Med-Surg and the Old Folks

[Iheartadvice]

By far my favorite population is the pleasantly confused, 80 - 90 yo... I know crazy. Especially because I work on a med-surg tele unit. The old ladies are always the sweetest... I can usually connect with them quickly and they are so cooperative after they trust you. We have plenty of combative patients too... I walked on to a patient that was called "the demon" all week... I worked fine with him, some issues, but it was due to understaffing r/t our now budget issues and low census.

This is my issue... My favorites.. these old crazies are always the most frustrating when you're understaffed, bc they require so much! Many are not made DNRs when they should be... Almost all require two people to get them up or to pull them up... all are incontinent.. Since our staffing has been changed... so many are neglected or left for hours soiled/new bed sores... mouths crusty /dry... I had a patient I was told was blind until I walked in to assess him and realized that this nurse just didn't clean the drainage off from an eye infection that noone looked into... even the ones that are the "lighter" load... as in cooperative, are so sick that they can't even lift their water without assistance... I know the obvious is to report it, but its become so frequent, even with the good nurses I follow. I know how our floor can be, its crazy somedays... today being the worst I had in some time. Nothing changes... seems to me that its either manageable or horrible... but one thing is steadfast... I am still very passionate about this population of patients.

I enjoy being that one nurse that broke through with them.. And knowing when I walked away leaving them A LOT better off than when I found them... I usually don't even tell anyone all the stuff I do... I know that I just care more about this group than most.. so I want to do something with that, but I'm about to burn out on this.. This weekend I walked into five patients, all of them total care/elderly/two were combative or confused and one was so unbearably sick with a chronic condition... oh and one FTT with family in denial and crisis... that's the hardest, when you do so much, but really there's not much you can do and the family lets their anger out on someone.... And lastly one that was snowed from night shift... I can tell none of them have been bathed in days... or they're incontinent with bed sores... just people leave them bc they can't do anything for themselves. This is also while we only had 14pts on the floor so our staff was cut down to 3 nurses and 1 tech who was just getting vitals and accuchecks. I walked into the worst couple of days I've had in a while. I'm ready to go in and quit tomorrow... I really thought I'd be on my floor for a couple more years while I went back to school (ADN - BSN - MSN/NP)... But feeling like this, I just can't do it anymore.

I don't want to lose this passion.. and its the environment, not my patients... That is one of the few things of why I still walk out of work feeling rewarded about something... I find it an honor to take care of them.. I don't care how nasty they are, that could be my granddad and with our staffing so low.. They are being neglected to a point that's almost unbearable for me to watch now... So, I need a new change of plan... I've stayed on our unit because of the diversity of conditions, we see everything.. and of course, that I love the age group so much... Being that I haven't really been thought out a change too well, what do I do from here... Eventually I'd love to be an adult outpatient NP... But without even having my ADN loans paid off... It seems so out of reach right now.

The economy is scary out there for us... I'm not sure what to do and feel pretty trapped to be honest. Its sad because everyone's lost all trust in our manager in the last several months... her agenda is very different than ours and she's lost touch with her staff... staffing to census is now the priority.. our sister unit always causes us to be overbudget.. we're the more acute unit and always over budget that makes it more frustrating.

I've tried reporting things that were really bad... Nothing done... I've worked on our floor for so long, the few that were there when I started have all given up... Some of the other nurses I work with I wonder if they've even turned that patient during the previous shift...

I've tried being proactive... I advocate with families, doctors, our manager for small changes... sometimes it works, sometimes it doesn't... I've been on our leadership group... fall prevention team... clinical coach... I'm the acuity documentation monitor. in hopes to improve our staffing through showing the true needs of our patient population bc noone's ever been educated on how our charting affects our staffing ratios... Nothing's done or changed... I still had hope... I lost all of that this weekend...

Right after I walked in and saw what I was dealing with, I emailed my manager on the weekend about staffing.. first time I've ever emailed her about something related to staffing (and as charge nurse weekend nights for almost two years... my manager never questioned my judgement on staffing decisions and we were able to keep that extra tech/nurse based on judgement of acuity, I was trusted to make those decisions). Now with our staffing matrix... there's no variations/no supervisor involvement really... We have what we have... and we have way too little... So I emailed her, simple request now looking back, could've saved me from where I am now actually and that's what makes me more angry... Asked to keep our 2nd tech... (she usually emails back in minutes and its bc I don't do it unless its important... but she never responded... not even worth a response??)... I have really just gotten to the point of just finished.. There have been other things lately with her that all of the staff has become distrusting of her.

I'd like to go in tomorrow am and tell her where to shove it.. Honestly, money is not why I'm working there, I don't need this job like some of my coworkers and I won't just sit and let this happen anymore... If that means I'm not a part of it, then so be it, its obviously affected my mental stability... Hence my rant here?! And I try to explain it to my husband, I love being a nurse. I don't want to quit... I just want to provide the standards of care that I'm expected to provide. And its been two months like this... I'm done..

Another assertive, hard working and loyal nurse down... so sad it happens like this...

So, all that being said... being as dumb as I was to how this was going to be... and literally at my breaking point... what do I do?

I have been just unprepared for the whirlwind of career change.. nursing school... then developing myself as a nurse... I thought it would be smart to focus on my education and experience... I got married.. and Now I'm not ready to quit but I swear I have to or I'm going to end up giving up this profession forever. I have not updated my resume in almost six years.. Would hate more than anything to go to another place I think will be great and ends up like this... I worked in PR with a business degree for many years and had management experience... and I had planned to start back for BSN and eventually NP... and here I am, this far along, disgruntled and still with a lot of student loans to pay back from just my ADN! I love working... I worked outpatient gen med while I was in nursing school... but don't even know where to start.

I'd like to tell my manager how awful she is and where to shove it, but I work for the best hospital group in town... sadly after this rant! I'm totally type A... controlled for the most part since adjusting to autonomy as a new nurse... I've adjusted to the different personalities at work and how to work with them... my coworkers are some of my closest friends... But I've learn that I thrive much more in a pampering/extras sort of environment... Guess it was my PR experience... but I had accepted that standards of care are what I shot for... And it shocks me what happens at the hospital.

Tell me, there are so many good nurses here... how can you walk away when someone who can't do anything for themselves?? How can anyone clock out from this job and not feel like I do?

Should I try to stay at the same hospital? I really don't think my manager is looking out for anyone but herself... and I don't know how it would go down if I told her how I want to quit like yesterday...

[katebean04]

It is comendable that you care for the elderly the way that you do.. it is so sad that others on your unit do not take the same caring attitude... You have a big heart, and I am I torn between telling you to stay or to go. If you stay, you might be able to notice something that others wouldn't.. but if you go- you might find a place to work with less stress, and people that feel the same way you do. I wish you the best of luck, you are an inspiration- and must be a patient person... I hope to be like you when I am done with NS : )

[rn4life2009]

I have been there before. I would go home from work and feel bad that I couldn't do more. I have chose not to go back to med surg. I have worked at nursing home, hospital rehab and I would say med surg(esp. mostly totals) has been the most understaffed. I love elderly patients! That being said I have worked other med surg unit that are not as strained. I would try to transfer from this unit and see if things are a little better. If not when the economy is better find a dif job.

[Iheartadvice]

I have known a change is in order for a while now...

I'm a sh*t or get off the bucket sort of girl... but this has held me working under stressful circumstances... the last two months of changes has just about broken everyone. Not sure if addressing them with her would make it better or worse... I would've originally said that she would've sent me along with a recommendation letter... I think if I came at her like I wanted to, I'd probably be walking in with the demented/combative/biting/spiting patient that was my total all weekend and shut/lock the door behind me... Surely there's a professional way to tell her that her floor is unsafe and pitiful, and she'd assist me with moving somewhere else...

I have a lot of contacts at the hospital now, but not anywhere that I'd want to work...

I feel so trapped or stuck to just quit.

[AvaRN22, MSN, RN]

Thank you so much for posting about your experience. I'm on a PCU, tele unit and in a similar position I feel better that I am not alone here. You described exactly how I feel. Last week I had one of the roughest nights I've ever had. All total cares and your classic combative and confused geriatric patient. I was working my fingers to the bone that night, hustling to get all of my work done and my supervisor has the audacity to ask "why am I so behind?" Uhm, maybe because I have a very heavy load and you guys are not helping me? I was like being kicked when I was already down. Other nurses saw how busy I was and offered to help, thank God. But the supervisors just watched at the nursing station and played on their i phones. The problem here seems to be the leadership on our units. Four nurses are leaving our floor in the next few weeks. Where are our nursing leaders with compassion, justice, and understanding?

[itsmejuli]

If I was in your shoes I'd be looking for another job, quickly.

[grandmawrinkle]

If I was in your shoes I'd be looking for another job, quickly.

She can look, but she may not find. These situations are getting more and more common. It's all budget related at the core. I firmly believe that in the future, it is going to be more of the same -- you can either put up with it, or leave nursing. The grass isn't always greener.

There are always going to be some facilities that are better than others -- the ones that have stellar reputations that people fly to from around the world will always make money and be able to provide good nursing care. I think federal/state facilities ***sometimes*** are better because they are less reliant on insurance payments, but there is a lot of indigent care done in federal/state facilities too which costs money.

Sorry you are going through what you are. You are not alone...many are in your shoes.

[Iheartadvice]

I think that in hospitals, these nurses that are our managers are so detached from what we do now... Our educators are the same.

I've read a lot of posts on all nurses about it.. thank goodness for this site. Seems like a lot of nurses like us quit - move on - go back to school - then when they return to management they are completely clueless about what I need in my stage of the game of being a nurse.

I just want to never be that.. and work bedside with the elderly with a little more control of my work day. I love the high acuity, I love the hard work... I am one of the hardest workers I know... but after I work hard for a 15 hour shift, barely eat, and I'm sweating... I want to walk out without crying.

The nurses I work with are the same... most know that I'm in the weeds but they say "leave...".. I think it depends what the floor is like when you leave... I reported to one of my favorite strong RNs on most of my patients, but realized that she had two new admissions that had arrived within minutes to the floor... And the other nurse she got report from left without finishing... I think there should be some teamwork with stuff.

And with the elderly, after dinner is when everything happens... oh and lovely sundowners... gosh, last night was awful... two of them hadn't been fed after I asked my tech to take care of while I was with my "demon".

He had just left... and to be honest, I don't blame him... I can't do it anymore..

[SaltyNurse]

I've so, so been there. One option is to have a heart-to-heart discussion with your manager about the grave disparity between how patients are treated and basic humane standards, what you've done to try to address it and how ultimately you don't see any hope for improvement without making changes in staffing. The cost of a lawsuit and unreimbursed care for hospital acquired complications, low morale and staff turnover, and low patient satisfaction, not to mention potential loss of acreditation far, far overshadow the cost of an extra CNA or even an RN. You could tell her that your overwhelming sense of futility and discouragement is causing you to seriously consider looking elsewhere for work or even leaving nursing entirely. BUT.... if you have trust issues with her, you may want to think twice before laying all your cards on the table with her before you've secured employment elsewhere in case she's the kind of crazy person that would sabbotage your future career. Likely, she is under incredible pressure that of course comes from the top and trickles on down. She may face being fired and hating her job as much as you. She very well may completely understand and sympathize with your viewpoint but be completely powerless to change things. You can try to keep going up the chain of command, but that is very risky with very little hope for a positive result.

Your second option is to transfer to a different unit (though things may not be any better), or try- at least try to find a position in another hospital. It sounds like you are very skilled and valuable. It doesn't hurt to just have all your resume stuff with you dressed for an interview, walk into HR and ask if the nurse recruiter has time to see you or make an appointment. Keep trying.

We need excellent nurses like you to stay in nursing. But find an environment that enables you to function at your highest potential. Facilities that refuse to allow sufficient resources to provide safe, dignified care should lose all their good nurses. They deserve to be stuck with garbage nurses who are stupid and/or don't care. Those hospitals will have to change their tune or they won't survive.

As an aside, one of the ways I escaped my unhappy situation was to transfer to intensive care. The patient ratio generally can't be screwed with, you have much more control over your patients' care, much better able to give them more time and attention. If you're an anal compulsive sort of nurse, It's a much better fit than a chaotic unit in which anything goes. Not to say you won't have your dog days, but.... it's a thought.

[Blouis, APRN]

I work in a place similar to what you are going through. One day after 7 patients, 6 total care, and a CNA that disappeared: I miscarried that evening. I worked myself too much because I wanted the patients to have good care. It cost me my child. I reviewed my life and tried not to get in that situation again. I got so burnt out that I went per diem and found another job to get away. I love the experience and missed hospital work so I joined the float pool where I would experience other units and not be so stressed on the hardest floor in the hospital.

[Iheartadvice]

Wow, that definitely puts things in perspective... I'm so sorry that happened to you. And it is very helpful here. I'll remember that story when I get into a position like that again.

I called my manager today and had a conversation I never had the guts to have with her... She listened. We found some common ground of how to get things to change... for me... not the floor. It was very empowering and my negativity I've been carrying around was weighing me down so much I could scream. No burn out for this nurse... at least not yet.

[CapeCodMermaid, RN]

Now you know what it's like for those of us who work in long term care...especially on sub acute units which are rarely only subacute. In A bed you have a fresh 3 day post op hip replacement who needs pain meds; in B bed perhaps someone who rapidly goes into flash pulmonary edema....in the next room the old demented woman who thinks she can still walk despite the fact that she has one leg. We do it every day...one nurse to 20 or 30 or 40 residents.