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Discussion

Help me set boundaries

Hi. I'm an RN with 17 years of experience in ICU, ER, rehab, and home health case management. I just finished my first week in my new position of Risk Manager at a 90-bed nursing home that is failing. Less than five years ago it was a 5-star facility and now it's a 1-star. They have had problems that have led to what seems to be an endless spiral of nurses quitting, DONs putting in overtime on the floor to cover, DONs quitting....they have a group of mean girls who seem to take pride in making new nurses quit. As their reputation has plummeted, they're now only being sent the patients nobody else will take. Right now most of the patients are medicaid patients, and they're the only agency in the area that takes medicare pending patients. They have a very high # of patients with severe behavioral issues, and don't have the staff to handle such high acuity patients. It seems to be a runaway train.

I can see the writing on the wall already. It won't be long until I'm expected to start filling in for absentee nurses. The current DON, who has only been there about 6 weeks, is losing his mind already. The ADON is a tremendous trouble maker and the leader of the mean girls. And by mean - I mean MEAN. They sabotage things so badly I can't even describe it. They set new nurses up for failure and keep themselves from being fired by calling the failures into the state all the time so they're covered as "whistleblowers." The state is LITERALLY there every week.

They NEED a full-time risk manager. The "gang" keeps the management (AKA the DON, corporate nurse and new administrator) so busy chasing their tails with covering shifts and interviewing and hiring and doing investigations, that there's nobody to run the ship and make sure things are being done safely I NEED to do risk management, and only risk management at this point. They don't even have an MDS coordinator and I need to learn a little bit about MDS so that I can make sure the care plans are in compliance etc. Hopefully MDS is similar enough to OASIS that I can do at least some good.

I feel terrible about all of the night shifts the DON is working, and his lack of sleep. He is trying so hard not to let the ship sink. I'm not willing to do what he's doing, though. I'm willing to work as hard as I possibly can full time and even overtime doing risk management and MDS if I can learn it but I'm not going out on the floor to be a target for those wicked women. They would eat me alive, and I would quit and the facility would be as short staffed as ever and still not have anybody doing risk management.

I think I need to tell the DON, administrator, and corporate nurse where the line is before it's crossed. I'm terrible at setting boundaries. I hate saying "no" so bad that it's hard for me to avoid crying when I have to. But they're going to have to choose between me doing a great job of full time risk management or leaving. They've been advertising for this position and for an MDS coordinator for months and offering very generous bonuses. They have an awful time getting people to work there.

Any advice on how to set the boundaries professionally without seeming mean and selfish? I'm also concerned that I might be accused of patient abandonment if I leave the facility when they're short staffed.

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    I worked at a disaster facility one time that had a similar "gang" of nursing assistants. A new DON wasted no time in firing them one by one and replacing them with adequate, if not always good, employees. If you are in an at will state, you do not need a reason to terminate one's employment. It is nice to have a paperwork trail, but not always necessary.

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    I am considering taking a Risk Manager position in a smaller facility. Being pulled to the floor is one of my concerns. (I'm actually a staff nurse there now)

    Sound like the ADON needs to go and maybe the rest will follow? Any way to use temp or agency nurses to fill in the slots? Is the DON on board with getting rid of the bad seeds? I second starting a paper trail. How the heck are they getting by without and MDS nurse?

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    "I think I need to tell the DON, administrator, and corporate nurse where the line is before it's crossed. I'm terrible at setting boundaries. I hate saying "no" so bad that it's hard for me to avoid crying when I have to. But they're going to have to choose between me doing a great job of full time risk management or leaving. They've been advertising for this position and for an MDS coordinator for months and offering very generous bonuses. They have an awful time getting people to work there."

    Do this above and tell them about the ADON....

    and;

    "Any advice on how to set the boundaries professionally without seeming mean and selfish? I'm also concerned that I might be accused of patient abandonment if I leave the facility when they're short staffed."

    Here is my advice as a LNHA and BSN:

    1. You have to set boundaries, the risk manager should always report to the Administrator NOT the DON and if this is not the case then you will fail at your job with the scenario you have described. Do not cry, stand your ground and who cares if they think you are selfish. It has been my experience one they know your boundaries they will step up and do what is needed from you and leave you alone. Follow policy/procedure, say to the nurses lets see what the policy says, the CMS rules are...I need this within the hour ensure you go back in an hour, if they do not have it done ask what the emergency was so you can document that. Sounds like these people are warm bodies, getting a paycheck with minimal work. The administrative staff is running their tails off.

    2. Say No I cannot do that right now, I have other duties you will have to gather your floor nurses and come up with a solution to your problem.

    3. Your job responsibilities are managerial administrative tasks not floor nursing. No nurse replaces your position when you leave. Job abandonment would not happen if you leave and the nurse who replaces you is not there....you are in administrative nursing, this responsibility to determine job abandonment is the DON who should be supported by the administrator.

    4. If you cannot set boundaries you will fail. If you feel you want to help I would certainly do this; ensure you report to the Administrator, if this is not an option and you report to the DON then you do need even more boundaries. Uplift the DON, encourage the DON to pair new nurses with the "mean ones" and have the DON set up success for not only the new employee but the "mean nurses too" i.e. for each nurse that trains a new nurse and that new nurse stays for at least a year the nurse who trained the employee gets a bonus. There ARE MANY WAYS TO STOP THIS PASSIVE AGGRESSIVE GAME THEY PLAY you have to have the backing of the Administrator, the DON on board and get rid of the ADON. If this does not happen within the next 2 weeks I would quit.

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    I was hired at a nursing home that was short staffed. Why were they mean enough to make me leave if they are short staffed?

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