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

Nurses Safety

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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!!

I completely agree with what Brandon & Altra both wrote and as far as what some of the posters said, they were way overboard on the dramatics.

To give you my personal thoughts on a few of your concerns:

1. Gloves, no I don't wear them for insulin injections, BUT, if they make you more comfortable, by all means, wear them. NOBODY is ever going to tell you to take them off.

2. Med times, think about it, if you have say 30 residents to pass meds to, how much of your med pass are you going to get done if you are breaking those admin times down, you would be continuously be passing meds the entire shift and getting absolutely nothing else done.

3. Daily assessments are just NOT done in LTC. This is the big difference from acute care. Your residents are living in LTC with long term illnesses and conditions, they are, for the norm, NOT acutely ill. The "exception " here is if someone is having respitory issues, by all means assess lung sounds, same with bowel sounds for constipation or abdominal region pain.

4. This last point is one of my big pet peeves. It bugs me when I hear a new nurse state, "I don't want to lose my license for, (insert so called infraction). I swear some older nurses like saying this to new nurses to strike fear into them. Believe me, you are NOT going to lose your license for any for the "infractions" you listed in your original post.

5. To sum up my very long winded post, go to work, pass your meds, do your treatments the way you were taught, BUT don't get all caught up in the "this isn't EXACTLY the way we learned this in school". You will be fine. We've all been there and can speak from experience. I hope you stick with this forum and give us an update in a few month. I'm willing to bet by then you will be much more comfortable in your new career.

I am a new grad starting my first job in LTC today... I had always heard that long term care was very different from acute care but never really heard anyone explain the difference. This thread has provided me with a preview of what to expect as a long term care nurse. I really appreciate the heads up on the insulin.. I haven't started orientation yet so I don't know what the facility policy is re insulin checks but at least now I won't be freaked out if they tell me not to worry about the second nurse confirm. ;)

Specializes in Med/surg,orthopedics,emergency room,.

Yes!! This is definetly a WHOOSAH moment. I would say to you, that if you are going to be working in an Alheimer/Dementia unit, many of those meds are geared to be given around dinner time. I would give all of mine during dinner, so after dinner the CNAs could do their thing, and if I had some 2200hr meds to give I would do them after the CNAs put their patients down. As far as assessments: What is we all learn? 'IF IT WASN'T CHARTED IT WASN'T DONE". It seems this facility needs a few good nurses! Don't be scared! We've all been there.One BIG thing you MUST learn is time management. That will keep you from pulling out your hair. I learned that after a few busy, busy shifts. Plan your work,and work your plan. Sometimes it will be easier said than done, but at least you had a plan in the first place. Good Luck, and best wishes!

Specializes in geriatrics.

Re: "If it wasn't charted, it wasn't done..."

Yes, this sentiment is true, but most LTC facilities chart by exception, meaning incidents that are abnormal or pertinent information (acute change in status, falls, new admission assessments, wound care, palliative care/ comfort care interventions).

With experience, you'll learn what needs to be charted and what is less important when your facility uses charting by exception. It is completely unnecessary to perform full assessments on each resident. When you are passing meds or providing care, you're assessing the patient.

What's "WHOOSAH"?

What's "WHOOSAH"?

Chill out, calm down, take it down a notch.

It's something one says to one's self when one is all worked up and about to do something crazy/stupid.

Thank you all for the advice. Quite a bit of it makes sense to me, about the med times and insulin and such. However, I will be resigning from the position tomorrow. I talked to my former clinical instructor today about my worries, and she agreed. Her advice to me was to quit immediately.

I do not feel comfortable signing off on the e-MAR that medications were given when they weren't or charting things that were not done/assessed. The charting IS a full assessment, including whether their bowel/lung sounds were normal, what their pupil reaction is, etc. I will NOT chart something I have not done/assessed. I will NOT pull meds, put them in a drawer, sign them off, then give them later. I understand where some of you are coming from, and I understand this is accepted as the norm in LTC, but I feel like it is a ticking time bomb for medication errors, and I do not want to be a part of it. Overall, I feel uncomfortable with this facility, I do not feel like I am able to ask questions without just being waved away with a "You'll be fine, don't worry."

Again, thank you for your advice! I do not want to come across as a rude/unappreciative person. I know I have to start my nursing experience somewhere. But I cannot work at this facility.

I agree with you on the MAR and charting. It was drilled into me at school that you only chart what you do and you give meds when they are prescribed! It is scary to think there may be a reason some of the meds are given hours apart. I am sure you hadn't had a chance to look each med up to see what they are and if they can be given with another med, since you've only had a few shifts with that many patients.

Good luck to you in the future!

Specializes in Medical Surgical.

IN LTC you shouldn't have more then 2-4 full assessments to fill out, then the rest should be by exception, just make a note of who needs assessments at the start of your day, then plunk them out one by one as you can, let your aids know who you needs to see and tell them that you would like to see them when they are in the shower or being changed so you can see the skin, you would not believe how much time this saves. Also pass out snacks, your CNAs will love you for helping and the residents will love you for bringing them food. You can usually squeeze in a listen with your stethoscope, remember for the really lucid patients you can just ask them if they have any issues and save some time there, they will usually self report anything, and skin issues they have. Dont make up charting for your assessments, I can't stress this enough. Also listen to your CNAs, they are your saviors in these situations. Anytime a CNA takes time to come find you and say "So and so is acting weird" thats cause for concern and has saved many of my pts lives.

Specializes in Thoracic Cardiovasc ICU Med-Surg.

I think it's extremely frightening that so many folks here think it's A-OK to have three days/nights of orientation for a new grad! and then expect that to be a safe, critical thinking nurse. OP do yourself and your education a favor and try to get a hospital job.

I think it's extremely frightening that so many folks here think it's A-OK to have three days/nights of orientation for a new grad! and then expect that to be a safe critical thinking nurse. OP do yourself and your education a favor and try to get a hospital job.[/quote']

It's not that I think it's a-ok it's just that many places only offer that amount. I think you should be ready with your basic set of skills though.

Specializes in geriatrics, IV, Nurse management.

It's not that I think it's a-ok it's just that many places only offer that amount. I think you should be ready with your basic set of skills though.

I agree. Nurses learn with experience and time but I do expect 3 days is enough to learn the basics of the unit and apply the basic nursing skills from school.

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