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NJnewRN 5,471 Views

Joined: Sep 9, '12; Posts: 114 (40% Liked) ; Likes: 116

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  • Apr 16 '16

    Good Morning!

    If you have no system and no training "yet" then create a system as another writer announced that commands respect. The first time you walk into interview (whether they know or do not know who you are) is when it begins. Make rounds, and on interview dress like a corporate executive. Smile, meet everyone's gaze, reach out and shake their hand; give your first and last name. There is no need for them to know you are the new DON candidate; either the Administrator (if that is who is interviewing you) or "word of mouth" will see you through.

    If you have not worked LTC do you know all about MDS, Medicare and Medicaid regulations; are you at least then going into a facility with a seasoned Administrator (for he or she can be your biggest variable in success), and another good variable is a consistent ADON (if he or she is in place) to help guide you through the hurdles.

    Acute care facilities are beating a financial death trap, and LTC is the wave of the future; with new sub acute wings opening up, insurers are willing to pay the days for a post op to come recover, and still receive medical care. It is relevant and highly significant that you as a DON do have some say on admissions with the Administrators; you must have a broad background to enter LTC and put those feet down solid and be recognized.

    Staff can be a nightmare and yet on the other hand they are endurance oriented. Just like residents stick around and do not go in and out the door (like acute care) staff can become inbred and dysfunctional, or they can become a healthy loving family. You see this can be your calling; do not show fear or exhaustion for all in all you are not there in the DON capacity to prove you can run rings as a floor nurse; many of us do not hit the floor but for rounds, a death, an intervention with family, a survey of course, and "pop ins" which I will make according to gut instinct to see how the night shift is really doing. You are a tower and yet you are the licensed RN at the top of the heap; make sure your heap is well cleaned and respectable for they will learn (all who are there) your personal style, and will want to be a part of, not apart from in the long run. Don't sprint you will burn out fast. Do not react, but ACT.

    You deserve training but we all know what that means. So just as I'd tell a novice nurse to "ask if in doubt" you must ask. That means your Administrator might have to hold the fort for a week while you travel over to a sister facility who has a seasoned DON and you might find all the answers on this one trip. Then there is practice makes perfect.

    Remember in LTC we have incredible demands in paperwork, and exhausted staff, much less finding good staff. We must inventory our day at the end of the day and make a list of all we did; not just what we did not do. Add to that an instinct to prioritize and that in many cases will always entail financial needs of the facility to provide nursing care. That breaks down to accurate MDS assessments, timely submission for payment, and even what I call psychologic bonuses when there are no financial incentives. A pizza party where nursing staff can hang out and be cherished goes many miles. Also an "open door" policy as a DON helps incredibly.

    Karen G.

  • Dec 5 '13

    Something is just brewing inside of me that needs to come out...

    This primarily an emotional response but there's some logic and reason that gird it...

    Try as I might, I just can't help myself...

    Flat out, I...


    OK, here it is... I...

    really like

    my job...

    and I almost consider it a privilege to work there (though I'm an unabashed capitalist and unionist).

    The patients...

    Some of my patients truly touch me... and I feel tinges of what the "it's a calling" crowd must be referring.

    Some of the patients are trying... but even many of them are an adventure...

    And some of the patients are complete jerks... and mostly I just blow them off and pat myself on the back for not letting them win the emotional tug-of-war in which they insist on engaging.

    I had a patient on whom a colleague asked me to start an IV... she was being confrontational. I'm always up for a good confrontation so I took the bait. At one point she said, "Your bedside manner sucks." I replied, "Yep, it does... but I'm really, really good at this so you need to decide if you want a 'one-and-done' IV stick by me or repeated pokes by Nancy-NiceNurse." She picked me and we ultimately found a functional way to interact.

    My coworkers...

    Most of them are kind and decent people who've got my back. It's almost like being in the military again.

    A (minute) few of them are catty and, um, doggie, but I actually enjoy engaging them and trying to win them over. Since I refuse to be respect someone's attempt to block me out and push me away... and because I continue to go out of my way to be helpful, we generally end up in pretty decent working relationship.

    The docs

    Oh yes, the physicians... they can be a pretty pushy, demanding, demeaning group of people..... whom I refuse to treat, or address, any differently than I do anybody else.

    However, nearly all of the ED docs, are really great to work with... love to teach... will happily engage if engaged... and recognize how much the patients need the nurses in order for anything to get done.

    Medical residents? I find them to be some of the most interesting people I've ever been around and I would hate to work someplace without them. (They also don't get ***** when I call them... and if they do, they're ~just~ residents :-)

    Even some of the attending MDs with ferocious reputations among the staff, have their way about them, and I enjoy figuring out how to connect. Sometimes it's by learning a lesson from doggie dominance... wherein I basically expose my throat and give them the option to rip it out... from then on, we usually get on fine... and I take barbs really well and can turn almost everything into a joke.

    Well, I've got my gripes, to be sure... but having been a senior manager with direct reports and budgetary authority... I also recognize that (a) I probably *couldn't* do it any better and (b) that I wouldn't want to even if I could.

    I've had a lot of bosses in my life and I can easily say that the food chain where I currently work is populated by a pretty good group of folks, especially by comparison to some that I've work for.


    Could I earn more? Sure. Have I earned more? Well, actually not... though I work an insane amount of OT to get it.

    Being an hourly, non-exempt employee under a codified contract (I'm a fan of the California Nurses Association) is a great way to work. I've been salaried/exempt... I've been at-will... I've worked as much as I do now but not been paid for it... and I've recently worked in nursing for $25/hr less than I presently earn with scant benefits... Yes, I earn twice what I earn at my last FT nursing job.

    I've got a good thing going... and we're not the highest paid nurses in the region... by any means... but we've got very good bennies and a good work environment.

    So, for anybody who's looking for a reason to go into nursing, I can say that, if I could magically change and be a doc or a pilot, I would, but nursing can lead to a very good thing... though it's not a given by any means.

    To summarize: I am a nurse, I am happy to be a nurse, and... while it's not cool to admit, I hereby confess that I *like* my job.

  • Dec 3 '13

    The bipolar disorder did not get Toni fired (love that name); her lack of a verbal filter got her fired.

  • Sep 11 '13

    I finally got a new job! One I have wanted for a few years. I will be working from home as an appeals nurse for a physician advisor company!

    After I left my job in an MICU to become a nurse manager, my career fell apart. I have been depressed the last 2 almost 3 years with way too many jobs that I took because I needed one. My last working for a home health hospice agency that has caused me so much stress and anxiety I had to go to per diem. I haven't had a steady income n a few months and haven't had health insurance.

    Now finally, my prayers have been answered, especially as a divorced mother of a 6 year old. I am home god forbid there is a snowstorm or illness. Just knowing my daughter is down the street at school and I don't have to " rush" home in fear of being late to pick her up is a load off my mind.

    I was persistent and patient with this company for a year and it paid off.

    I'm happy and excited beyond words!!!!

  • Sep 11 '13

    Cuddle with my Hubby and hang out with my animals, my garden, put on my favorite CD and sing praises to God for fighting my battles.

  • Sep 11 '13

    Congratulations!! I know exactly what you feel, I was there too. Some places are just toxic and there is nothing you can do but to leave it behind. Just let it go... and it feels great to be alive again.

  • Aug 27 '13

    20 years as a RN: med-surg, critical care, trauma ED, flight nursing, admin, education. The majority in critical care/flight/trauma.
    Now FNP in a family practice clinic, light years away from all of that. I have moved on and don't care if I never set foot in a hospital again.

  • Aug 13 '13

    That too is personal, what is stressful to me might not be for you.. I found the floor very stressful but have loved the ICU since day one. Others have found the opposite to be true..

    Happy hunting in what ever you decide

  • Aug 9 '13

    I received my RN license 30 days ago. I have been working with my current job for 2.5 years. They knew when I started the program, when I finished, and when I passed boards. I am still working as an LPN with the same pay. I have never been late to work. I turn in all my paper work before its due. I have never called out. I was told that I have to complete a 4 month orientation for my RN title. This is the same job I have been working for 2.5 years. Thankfully, I received a called for my dream job but not my dream hours. I took the job. It really felt great to tell my current company I was leaving in two weeks. WOO HOO !

  • Jun 29 '13

    After thirty years psychiatric nursing experience in various roles, locum tenens is perfect for me. When I want to work, I sign up with a few agencies, tell them my availability and hope something will come through. This time I can only work in 2 month blocks- a normal assignment is three months so I was not sure anyone would take me for only two months. Luckily my recruiter found me a spot.

    "The position is in corrections." She said. My husband was immediately worried about my safety. I had my interview and I found out the facility was a forensic hospital, not a correctional setting and that I would have inpatient responsibilities. I have many years of inpatient experience working as a staff nurse and a manager. This will be my first inpatient experience as a provider.

    After a week of orientation mostly about HIPAA, and using the computer system, I start on the units. I have two inpatient units and one 4 hour block of outpatients. I am on transition units where patients are preparing for discharge to the community. They work at least 15 hours per week at on campus jobs, go to groups, and have privileges to go outside, some alone.. For admission to the facility patients are committed by a judge as mentally ill and dangerous. Many of these patients have caused harm to other people, usually when they were not taking medications or were abusing substances. The average length of stay is seven years and the patients home community has input into advancing privileges and determining discharge.

    My role is to do a psychiatric interview and review psychiatric medications at least every three months on my assigned units. On the inpatient units, this is called "rounds". Patients are invited in one at a time by appointment. Several staff are in the room to observe or participate in my interview. I have never interviewed patients like this before. One of the social workers told me she likes to come in the room to make sure the patients are giving me the correct information and this can be helpful. A pharmacist is there also, to take notes and sometimes participates. I try to talk to her before or after my time with the patient so I am not distracted by medication information during my interview. Since I am doing the assessment and making the medication decisions, I have to make sure I am comfortable. I also put in my own orders which is a change for them. Because of the cumbersome computer system, previous locums had operated using mostly verbal orders which were inputted by either the nurse or the pharmacist.

    There is a shortage of psychiatric providers at this facility. Systems like the pharmacist taking notes, which are minutes of the interview, and verbal orders are a way to provide some continuity and compensate for the shortage. I am the sixth psychiatric provider in two years. They are recruiting and in the meantime I learn a lot.

    The main things I learn about are high dose neuroleptics, polypharmacy, and clozapine. Traditional psychopharmacology tells us to streamline medications. With these patients, it is not entirely clear if patients could do as well on lower doses or if they need the high dose for stability. There also seem to be a lot of negative symptoms of schizophrenia, ie poor motivation, blunted affect, which one of the psychologist says is not treatable with medication. My research tells me medication is worth a try but I am not there long enough to introduce this. I wonder if some patients are overmedicated but I am reluctant to adjust doses very much because of being new, unless, of course it was clearly indicated. And I become proficient in laboratory guidelines for long term medication monitoring.

    Every patient has a primary MD who has been treating them for years and each patient gets a comprehensive physical every year. These MD's are readily available for consultation. The pharmacists are also available for consultation and also seem to like attending my rounds. There are also other professionals including psychologists, social workers, nurses, and security counselors. I found out later that there are some psychology fellowship classes I could have attended if I had known about them.

    I am scheduled to return to this facility in a few months. Locums gives me the opportunity to learn. When I return, I look forward to getting a better understanding of high dose neuropletics and polypharmacy and I may try to medicate negative symptoms . Or since I now know the system, I may be assigned to an acute admission unit where I will learn about rapid titrations of psychiatric medications and ordering seclusions and restraints. If I come back to this unit, I will better be able to treat the patients since I have interviewed everyone at least once and have the trust of some of the staff.

    Forensic psychiatry is not a popular area of psychiatry. Many of these patients are severely and persistently mentally ill and have crossed the line into criminal activity. They are well care for at this facility as the long term psychiatric patients which they are. Many of them will never be able to live in the community. In the old state hospitals and if they hadn't committed a crime, many of these patients would have stayed for years living in a community within the hospital. Some may have been discharged to group homes with case management. Some of my forensic patients may also be discharged. Evaluating stability, degree of outpatient containment and likelihood of relapse is very challenging and the focus of much of their treatment.

  • Jun 29 '13

    I've seen the psychiatrist on Law and Order and always wondered what psych APRNs actually do in real life forensic nursing. Thanks for sharing!!

  • Jun 16 '13

    I think it's a combination of a lot of things, primarily two: 1) people of my generation were promised this 70s/80s dream where all we had to do was get a liberal arts degree, and settle into a cubicle and all would be well. For many of us, that dream turned out to be BS. Most corporate jobs are meaningless, soul-crushing and void of potential. Then you have a bunch of us hitting 40 (or nearabouts) during a recession. Lots of divorces, layoffs, underwater mortgages.....& it's a perfect storm of career changers.

    And 2) nursing, because of the ACTUAL shortage in the early 90s, has been VERY effectively marketed by schools as a "recession proof, high paying, secure" career choice. This has hatched a lot of myth about what this industry is really like, and worst of all, created a glut of new grads who can't find work (because baby boomers won't let go and retire). 2nd career seekers, likely with a layoff or other disaster behind them, are seeking something secure and meaningful, and bought into the marketing - hook, line and sinker.

    I have a BA in Insert Useless Liberal Arts Dreck Here, and ended up working as an IT help desk jerk for 7 years until I decided I needed to do something ACTUALLY more helpful than telling people to turn off their caps lock. Lucky for me I graduated pre-recession with my BSN and dodged much of the desperation I see here from ADNs, new grads and 2nd career seekers.

  • Jun 16 '13

    Ever thought about doing foot care? Im basically in the same boat as you, except my goal is to be totally self employed. Check out the foot care thread under nursing specialities on this site. Ive already started my training, and will hopefully be certified by the WOCN by next month. Start up costs should be between $500-1,000. My plan is to do care in the patients home, so wont have the overhead of a brick and mortar business. I cannot bill medicaid\medicare as a RN in my state, which is fine......they have basically stopped paying for nail trimming unless pt meets strict criteria (for podiatrist to perform) . I prefer a cash only business, and will cater to those who can afford to pay.

    If you are interested, there's an AWESOME podiatrist who has been the pushing force in getting nurses trained/ certified/ allowed to perform this service, once only performed by podiatrists. She has a training class I have attended that is incredible. She also has a business package you can purchase (I have) which is basically the entire foot/nail care business on a silver platter. It includes every form/consent/guideline you could ever dream of needing. Her name is Dr Julia Overstreet, and she is a HUGE advocate for RNs breaking into this very new field. I felt very honored to meet her, much less train beside her.

    Anyway, just a thought. If you want any further info, let me know!

  • Jun 8 '13

    I do think residency will be great. Realistically speaking, who will pay for it? Government probably will not. They are already struggling financially enough for residency for other professions (dental/medical). I think the best solution is to let we pay for it ourselves. We can make DNP more specialized and require more clinical hours for specialized area. Instead of having DNP in FNP, we can have DNP in FNP with specilization in oncology etc.. and require another clinical rotation for it..

  • May 29 '13

    I went to FDU for my post masters NP. I did well and passed my test but the school has its issues. I was held up taking the test because the incompetence and now my license for the same reason. They changed things while students were in the midst of the program making it very stressful. I am just glad to be done!