First nursing job, need help!

[bigmamabear]

Ok, so wooohoo! passed my NCLEX-PN in December (right before Christmas), and landed my first nursing job 2 weeks later at a very nice nursing home. I started on the 3rd of January this year, did a few days in a classroom style orientation and then 2 weeks of shadowing a nurse on the floor, which I felt was pretty generous of the company. I started on my own last weekend, they put me on one of their easiest med pass halls two days in a row and I managed to stay afloat and stay 'in the green.' The last two nights however, I was moved to two of the heavier med pass halls with a few more acutely ill residents and I drowned. The ratio was initially indicated in orientation to be 1 LPN: 3 CNAs: 20 residents max, however it's been more like 1:2:20, which is still fine-as long as everyone is doing their jobs. I have done clinical rotations in nursing homes with 1 LPN: 2 CNAs: 30 residents, so this seemed a whole lot better.

A little background-I never worked as a CNA before nursing school, I did a year and a half as a patient care tech (PCT) about 15 years ago in a mental health facility, but I'm finding out that is nothing like being a CNA in a nursing home. Nursing school was mainly working 5-7hr stints at the hospital 3 days a week, max of 3 patients. We essentially did the half-role of CNA and assisted with brief and bed changes, bed baths, toileting, and just checking up on the residents; we were not allowed to pass meds, change bandages, give showers, or anything of that nature without our instructor or a staff member present. As far as time management goes, as long as you could give a bed bath if needed and change linens for 3 people in 5hrs, you were good to go. Most of us walked the units in circles just so we weren't sitting around.

Don't get me wrong, I didn't come out of nursing school a young pup with no idea about how the world worked, or with that glassy smile on as I pinned the ID on my NON-SCHOOL scrubs with my name followed by "LPN". I knew that this would be hard work. I knew I had a lot to learn and what I learned in nursing school would not prepare me for everything in the real world.

I have a lot of questions about what my responsibilities are as far as being an LPN, one of them being patient care. I have been told by a few of the nurses at the facility that were so gracious to pause their own med passes and help me when I was drowning in my own (and fighting back tears after being yelled at by two residents for med pass timing tbh) that the CNAs know I'm a new grad nurse and I don't know the roles yet, so they are taking advantage of me. I'm getting used to the scheduling, but the supervisor changes the CNAs on the unit around without letting the nurses know, I don't know where the CNAs are at half the time, and by the end of my shift last night, I had one resident still in a dirty brief, a room that wasn't picked up (washcloths, trash out), VS were not all done as asked, one resident who didn't get oral care, not to mention one pissed off oncoming CNA. I could not find my CNA to rectify the situation, and once I did, I was informed that he got in an argument with the oncoming CNA and clocked out/left for the night. The supervisor was notified, but I was also informed that they rarely do anything disciplinary-wise, I'm believing this to be because of the high CNA turnover. I'm only 4 days in to being on my own and I can tell you I'm so irritated with the lack of communication I'm coming close to going off-which is not like me, I'm usually a cool cucumber.

I will make it a point to better communicate with my supervisor to know who my CNAs are on my next shift, and I'm pretty good about asking what to do in situations I've never been in (TORB, calling physicians, charting for different issues:unsure:). I'm trying to find out what roles the CNAs are supposed to fulfill and how I could stay on top of that along with trying to learn/do the things I'm supposed to be doing for the shift. I have thought about having a pre-shift meeting with myself and the assigned CNAs on my hall to discuss expectations and lay out my needs, I already put out a highlighted VS sheet with a bright orange note that I need them by a certain time (which is *consistently* ignored, btw). I also know I don't want to seem pushy and overbearing, there's a fine line between being firm with expectations and just plain being a witch. Someone with more experience please guide me!

[scrublifenurse10, LPN]

First of all, congrats on the job! Sorry that you're being faced with so many struggles right out of the gate...but just know that we've all been there, and it does get better!

Second, the best tips that I can offer are the following:

* time management is essential. Have your entire shift planned out prior to even getting to work. Now...realistically...things are always going to go differently than you have planned, but having a plan in place will give you a "guide" for your shift and help you stay on task.

* Start your med-pass as soon as you've gotten report and make sure you have an uninterrupted med-pass. By that I mean, unless it is an emergency situation, don't leave your med-pass to deal with anything else. Make sure your CNAs know this! Let them know the kinds of things you can be interrupted for (patient decline, patient with chest pain, high fever, unstable vitals, etc). Have a small notepad on your med-cart that they can either write down non-emergent notes for you (room # ? asks for pain pill, such-n-such has loose stool x2). Those are things that you can address whenever you get to that patient on your med-pass. This will help you have less interruptions and help your med-pass go smoother and be more time efficient.

* I use a 4-color pen that makes a huge difference for me in my organization. Black - notes when receiving report. Green - check mark next to patient when meds have been given and to write next to patients name any PRNs given during my shift. Blue - treatments to be done during my shift and any nursing notes that need to be made for the patient. Red - anything that I need to call the dr about or any patient complaints that need to be addressed.

* Your CNAs don't have to like you but they have to respect you. You are their boss during your shift. You have to find a way to be firm but friendly. Laugh, joke, have fun when it's appropriate; but also give instruction, delegate tasks, and be firm when it's time to get the job done. If you tell them that you need you vitals by ??:?? time...and you're not getting them...then take the vitals sheet/clipboard to them and say "I know you all are busy, but I really need these now, and I will need them by ??:?? time from here on out to be able to take care of my patients correctly." If they refuse to comply, that is considered insubordination and you need to go to your unit manager or ADON or DON. If you are having a problem with one of your CNAs go to them (not in front of others) and say "Look, we've had a good working relationship so far, but I need to ask you about ??? (whatever the problem is)." The more your CNAs see you taking the lead, being firm, and being in charge; the more they will respect you and comply. It will make your job much smoother.

* Know that it takes a good month or so to really learn your residents, your unit, your co-workers, and get your into a routine. There will be days that you have so much extra time it will feel like you're missing something, and other days you will feel like you've fallen overboard without a life-jacket. Just know that you are a great nurse on both of those days as long as your residents are being taken care of appropriately.

* MOST IMPORTANTLY - DON'T GIVE UP!! Every shift (no matter how bad it may seem) will be over eventually and you will be able to go home and rest and refocus for the next day. Try to remain as positive as possible (trust me I know from experience this can be hard).

Hope this helps some, and I'd be happy to try to help answer any other specific questions you may have. Good luck!!

[ltcnurse4u, CNA, LPN]

The above poster gave some really good tips. I have a cheat sheet that I use for my shift. I work on a TCU and the residents are very much like med-surg patients. My cheat sheet has a space for vitals, blood sugars, weights, BM lists, PRNs ect. I also use a four color pen. I am no way a neat freak or organized at all..but at work..I am . Everything has a color and is written down. Med pass is a very important time and cannot be interrupted. That is where the cheat sheet and time management will come in. Blood sugars first, before meal meds next ect. As they are getting ready for bed, this is a great time to check the skin and apply barrier creams/treatments/dressing changes. Any time someone is using the toilet, take advantage and check the bottom. You will learn tricks of the trade as you go.