Limited Orientation; High Ratio; How to Survive?

Specialties Geriatric


Specializes in Primary Care, LTC, Private Duty.

Looking for advice on how to how to get through my first off-orientation nursing shift with 50 residents. If you don't have time to read the details, I'll still appreciate your experience on making it through safely with so high a census. I've done LTC before, but at the other facility: I was oriented to the facility first, had received a better orientation to the actual floor, trusted the aides I worked with, and the census was smaller. Before this current LTC job with 50:1, I was working in an outpatient clinic setting for the past year, before that the smaller LTC, so this is like nothing I've ever faced before.

When I was hired, I was:

1) assured that I'd receive a thorough orientation. Instead, I was given two overnights on the cart, with a preceptor who told me "I'll be around if you need anything" and then disappeared off the floor without showing my how she manages a census of 50 or actually being around when I needed her. My second preceptor was one who never had worked that floor or shift, just another warm body, and had no clue on how to run 11-7 on that floor; in fact, I was showing her our tasks for 11-7 (glucometer checks, 24-hour chart checks, etc).

2) assured I'd have 3-4 aides on the floor. Instead, I have 2, who refuse to do first rounds because they're "too tired" and "don't want to deal with anyone who wakes up".

3) assured that the residents would be sleeping (HA!) most of the night and are stable. Well, on my orientation nights, they were setting off the alarms Q10-15 minutes and the aides "got tired" of checking on them so I ended up running all night so that no one fell (which put me behind on my other work responsibilities). Twice, we came close to having a fall, one of which was five minutes before 7-3 came on because one of my aides told me to my face "just leave it, 7-3 will be on in five anyway". And so much for being stable! We have multiple residents going downhill, two on hospice, one that had been sent out right before my shift, another who just came back---not in the best condition---from the hospital on O2, Q15 minute checks, etc.

I just don't know what to do. The scheduler is hassling me to pick up more shifts, starting to get an attitude, and I'm just at panic-attack-level anxiety about getting through the next one.

Specializes in LTC, assisted living, med-surg, psych.

I have three words of advice for you: RUN LIKE HELL.


That is all.

My best advice:

1. Follow VivaLasViejas advice. I myself would never accept a position at 50-1, even with 5 aides.

My second best advice:

1. Ignore the pissy scheduler, but don't be afraid to back her off on the attitude if you need to.

2. Arrange a 'Come to Jesus' meeting with any aide who refused to do their job. They probably testing you. They need to be reminded that they are taking care of human beings.

3. Arrange a 'Come to Jesus' meeting with the pigs in charge. They need to be reminded that their facility is entrusted to take care of human beings on both sides of the cart.

That facility most likely needs you more than you need them...but, be prepared to look for another job.

I was an LTC nurse, it was the area I wanted to stay in right from first stepping foot in my first nh during clinicals. No way in holy hell I'll ever go back to work in one again.

Specializes in Primary Care, LTC, Private Duty.

Thank you for your feedback! Because I have a history of job-hopping (funnily enough, due to dissatisfaction due to high censuses and insolent aides in LTC), I was starting to doubt myself and thinking that maybe I just couldn't "accept" that this is "just the way things are" being a relatively new nurse. I'm glad I'm not the only one who feels these ratios are INSANE!

The 50:1 on 11-7 isn't the real problem. I've worked in LTC for the last 20 or so year in different roles and on different shifts. We generally run about 48 residents. I would say that 12-15 are skilled or higher acuity. We staff with 2-3 CNAs on 11-7. The CNA staffing will make it or break it for you! We generally have the 3rd CNA scheduled when we have a lot of active dementia residents with their day's and nights mixed up.

As for the orientation...yes!!! you need more!! Demand it.

You have two choices.

One, explain the problems to administration as you have to us and demand immediate improvement.

Secondly, quit.

That's it.

Specializes in Geriatrics, Dialysis.

Limited orientation is not at all unusual in LTC, there is none of that 6-12 weeks with a preceptor, heck in most cases you are lucky to get 6 days. Even a ratio of 50-1 on nights isn't unusual. What is completely unacceptable is working with CNA's that openly won't do their part of the job and get away with it. If this is the normal culture you won't be able to do much to change it unless you have the total support of management. Sadly I'm guessing you wouldn't have the kind of support from management that you would need to cause any kind of meaningful change. Attitudes like that don't develop overnight, this is probably exactly how the NOC aids have been acting for a long time and there's no way you can really get all your work done and essentially babysit an ineffective staff to ensure they get their work done. My advice is the same as everybody else, leave.

Nursing homes are owned by business men/women who only care about the bottom line and making money. The nurses license and sanity mean nothing to them. The residents health and well-being mean nothing to them. They will always find another nurse to work under the terrible staffing situations. In the link above you will see how assigning me, a new grad LVN, 47 residents broke me.

47 residents on the 2 - 10pm shift.

Get out of that hellhole now. LTC is not a place of peace.

If you like working with geriatrics, have you considered Assisted Living? I did that as a nursing director for years and then got promoted to executive director. AL often looks the nurse to be a manager. Good luck!

Specializes in Primary Care, LTC, Private Duty.

I left, after securing another job while still working there. Having worked there only a month (I was per diem, so only doing a couple shifts a week), it certainly won't look good on an application/resume, but it was definitely better for my long-term health to do so.

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