chart defensively, especially with electronic charting..it becomes very easy to click boxes and not explain what is abnormal. If there is an order make sure it is done, doesn't matter if the 4 people before you didn't so it. Always perform your own head to toe assessment, don't rely on the person before you.
That charting was ... just not intelligent. I understand that in LTC settings a full set of vitals including SpO2 may not be obtained every day, let alone every shift. But if there is a physician order specifically to obtain SpO2 daily ... what other evidence can be offered that the order was implemented if no O2 sat is documented? Duh.
There are too many good reasons to lie about adverse events for the truth to always come out.
Best McGyver moment in LTC - cutting the end off oxygen tubing to insert into a gtube that had a broken seam on the cap which would leak during feedings. Best funnel I've every seen!
I have worked LTC for 29 years. A few times I have tried to get out of the LTC grind-house, by trying to get into Acute Care hospitals or Home Health. Each time you meet the same barrier - many do not see or accept the experience and years put in doing long term care. For a lot of the Nursing/Medical employment LTC is looked down upon.
A typical day/shift has the nurse coming into the building already *Drowning* lately. You either have work thrown on the next shift by the prior shift, or by the Nursing Managers, or simply because the day itself has been a mad house. Lately it is the 2nd shift ( 2-10pm or 3 -11pm) that can get hair pulling crazy. Yet - understand, this is only via my personal experience. On the evening shift you get Admissions which can come in any time during your shift - up to the time your shift ends, you have doctors/FNPs coming in during the evening and writing orders, you have family members underfoot. Then you also have the support leaving you after 5 -6pm ( ie; Managers, etc). Some will see their staff struggling and stay alittle longer to aid you if able. Sadly though many notice and just walk right out the door.
Toward family members many are actually very nice and caring toward the LTC staff. Still it is the one or two that come in, believing NOTHING you do is good enough, that can break the work day. And though you want to just tell them to take their family member home sometimes inside....you put on that warm caring smile, bite your tongue and again try to appease that family.
Then in the past several years you notice CNAs you are getting want the paycheck but try to do as little as possible, so you have to play Warden....having to chase them continually to get things done. Then you have Managers telling the nurse "You need to really stay on top of your aides," when you are already doing the best you can.
When you finally get done at the end of your shift, a day that was so busy you could not take a break, had to sign out for supper but had work through it to get done on time, you now have to wait on your relief nurse. It is now 30 minutes after your end time, no call or anything, and your relief saunters in late habitually. So you know the next day you will get called in to the office for working late because at your facility *There is NO excuse for working late accepted*.
And at least where I work LTC.....this is considered a GOOD day ( LOL).
Not every long-term care nurse chooses LTC as a profession. Sometimes, it chooses us.
But no matter how you've arrived at your first job in a nursing facility, there are challenges awaiting you that you didn't anticipate, especially if you're coming from acute care or another environment where even chaotic conditions have some form of logic to them. Here are a few things you should expect as a new long-term care nurse:
Expect to chase after supplies.
I have never worked in a nursing home where they kept everything in one place. You'd think they would put all the catheter supplies together, but no---whenever I had to change a catheter, I had to go to three different storage areas to obtain the necessary items. Even house stock meds were kept in different cabinets: vitamins and supplements at the nurse's station, OTC pain relievers and bowel care meds in the medical records office. I never did understand the reasoning behind this, so I lobbied administration to change the layout of the supply closets so we didn't have to waste time running all over the facility. Of course, they never did.
Expect to become the nursing version of McGyver.
LTC nurses need to be creative in order to solve the problems that frequently arise in a facility which always seems to be short of supplies and slow to make necessary repairs. You'll use washcloths or foam pipe insulation to wrap around the arms of wheelchairs when the vinyl gets torn up and causes skin tears. You'll utilize foam tape to "Nerf" splintered doorframes and the sharp corners of nightstands to prevent injury. Sometimes you may even have to use a Foley catheters as a G-tube because nobody ever remembers to order the insertion kits.
Expect to be challenged by a wide variety of situations.
Contrary to popular opinion, LTC is NOT boring. Yes, you will have routine tasks such as med passes and fingersticks on your 17 diabetics, but no two days are the same, especially if you work on a skilled unit, which is like a hospital only without the staffing and the equipment. Unfortunately, SNF patients are sometimes transported from the hospital in unstable condition---in fact, I've sent patients right back to the hospital without allowing them to be transferred from the stretcher. But even on the custodial care unit, you'll deal with a host of problems: falls, dementia, hovercraft families, scabies outbreaks, diabetic crises, psychiatric issues, and fights between residents.....to name a few.
Expect to become a diplomat.
It is difficult to hold your tongue when a resident's family member chews you out for the umpteenth time today because "Mom" isn't drinking enough fluids or eating enough or getting out of bed every day or having her 20-minute dental routine followed to the letter. It is beyond tempting to tell them to take her home with them if they feel they can take better care of her. But as you become more experienced, you learn how to let their constant complaints and demands roll off your back, and how to de-escalate a crisis situation by "killing them with kindness".
Expect to be looked down upon by other healthcare professionals; but remember, you are the expert on your residents.
Regrettably, long-term care is still regarded as the bottom of the barrel by many nurses in other specialties, as well as administrators, doctors, therapists, and even EMTs. I can't count the number of times I called the ER to give report on a resident I was sending out and was asked if I'd taken vitals! It's as if they think LTC nurses don't have the sense to do the basics before calling in the cavalry. And if I had a dollar for every time I tangled with EMTs over their reluctance to transport a resident because of insurance issues or "she looks OK to me", I'd be a rich woman today. But there is no need to let the idiots get you down.....when it comes to your people, YOU know best.
Expect to be chronically understaffed.
This is an issue everywhere, even in the best facilities. Granted, you can have days when there could be 15 staff on the floor for 30 residents and it still wouldn't be enough, but even on a good 3-11 shift, 3 CNAs and one nurse for those same 30 residents is pathetic. And when you complain, the general response will more than likely be "Suck it up, Buttercup" and that you should be grateful because XYZ Nursing Home's staffing is better than what the state requires.
Expect to fall in love.
LTC nurses don't do what we do for the money (it's also one of the most poorly paid specialties). We do it because we find so much to love in the wizened faces of our elderly, the funny things they say, the way they hold our hands in a tender moment. No matter how demented or ill, they will provide you with wisdom gleaned from their eight or nine decades of life, as well as a million and one laughs! I'll never forget the resident who once asked me, when I knocked over a couple of Jevity cans in the next cubicle, if I was the cat. Knowing that despite her dementia she had a wicked sense of humor, I said, "Yes, Elaine. MEOW!" To which she replied, "Oh, OK, thanks for letting me know," and promptly went back to sleep.
The hardest part of these special relationships is that sooner or later, your residents will break your heart by leaving you.....and every loss will change you. Some deaths will hit you harder than others, but eventually you'll learn that good-byes are not always the worst thing that can happen.
Loved this article! I started out as a CNA in 1980-1981 and was laid off a year later because CNA's were no longer permitted to work in a hospital. The skill mix went to LPN/RN only.
1984: Obtained my LPN because of wait listing to an RN program. I worked as an LPN for 4 yrs in a hospital and LTC per diem. Around the early 90's, the LPN were being slowly phased out of hospitals and going to a strict RN skill mix. Still no CNA. Mid 90's, I saw the LPN phased completely out in my area and an RN/CNA mix back in style. LPN's were left to work in LTC.
This has seemed to stay this way with select few hospitals retaining LPN's, but the vast require RN or CNA.
So, just when we think we have it figured out, hospitals throw in the mix the ADN vs BSN controversy.
I feel as though my life has been a pig pile of nursing degrees. I initially started out as a CNA, then obtained my LPN, because CNA work was becoming increasingly rare in hospitals. Once an LPN, I was relegated to the bottom of the heap, because the LPN wasn't good enough, so I went back to school to earn my ADN. The safety net of the RN started becoming full of holes, because even though I had my ADN, I still was at the bottom of the pile. I realized to get to the top of the pile a BSN was necessary. I went back to school and achieved my BSN. For now I feel safe, but if someone even mentions needing an MSN at bedside I'm going to hurt them.
I, and others, have said this earlier in the thread but apparently it bears repeating: You do not have to provide any sort of excuse or justification for calling in. PTO is earned. It's part of an employee's compensation. By definition, I am indeed entitled to it.
All facilities have policy regarding how often emplyees can call off in a given time frame. If I violate said policy by all means, punish me accordingly. If I am not in violation of any such policy, well, then kindly mind your own business. I have never provided a song and dance as to why I called in and I never will.
Isn't this profession already plagued enough by martyrs?
I just prefer if people don't tell me. it's none of my business...if there is an issue the manager can talk with them. I once had someone call in and tell me they "have the runs" then she got all descriptive. Yea, even though im a nurse I prefer not to hear about my coworkers "runs."
just say your calling in and if there are issues manager can call you. I don't care.
a calf just got out of my pasture, it will be a while
a red wasp stung my right hand , swollen cant grip a pen
I would definitely call in if my dogs were too sick, they are my babies :-)
we had been working short handed for a while and it was crazy. one of the nurses called off and when asked why she said "because this place got on my last damn nerve yesterday, and its best i stay home today!".
When I was a manager I had an employee call in because her newborn spit up on her scrubs and she didn't have any clean ones...... I told her that we could issue her a pair of OR scrubs for the day. She then said that the baby vomit got on her shoes too.
This actually happened - I swear (because you could NOT make this up!):
I was the house supervisor over the four day Thanksgiving holiday/ weekend. ICU nurse calls in because her cat was missing. On Thanksgiving. That's Thursday.
She's scheduled off Friday and Saturday.
Sunday, she calls off again because (wait for it.....) the cat had returned but seemed 'emotionally needy'.
Her manager was sitting next to me at the time the second call came. I just put it on speaker and asked her to repeat what she had just said.
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