New Grad drowning in LTC

rpsychnurse · Jul 2, 2015

It sounds like you're taking responsibility for yourself- which makes you a great nurse already. The fact that you can recognize your limitations is awesome! We all - old and new grads alike- have things we don't know.

That being said- LTC is a tough place- especially for a new grad! So good job for taking it on! You tend to have less staff and less support than a hospital setting which forces you to work more independently. And- let's be honest- grads need support! To learn and to develop your nursing skills. School gives you the foundation but you learn so much more on the floor.

My advice- keep at it. Keep asking questions and doing research on things you're unsure of. The nice thing about LTC- you tend to have the same patients for a long time so you can learn about them in depth. Don't be afraid to ask for help from the other nurses. Heck- I'm the charge nurse in my LTC and I still call my manager for help some days! I know I'm not perfect and that's okay!

LTC can be an awesome place to work and learn, but it can be overwhelming. Know that you will become more confident in time- you will become faster/more efficient and soon you will be answering questions.

But don't be afraid to move to a different area of nursing if it doesn't work out for you after 6-12 months. Or whatever. LTC is a specialty and it can be tough! I know I said this before but the lack of support compared to a hospital can be really really tough. Sounds like you've got a great attitude though- and that matters the most! Not sure if my rambling post helped or not but just know, I've been where you are and it does get better. But I still have days where I want to cry because I'm so darn overwhelmed.

Adele_Michal7, ASN, RN · Jul 2, 2015

I'm so sorry to hear this. I know it sounds trite, but it will get better.

If you list specific areas in which you need assistance, maybe we can help.

Do you have a good brain sheet?

What overwhelms you most?

One thing that will help is show up early, even if you aren't allowed to clock in. Write down your census if it's not pre-printed. Get a feel for the vibe of the floor/unit, take time to put away your stuff and fill a water bottle.

Nothing will start a shift off worse than showing up exactly on time. Lol.

When you're at home, relax. Elevate your legs, online shop, stretch or do yoga. Watch ridiculous cat videos on you tube.

Try to make one good friend/mentor if possible. This will ideally be a nurse who has been where you are and was able to blossom into her role. Someone who hasn't been there so long that they forgot what it feels like.

If you're not sure who to ask, this nurse will look like the nurse who is smiling, efficient, doesn't look too stressed, and knows the patients well. She will most likely smile at the new hires. Lol. Bring her a coffee or just walk up to her.

Answer my questions about what's overwhelming you. Maybe I or someone else can help.

Been there,done that, ASN, RN · Jul 2, 2015

The reality is... no new grad can function in LTC with 12 shifts of orientation.

You need a restart.. this place will drown you.

Oswin · Jul 2, 2015

First off ::hugs:: New jobs can be so stressful. I've been working at my LTC job for 2 years and I still ask questions daily and ask for clarification on things... and I'm one of the trainers! No one knows everything, and usually from school we don't get the the experience of taking care of 30+ people at once... regardless of acuity!!

If you really aren't feelings safe to be alone, ask for some more orientation. Tell your boss you don't feel safe yet, remind her it's your first job out of nursing school, and first time in LTC - tell her you feel unsafe and why and what you'd like to work on with your preceptor in additional orientation. When I started as a new nurse in LTC, I had a full month of orientation. I know that 12 shifts seems like a lot compared to what others have said for LTC, but if you've never worked in one before, it's really not. Especially for a new nurse. At the least, I'd ask for a second nurse to be with you when taking doctor's orders.

Also: I'd try to take a few minutes on a break (i know, I know... what's that) to write down what's tripping you up the most and study up on it on your days off. Do you know the meds you're giving? If not, write down the most common ones you're giving and look them up. Start with 5, and build from that. Write them out as flash cards and go over them like you did in school. Review your key "troublesome" residents' careplans... what's careplanned to do for that alzheimer's resident when she gets violent? Then chart the behavior, how you addressed it, and if it was effective.

Ask your boss if you guys have the Interact Care Paths, if not, maybe they can look into getting them. They're useful tools that provide helpful flow charts for what to do if your patient is exhibiting _______________. They can be a pain to find and follow in an time-sensitive situation, but are useful tools if they can be organized appropriately. (example: http://www.med-pass.com/media/pdf/MP5660PS-4_sp.pdf)

Review:

Your facility's standing orders

s/s sepsis (elderly people may not run a fever, or may have an elevated temp from their baseline which can be within normal)

s/s UTI in elderly persons (may include behavioral changes, shivering, chattering teeth or other odd symptoms)

what to do and what symptoms to watch for after a head injury

s/s and assessments you need to do people for CHF and COPD

what to do for chest pain

Generally speaking: if someone's acting out of the ordinary > ask them what's wrong and assess any complaints. If they're diabetic, check a blood sugar. If they're on oxygen, check a pusle ox and oxygen connections/settings. if they're not able to give you any complaints do a quick visual assessment > facial/body symmetry, breathing rate/quality, skin color, etc. > fully assess any abnormalities or do a quick head to toe. Get vitals on anyone acting weird just in case. If nothing else came up in assessment, consider a urine dip unless your facility has stricter policies on them.

Get organized!!

I have a shift sheet for each hall set saved on our computers. At the beginning of my shift I edit it for any changes and print it out.

Mine is half a sheet of paper with 2 columns and has:

People who need accuchecks with a space for the result

people on oxygen, space for pulse ox and their o2 orders

Assessments needed:

people on ABT and med a. Then I add the names of anyone that was having issues passed on in report

Treatments due

monthly summary

then a big space for "To Do:" that I update through my shift so I don't forget things.

If you're not sure about your charting, ask. Charting is important for the facility getting paid if it's not strictly private pay facility. They'll want to help you with that!

Hope something in here helped... remember, if you get overwhelmed pause and take a deep breath before proceeding!

anonomous · Jul 2, 2015

I think what is overwhelming me the most is trying to take the doctor's orders. I have a lot of difficulty understanding their accents. Plus, when I take telephone orders I can barely hear because of all the bells going off and people talking around me. The second thing that is overwhelming me is the med pass itself. One unit has over 30 patients and I am the only nurse passing meds. I am also responsible for treatments, emergencies, answering the phones, managing the cnas etc. I'm not sure what advice anyone can give about how to improve my efficiency during a med a pass. I am also getting really stressed out over the fact that I never have the supplies I need. At first, I didn't even know what I was looking for... Now that I recognize the names of the creams and bandages and stuff, they are never available!!! I'm terrified ot leave my unit because I'm the only nurse there.

Oswin · Jul 2, 2015

I think what is overwhelming me the most is trying to take the doctor's orders. I have a lot of difficulty understanding their accents. Plus, when I take telephone orders I can barely hear because of all the bells going off and people talking around me. The second thing that is overwhelming me is the med pass itself. One unit has over 30 patients and I am the only nurse passing meds. I am also responsible for treatments, emergencies, answering the phones, managing the cnas etc. I'm not sure what advice anyone can give about how to improve my efficiency during a med a pass. I am also getting really stressed out over the fact that I never have the supplies I need. At first, I didn't even know what I was looking for... Now that I recognize the names of the creams and bandages and stuff, they are never available!!! I'm terrified ot leave my unit because I'm the only nurse there.

ALWAYS read back telephone order to the doctor to make sure you got it down right. This is legally required, and if it irritates them, too bad Maybe you could put it on speaker with another nurse listening. Or when you answer the phone and realize it's a doctor say "this is _______, I'm a new nurse, would you mind speaking slowly so I can make sure I have the orders down right" before they start rattling them off

As for the med pass... try to organize based on those residents. Pay attention to who goes to meals early and try to get them first. If there are neb treatments to give during a meal... do them before the meal, or get them going right before the med pass, even. That IS something that will come with time as you learn the residents' routines. And you'll get faster as you learn everyone's meds, too.

Write down the supplies you don't have and take it to your manager so s/he can try to order more of it. An unfortunate thing I've learned (at least in my facility) is that many nurses don't apply creams but chart that they did - even when it was never ordered... check to see if they were ordered even if they've been charted as given, and if they haven't - order them. If they're available and you can't find them, ask how they're organized. If there's not an organization system, ask if you can stay late one night on the clock and develop one! (just make sure you write it out so everyone else can follow it, too, lol.)

Adele_Michal7, ASN, RN · Jul 2, 2015

I think what is overwhelming me the most is trying to take the doctor's orders. I have a lot of difficulty understanding their accents. Plus, when I take telephone orders I can barely hear because of all the bells going off and people talking around me. The second thing that is overwhelming me is the med pass itself. One unit has over 30 patients and I am the only nurse passing meds. I am also responsible for treatments, emergencies, answering the phones, managing the cnas etc. I'm not sure what advice anyone can give about how to improve my efficiency during a med a pass. I am also getting really stressed out over the fact that I never have the supplies I need. At first, I didn't even know what I was looking for... Now that I recognize the names of the creams and bandages and stuff, they are never available!!! I'm terrified ot leave my unit because I'm the only nurse there.

Let me address the doctor's orders first. It can intimidating at first. Just remember, you are the nurse. Don't be afraid to ask them to REPEAT themselves: if they have a thick accent, they are probably used to having to do it. If you still can't understand, or you don't want to do it, ask them to spell it. If you feel nervous, just remember: if it was your family member, you would be bugging that doctor with impunity. So be polite, but ask him as many times as needed. I'm sure in time, you will be able to understand him/her/all of them with ease.

As far as the med pass, it's going to take time. Don't rush. Don't constantly look at the clock. Just accept the fact it's a large task. It's going to get done. It's going to take a long time at first. It takes EVERYONE a long time at first.

As everyone will tell you, get all your needed supplies before you start. You'll save time.

Treatments? Well put it this way. Your priority is meds. Focus on those first. Figure out what treatments are emergent/must be done/must be done but can wait.

A big part of LTC is prioritizing. You mentioned CNA's, phones, and treatments. Can someone else answer the phone? Can you talk to your manager/DNS about this? I would imagine she/he would not want you running to interrupt med pass to get the phone. Where I work, during day shift we have unit managers. However, if it's a doctor, I'm going to need to take the call. So that's something to think about.

If CNA's are interrupting your med pass, you need to start to prioritize what they're telling you so that you don't become overwhelmed. You may get 10 interruptions in 20 minutes regarding someone needs pain pill, this one wants to know if they have therapy today, another one has blood in their stool, and the patient in 2A has elevated BP.

Well, the one you will want to check on immediately is the patient with bloody stool. You can write down the patient who needs pain medication next. You get my idea. Not everything can be addressed immediately and simultaneously.

Adele_Michal7, ASN, RN · Jul 3, 2015

Med Pass/LTC "Hacks"

-Write down some of the most important numbers in small print and tape them to the back of your badge: DNS, Supervisor, Pharmacy, On Call Doc, Door Codes... You will spend so much time looking for these and having them at your finger tips will save a lot of time. (You could also paste them on your clipboard.)

-Speaking of a clipboard, use one. Makes your life easier when taking report and can double as a tray when you need to carry multiple items into a resident's room, just remember to put a barrier down.

-If you have to give someone Miralax and they aren't a diabetic, experience has taught me they will likely want juice to mix it with... Try to keep it stocked in your cart.

-Know your facility's basic policies way before you need to know them. I.E., Hypo/hyperglycemia, Sending a resident out, admission process, reporting a fall, using e-kit... This will give you confidence. You'll still likely need to ask for help, but since you'll be aware of the policy, the person you ask for help will see you are proactive and be more enthusiastic about helping you.

-If CNA's take vitals, keep a wrist BP cuff with you for those times you need to double check a questionable BP (consider a portable finger pulse ox, as well.) Just check with your DNS if they allow the wrist cuff. I worked somewhere where they weren't.

Anyone have more to add?

SWM2009 · Jul 3, 2015

I think what is overwhelming me the most is trying to take the doctor's orders. I have a lot of difficulty understanding their accents. Plus, when I take telephone orders I can barely hear because of all the bells going off and people talking around me. The second thing that is overwhelming me is the med pass itself. One unit has over 30 patients and I am the only nurse passing meds. I am also responsible for treatments, emergencies, answering the phones, managing the cnas etc. I'm not sure what advice anyone can give about how to improve my efficiency during a med a pass. I am also getting really stressed out over the fact that I never have the supplies I need. At first, I didn't even know what I was looking for... Now that I recognize the names of the creams and bandages and stuff, they are never available!!! I'm terrified ot leave my unit because I'm the only nurse there.

Ask whoever is making noise around you to quiet down when you are on the phone. Just today I had to make that request to some staff members who were oooing and ahhing over baby pictures while I was on the phone. Make sure the volume on your phone is turned up loud enough that you can hear the caller despite some of the unavoidable noise - like call lights, chair/bed/door alarms, noisy residents. Regarding the doctors, ask them to spell the medication out for you, and re-read the order back to them before you get off the phone. You will most likely be dealing with the same MDs over and over again and with time you will get used to the accents. You will also become more familiar with the drugs these MDs order for UTIs, URIs etc and that will also make taking telephone orders easier.

Efficiency in your medication pass will come with time. Take the time at the beginning of the shift to make sure you have all the things you need - cups, straws, pudding, alcohol wipes, insulin syringes, tylenol, colace etc. so that you don't have to stop in the middle of your med pass to run to the supply room to stock up. During the med pass, let your CNAs know not to interrupt you for non-emergent stuff "Mrs B refused to get her shower" can wait till later or can be written down in a note and placed in a pre-arranged place like the nurses desk or on top of your cart. I will usually only answer MD calls or the occasional pharmacy/lab call if there is an urgent matter. All other calls are dealt with after the med pass. Hopefully you already have a good brain sheet with info on who gets accuchecks, who takes medications crushed and so on.

As for treatments, are you trying to do them as you are passing medications? The DON at my facility encourages new nurses to concentrate on the med pass first and save the treatments for later. I've been working there 17 months and I still do it that way - I work day shift and that morning med pass is so heavy I cannot reasonably do treatments when I am passing meds.

There is nothing more frustrating than being ready to do a treatment and finding out you are lacking most of what you need. I would advise that you find out who is responsible for ordering supplies - if it is the nurses then go ahead and order per your facility procedure. If it isn't a nursing responsibility then let your DON or person responsible for ordering the supplies know what you need.

Do not be terrified to leave the unit, remember your CNAs are your ears and eyes. Let them know where you will be so they can come and get you if something happens while you are away from the unit.

This is my 17th month as an LTC nurse and it took a good 4 months after orientation before I stopped feeling so overwhelmed.

JenWork · Jul 3, 2015

I feel the same way. I have dreams about work. and so much anxiety and stress to complete everything. the work load is crazy.

anonomous · Jul 3, 2015

this was extremely helpful. thank you