New job: "Don't worry about following the MAR" & other scary stuff

  1. 1
    Hello everyone!
    I am a newly licensed RN and just got my first ever nursing job! I was super excited to get started, but now I am so worried about harming a patient and/or losing my license! Many of the things I am told to do at work goes against everything I was taught in nursing school! I am trying to decide if it is as bad as I am thinking it is & whether I should quit or not.

    First off, it is a LTC facility, on a dementia/alzheimer hall & I only had 3 days of orientation before I was on my own. I have about 20 patients to care for. I oriented on day shift & began my first shift alone on nights (which I have never oriented on). I am the only nurse on my hall, and there are only 2 other nurses in the building after 5pm.

    Here is my list of things that worry me:

    #1: Not double checking insulin. My preceptor told me not to worry about doubling checking. "We just draw it up & give" since there are lack of nurses around.

    #2: Not following the MAR. There are patients who get meds a 1800, 2100, and 2200. The patients usually go to bed after dinner, around 8, and I was told that "you do not want to wake them or your night will be ****." So I was given a list of patients to give all their meds (both 1800 & 2100) at 1700 & the other half of the residents, I am to give all their meds (again, both 1800 & 2100) at 1900.
    If this isn't scary enough, I have to pull the 1800 meds early for those patients & sign them off the eMAR so they won't be past due, was told to put them in med cups, label the cups & put them in the drawer until I am ready to draw up the "1900" meds.
    The ADON agreed with my preceptor that this is how they want to be done. I did it on my first shift, but it made me so nervous! I think this is very very wrong & puts me at high risk of not only giving wrong medications, but doubling up or missing medications that I am signing off on giving!
    Also, by the time I was giving those "1900" meds, I don't even know what I have in the cup any more! Once you sign off on the meds, there is no way (or at least, I wasn't shown how) to go back & look at the medications list.

    #3: Charting "the usual". My preceptor fills out the charting with the patient's usual, sich as "active bowel sounds", "no adventitious lung sounds", etc. I was told not to worry about assessing them & was given the "answers" to fill out their charting. I have been there a total of 4 days & never once seen anyone assess the patients heart/lung/bowel sounds! With the crazy number of patients & their medications, I only have an hour that I could spend assessing them anyways!

    #4: Not wearing gloves for anything! I've seen me preceptor & other nurses draw accuchecks, give insulin, and eye drops with no gloves on! She told me not to worry about it (I did not listen to her, I refuse to give injections or draw blood of any sort without protection!)

    So adding all this to the fact I am brand new, on my own, and no one to ask questions to, I am pretty sure you see how uncomfortable I am. I cried the whole way home from my first shift, terrified I am going to harm a patient or get my license taken because of the things they expect me to do. I tried to talk to the ADON and other upper level managers about my worries & feeling like I am not ready to be alone after only 3 days, but I'm just told "you're fine. It'll be ok."

    I really think it is in my best interest to quit, but my husband is worried because I need a job & he doesn't understand how bad these things are. I need advice, please!!
    Susie2310 likes this.
  2. 11,236 Visits
    Find Similar Topics
  3. 49 Comments so far...

  4. 12
    We don't double check insulin either. That's not a rule everywhere. Stop worrying about that its okay!

    Two...maybe this is awful but I don't see a huge issue unless its a narc or an antibiotic. If you are at home, you don't get one pill at 6 pm, 1 at 7, two at eight and three when you go to bed. Would you like to be bothered that much?? As long as you are keeping track it's not a big deal.
  5. 2
    Honestly I think you should pack it up and find something else. Yes, the job economy is bad but not bad enough to put everything you've worked so hard for at risk. Giving the medication like that may not sound so bad, but If they tell you to do that, imagine what might be next!. And not assessing any of the patients? That's a big NO-NO. Suppose one of your patients goes bad and they happen to have a family that is fond of litigation. All they have to do is go back into your charting and they will find discrepancies. Next thing you know you are in court and on the verge of losing your license. What are you going to say? That the facility told you "don't worry about it? Get out NOW.
    Not_A_Hat_Person and newgradbms like this.
  6. 30
    1. Double-checking insulin is a common (though not universal) practice in acute care, where you likely had the bulk of your clinical experiences as a student. It is not universally required.

    2. For patients in a long-term care setting, there are few meds that really need precise timing. Administering meds in that setting at 1800, 1900 and 2100 is neither necessary nor efficient practice, and likely is bothersome to the patient. I would suggest that a longer-term goal of nurses in your facility should be to get the patients' physicians to change their orders to reflect something more reasonable.

    3. Again, for LTC patients ... daily assessment shouldn't be required. Your documentation should not be designed to set up the expectation of daily system-by-system assessments. In an LTC setting I would expect a note at least daily, if not each shift, that indicated a more general assessment - skin color, respirations unlabored, no cough, ambulating/moving in a manner consistent with that patient's baseline, at baseline mental status, tolerating p.o. intake, no reports of new pain, etc. Listening to bowel sounds on each shift in LTC??

    4. If you want to wear gloves - wear gloves. Generally accepted standards on universal/standard precautions and OSHA regulations are on your side.

    The first year of nursing practice is often frightening. Learn all you can, and accept that there will be rocky spots. Lots of support here at AN. Good luck to you.
    BuckyBadgerRN, canoehead, catlvr, and 27 others like this.
  7. 10
    Quote from fivefeet05RN
    Honestly I think you should pack it up and find something else. Yes, the job economy is bad but not bad enough to put everything you've worked so hard for at risk. Giving the medication like that may not sound so bad, but If they tell you to do that, imagine what might be next!. And not assessing any of the patients? That's a big NO-NO. Suppose one of your patients goes bad and they happen to have a family that is fond of litigation. All they have to do is go back into your charting and they will find discrepancies. Next thing you know you are in court and on the verge of losing your license. What are you going to say? That the facility told you "don't worry about it? Get out NOW.
    OP is in LTC, which is structured differently than acute care.

    OP, you must WHOOSAH and realize that you are in LTC...it is structure around a home setting, so assessment is mostly eyeing the pt, unless there had been a change in baseline status, on abx, or returning from acute care; passing meds and giving treatments. YOU are NOT going to lose your license for not giving meds on time, not using gloves, etc.

    This setting will challenge you to be prudent in being aware of the residents changes. You will get to know what a patient needs, especially if you are on a permanent floor. It will take time, but you also have staff around if something is absolutely acute happening. Utilize the nursing process, facility policy, and collaborate.

    Altra have you some wonderful sage advice...use it.
    NurseNightOwl, nrsang97, VickyRN, and 7 others like this.
  8. 7
    I have to agree with a lot of what others have said. I work LTC/skilled and things are different than in acute care. On the medication times, one thing we did is get the doctor to order all evening meds for HS for the whole facility. Now they can get them on a schedule that works for them. No one at our facility double checks insulin, it's just the way it is. Good luck, I know they teach you things a certain way in nursing school but there are so many different types of facilities and each one does things a little differently.
  9. 0
    Quote from fivefeet05RN
    Honestly I think you should pack it up and find something else. Yes, the job economy is bad but not bad enough to put everything you've worked so hard for at risk.
    This is my thought too.
  10. 3
    Hello!

    I'm a new grad RN too on an Alzheimer's unit in a long-term care facility. I just finished my 30-day orientation, which I felt was reasonably adequate. I go on my own next week. I don't think three days of orientation is enough, but you will likely get into your own groove quicker than you believe is possible now.

    I agree that most meds don't need to be given on a precise schedule, with the exception of insulin, antibiotics, and, to a lesser extent, antihypertensives. As far as keeping track of what you're giving to whom, can you print out a backup copy of the eMar for your shift? That way you can check administrations off and make notes as you go. Then, when it's time to check them off in your eMar program, you'll have a matching reference to work off.

    Also, I've found that doing nebulizer treatments simultaneously saves time. You'll quickly start to remember who gets them and who doesn't (though, of course, you should always double check for order changes). My residents all get the same nebulizer solution, so I can load my pocket with the number of bullets I need, work my way down the hall, and get them started at the same time. While those are running, I can administer meds to other residents. Also, I find it's helpful to either do my PEG tubes first or last.

    Finally, one nurse gave me this tip: For residents getting BP meds, place those drugs in a separate (labeled) med cup. Then, you can go in the room with all the meds (BP meds separated), take the BP, and give the antihypertensives if appropriate (or discard them if the BP is too low).

    I still have a lot to learn, but I'm really enjoying my work on the dementia unit. I'm surprised how far I've come in just one month. I feel that I have a reasonable handle on things, though I would never say that I'm confident. It's helpful to know who to call when. Hopefully, you have a good nursing supervisor and helpful coworkers on duty when questions arise.

    Best wishes to you!
    canoehead, VivaLasViejas, and VickyRN like this.
  11. 2
    I completely agree with Altra. Plus the problem of resigning and finding a new LTC job....well, it's most likely going to be the same if not worse in MOST other facilities. The grievances you have so far are in my opinion, pretty light. However, I completely understand your concerns, I really do. As far as giving meds at once, its just because the prescribers and nurses havent communicated a better solution. (Giving most meds together.) When working LTC, I combined med times but used my nursing judgment. If they are prescribed 2 BP meds, Im making sure they are getting them at the proper times. Antacids? Definitely give them as prescribed or they wont work properly. Psyc meds....GIVE AS PRESCRIBED. Other nurses arent doing this because they are lazy, they are doing it to make sure they everything done! As far as assessments, Im only listening to bowel sounds if Im noticing constipation or vomiting or other symptoms. Head to toe assessments are not done on every resident in LTC. You're assessments come to you all shift as you observe them. A time doesnt have to be set aside doing it. Above all, do what you feel is right, but be prepared for similar or worse practices elsewhere
  12. 1
    Quote from Altra
    1. Double-checking insulin is a common (though not universal) practice in acute care, where you likely had the bulk of your clinical experiences as a student. It is not universally required.

    2. For patients in a long-term care setting, there are few meds that really need precise timing. Administering meds in that setting at 1800, 1900 and 2100 is neither necessary nor efficient practice, and likely is bothersome to the patient. I would suggest that a longer-term goal of nurses in your facility should be to get the patients' physicians to change their orders to reflect something more reasonable.

    3. Again, for LTC patients ... daily assessment shouldn't be required. Your documentation should not be designed to set up the expectation of daily system-by-system assessments. In an LTC setting I would expect a note at least daily, if not each shift, that indicated a more general assessment - skin color, respirations unlabored, no cough, ambulating/moving in a manner consistent with that patient's baseline, at baseline mental status, tolerating p.o. intake, no reports of new pain, etc. Listening to bowel sounds on each shift in LTC??

    4. If you want to wear gloves - wear gloves. Generally accepted standards on universal/standard precautions and OSHA regulations are on your side.

    The first year of nursing practice is often frightening. Learn all you can, and accept that there will be rocky spots. Lots of support here at AN. Good luck to you.
    Excellent advice for a new LTC nurse to follow!
    Psychcns likes this.


Top