Published Mar 21, 2020
I know this subject can be redundant and for everything else that is going on with a pandemic I feel like it's out of place, but I'm going to post this anyway!
I will reach my 1 year anniversary as a nurse in mid April, and I feel like I should be more adept/confident/faster than I am....I am always running behind, and especially when I'm floated and don't know any of the patients.
First of all, let me say I work in a Long Term Care Acute Facility, so the patients ratio is 1:20 on non vent floors and 1:10 or more on vent floors if they are short staffed (it happens often). On the non vent floors I'm pretty comfortable (though slow), because patients tends to be less intense (don't have to take BPs 3x per shift, every other patient isn't on contact precautions), but really that's on an assignment I know (even short term patients are there at least a month). If I don't know the assignment, I feel totally overwhelmed and incompetent. Types of meds are different, wound care is different, etc. Does anyone have advice on how to prepare for new patients and develop a flow so to not feel like your drowning? I look up general things about patients like wound care and starting tube feedings but there's only so much time before you need to get moving. Is this something that becomes more comfortable with time or am I missing something? The other nurses I work with are supportive but I still feel embarrassed that I feel so behind. And even though I am more comfortable with familiar assignments I feel like I am always behind. (Experienced nurses how are you so fast at med passes!)
Technical skills....things I passed on a nursing school exam on a dummy but now feel totally ill equipped and terrified to do...IVs, Inserting GT tubes...I rarely do them so when they come up I have an anxiety attack and ask for help, but then never get the experience I need to gain confidence....how do I get past this hurdle? I want to learn the skill but am terrified of hurting a patient, and I can't bother everyone for everything especially when we are short staffed. Am I being too soft/lacking confidence? If so how do I change this?
I don't mind the facility I'm in I just feel overwhelmed sometimes. I'd like to say it's just the patient to nurse ratio but I don't think that's it. I want to move to a hospital setting because I want to learn more but am sometimes worried if I feel incompetent in a LTC facility if I would make it in a hospital....I hear it's more difficult. Any advice to a new nurse who's trying to gain confidence/get it together/manage stress is welcome.
First of all, it is perfectly OK to post something not r/t to Covid-19. It would be worse not to seek guidance and opinions and just keep trying to figure things out.
You are still fairly new and you will get more comfortable and thus have more confidence as time goes on, this is completely normal. I have worked both hospital and LTC, both have their unique challenges.
Med pass: In LTC/LTAC you have many patients and it is hard to manage that many patients. The experienced nurses have found work arounds (this applies to meds plus other tasks). Find some work arounds (short cuts) but not the kind that can do harm.
Technical skills: Dummies are not real people so of course it will be different and scary. You need to practice these skills (on people) to gain competence. If you are unfamiliar with a procedure do ask for help but do the procedure yourself (ask them to walk you through the procedure but you do the hands on). It is easier to gain skills in the hospital bc you have more opportunities but you will gain them there also. Try to watch you tube videos on those procedures you mention. You will get the skills but in the mean time don't be embarrassed for asking for help, every single nurse was a new nurse at some point, hopefully the nurses you work with remember that.
I am not sure what you mean by being to soft but you do need to jump in, this is how you will gain confidence, by preforming procedures over and over and getting confident in your abilities. I was a nurse for over 10 years before I placed an IV (I worked in a hospital that had an IV team, plus most of our pts had some type of CVL). I was terrified at first but I learned and got competent by doing (although that doesn't mean I didn't bungle some along the way). You will get competent too!
Hospitals are hit and miss as well as the units within them. Both places are just hard but it different ways! For now IMO your best option (esp if you like the facility) is to stay there and think about ways to improve your daily workflow (maybe ask or watch the nurses you work with) and continue to work on obtaining those skills. (For instance, one of the nurses I worked with let himself be constantly interrupted by pts and did whatever they asked, you have to delegate, you can't do everything yourself).
It is hard to be new no matter where you work, it will get easier, you will obtain competency in your skills/abilities, and at some point you will be in a position to help a new nurse yourself. It just takes time.
Try everyday to obtain experience and/or new knowledge. You got this!
I work at an LTACH and have been a slow med passer since I started. I try different ways to set up my day and sometimes I can get the meds passed quickly but it is hard to do. I do my assessment during AM med pass. Then I will do the cares like drsg changes, wound cares, ostomy cares, trach cares after meds are passed. It is very easy for me to 'get stuck" in a pt. room longer than I would like to. Also having to grab PRN meds can become so time consuming. It is challenging to be a nurse in any type of care setting. At my current position, I just can't leave a pt. Who is uncomfortable. For example, recieving tfing and is not at a 30°HOB angle or a pt w a trach whose mask is dirty or may needs suctioning. Even oral cares can really slow me down sometimes. Other nurses suggest I delegate but I know the CNAs are busy so a lot of times I try to lead by example and pray the CNAs will recognize my effort to give great pt. Care.
Fortunately, I am still employed there despite my lack of speed. I thk it all depends on what type of nurse you are. You will get faster as you become more comfortable. Try to not beat yourself up as this does nothing but block your ability to provide best pt. Care. Keep a positive attitude. Ensure you are eating well and stay hydrated throughout your shift. Nothing throws off a day like having an episode of hypoglycemia. Also, arrive a lil early if you can to make sure the day is semi planned well.
Try writing out a simple template. I usually will make my own and put down what needs to be done then chk it off or cross it out when is done. Keep it simple and to the point w info r/t diet, med times, BS, I&O. I keep an extra highlighter on me to color code my sheet for extra info such as supplies, ?s, family, and new info to update MD and RNs.
Never worked at an LTAC but it sounds like a lot, that first assessment and med pass should be priority. You have to delegate at start of shift. You can go back and do cares and dressing changes later.
One way to get experience doing procedures like inserting IVs or NGs is to ask your peers and shift manager to allow you to do the next 3 or 5 on the floor, whether your pt or not. While you take the time to do this, perhaps the other nurse can assist/coach or even do something with one of your pts. Here is a tip for starting IV: Should you be the one to take a new order for starting an IV, ask the doctor for an alternate order in case you are unable to get the IV started. You can explain your inexperience in starting IVs. I did this one time when I was the lone licensed nurse on night shift and I was getting slammed. Doctor had no problem accommodating me. Develop a paradigm for your med pass and try not to deviate. This will help you gain speed over time. Pts or room numbers X first because they are easy or hard, pt Y last because they get combative and you need assist of CNA, all tube feeds now, all BG checks then, start prep at Z time, start at this end of hall first, etc. Whatever makes sense and works for you.
Thanks for the tip about asking for an alternative way to give a med and volunteering to do a task to gain experience, I will try both.
If I know the patients I can arrange my med pass on how combative/uncooperative they are, but if they are all new to me they are all new to me. That's one of the skills I'm looking to work on, I've seen more experienced nurses able to convince patients to cooperate (sometimes it's just a matter of letting them warm up to you and coming back to them later), but this is extremely hard if you have 20 patients, and 5 of them are not cooperative. And sometimes, even with support, they are just not having good days and will not take medication. Ideally I would like to say that I would like to take the holistic approach and try and see if there was an underlying problem (there is a great instagram post: "If the residents are giving you a hard time they are having a hard time."), but I'm already so pressed for time I can't. I think a lot of it has to do with how well the patient knows you as well.
If this is first time with pt, write down one or three word note regarding anything you would need to know later. Should you get them again, incorporate that knowledge as you plan your shift. This might only save you five minutes but five minutes here and there add up.
marienm, RN, CCRN
I work in-hospital ICU but something I've noticed that nurses who come from the floor tend to include in their reports (and ask when getting report) is how a patient takes their meds...whole/G-tube/crushed in applesauce/one at a time with a mouth check afterwards...it's always struck me how helpful this small hint can be when preparing! I truly don't know how much report you give/get in your facility but would it help to start asking this question?
I think the major difference between a hospital and a long term care facility is the nurse to patient ratio- I work in a long term care facility which is nicer than most, and the nurse to patient ratio for long term care/ short term care is 1:20 (this is not as much as other places which can be 1:40 ?)....the things you usually get report on are abnormal VS or antibiotics, something really important because otherwise everyone just depends on the computer or if there's a regular nurse they'll help, but sometimes them helping makes things worse because they waste your time telling you things you can see easily in the computer, or they haven't worked the assignment in a month and they get patients confused.
I think that's really why I don't like about it....you have to do so many task driven things you really don't know the patient's conditions (you get some ideas by their physical condition and types of meds they have), you just don't have time to look through the file for 20 people.
I never have had 10 or 20 patients! That is insanity. I have a hard time with 7. I hope things are getting better. The LTACH I work at would never give nurses that many patients.
How are things going?
I moved to an acute care setting and it present different challenges but not 20 patients! The most I have now is 10 with a LPN to help me. I can't believe I dealt with so many patients before! I've gotten better at putting IVs in and if I can't get them I have more help putting them in now. Sometimes I do have a patient that won't work with me but having 1 out of ten is much better than 1 out of 20.
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