New Grad in LTC - Feeling Overwhelmed (21 pts)

Specialties Geriatric

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I started my first job as a RN yesterday and was completely overwhelmed with my responsibilities. When I went for my interview and talked with the DON I was under the impression I would be managing and taking care of their 21 bed sub-acute unit with some help, like one maybe two LPNs. Well I did not realize until yesterday, that the unit was mine and only mine. I have 2 CNAs to get the pts. washed, in their chairs, and feed however; that's all they are allowed to do as per their contract and union. So I am left with 21 patients that need all their meds, dressing changes, suctioning, IVs, and documentation. To me that sounds crazy!!! I am fine with doing work and busting my butt, but 21 patients for one nurse seems unsafe. On top of that I was only going to be give 3 days orientation but I asked for more and got 5, which I feel still isn't enough.

I just want some feedback to see what other people think about my patient load and situation. I know being a new grad is hard and everything will come with time but like I said before, I think anyone would feel unsafe with 21 patients.

PS-So it doesnt sound too "extreme"...Not every pt needs dressing changes, has IVs, or needs suctioning. Its like each pt has one "extra" like one pt has an IV the next has a wound and needs dressing changes, the next is a trach and needs suctioning and around the unit we go like that.

So... what is the actual acuity level of the 21 residents? Post-acute, recovering, ortho, or long term care and stable and predictable? It makes a hugh difference. If LTC, not sub-acute, you are lucky, nice unit has only 21, most have 40. If sub-acute, how many are truly sub-acute? This is prn suctioning or always suction? Dressing changes are pretty common on any unit, passing meds is just a piece of it. Charting on the "alert" folks, otherwise if LTC, what charting? CNA's get vitals, you chart them. You had clinical experience in LTC? Acuity is the key.

I find charting to be significant because we have so many alert and Medicare/caide charts to complete on top of a huge number of po meds. Most have to be crushed but I have to look up and learn the uncrushable. I study at home on my own time but I've found it hard to just jump in and take a hall when I have to. I don't know what to say, I have resorted to sloppy nursing and cutting corners just to finish at a reasonable time. I am not happy or proud when I do. I too know it will get easier but wow!

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Hang in there. I am in the same boat, except I now have a month under my belt. I have days were I just want to cry and then some good days. Night before last I actually finished on time and actually felt like I was getting the hang of things. I had 2 days orientation and have been switched to different halls. I now know the patients on all the halls and feel more comfortable. In the beginning I was missing treatments and charting and missed giving some meds. I was just sick to my stomach over the whole thing. It is not my dream job by far. I was an excellent student, did very well in my clinicals and had great reviews from my preceptor, yet I was not going to to turn down a job in this economy. In my graduating class I would say there are only 10 of us that have jobs. Most the others had worked as CNA's or LPN's and are working at the hospitals. I promise it well get better and you won't be doing sloppy nursing as much. Just keep at it. I study on my own at home also, try and ask as many questions from the "good" nurses that work there.

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Specializes in Rehab, LTC.

I'm a brand new LPN working in LTC with 26 residents, got 3 days of orientation that were jacked up because state was there. The good thing about LTC care is these residents get the same medicine, the same treatments ect every day so after 1 mont I can almost memorize what each one gets. In my shift I have 2 med passes to 26 residents, 2 g-tubes, 1 trach, 12 residents who get accuchecks and insulin 2 times on my shift (2nd shift). Plus treatments, including breathing treatments, vitals on anyone with a change of condition in the past 72 hours, charting, admissions and anything else that might happen. Thank god my hall is now full so I won't be getting anymore admissions anytime soon. So far the key is organization. I made up my own report sheet that says how they take their meds (crush, ect) their Dr., if they get an accucheck, treatments, or any other misc info. Welcome to LTC!

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Specializes in Pediatrics.

21 sounds fairly good to me. My 1st job the LTC wing there are 30 patients lots of patients with dementia. Then the next hall has 25-30 a mix of LTC and skilled. Then the skilled wing has 25 patients and that hallway is a constant revolving door of admits and D/Cs.

Then the last hallway the one that scared me the most to work on was the vent hallway where you had 15-20 patients who all were trachs and vents and more than half had g-tube feedings. However my facility also had RTs for all suctioninng and trach care.

8 months later I am finially comfortable on the vent hallway, I think that the shift makes the difference too. I just swtiched from evenings to day and evenings where awful never could get out on time. now on days I had finished on time.

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Specializes in Cardiac Care.

Hang in there. Its not ideal. Its crazy, but you will get it. Unlike a Hospital almost all Nursing Homes, Rehabs, SNFs are pretty much the same.

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Specializes in A little bit of this and that.

Yea doesn't sound too bad. I had 10 days orientation, but 35 patients, as a new grad LVN. And many seemed to have a higher acuity than what our facility was meant to handle, but alas it's all about the bottom line.

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Unfortunately this IS the nature of LTC.

I do not know why we still call it that since it is often anything BUT long-term care anymore.

You need excellent organizational skills and you have to learn to manage priorities, keep tabs on the staff your supervising (you have to be a good leader), and be able to hop back and forth pulling PRNs while doing medpass because many patients (guests, residents whatever your facility is calling them) in SNF/LTC are more alert, aware of what they take, and aware of how often they can have it, and they come with multiple co-morbidities, complications, and wounds.

On top of this a new nurse must learn to pull her weight ie take care of her own orders, contact the MD when needed, do changes of conditions, assessments, and charting because many of these "guests" or "residents" are Medicare and on copious charting for MDS so the facility can get paid and you can keep your job.

Many nurses think SNF/LTC is the place to start because it is often viewed as "easier" than other areas of nursing. This is a false assumption which usually results in many new nurses getting in over their heads.

These facilities are everywhere and they share the same things in common - a bad facililty will put you in jeopardy (license or safety), there will be staffing issues and unsafe practices going on. You will have way too many "residents" to take care. You will quickly become overwhelmed in your duties, You will be asked to work extra shifts, you will be hounded day and night to "please can't you just come in so and so called off again". You will be used, mistreated and abused by administration and possibly your co-workers and staff underneath you.

A good facility might have moments where you feel unsafe or in jeopardy but overall you feel fairly safe practicing there. There will be staffing issues and call-offs frequently but you have a solid group of "regular co-workers and staff that you have learned to rely on and who can rely on you. You will have too many "residents" to take care and get overwhelmed at times but you have some reliable co-workers and you help one another out. Your co-workers work together as a team (for the most part) and there is minimal back-stabbing. Administration will back you up sometimes instead of throwing you under the bus. You will still be asked to come in "please, please because so and so called off again" and there is nothing for that one. And lastly people will still try to take advantage of you unless you stop them. Nothing for that one either, it's human nature. The harder you work....well...the harder you work and you get asked to more.

If after you have been there for 6 months and you STILL feel overwhelmed (as overwhelmed as when you first started - then perhaps your in the "bad" facility category. In any case it is hard to tell at first unless we're talking blatant issues from day one. In that case....run....RUN very, very far from this position and try another one.

SNF/LTC is not for everyone but jobs are tight right now. You have to learn to balance dream job with reality job. Good luck!

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So today wasn't so bad. I finished my 8am meds by 11am and didn't feel so overwhelmed. Its still a lot but I think I'll get a hang of it eventually. I just had a really bad day yesterday.

And for my pt. load. Its mostly subacute (about 50% require rounding at least every 2 hrs to make sure they are still stable with no resp or cardiac issues ) with some ortho and a few ltc pts...And I have no exp in a hospital or LTC as an lpn or RN. I was an EMT for a year but that's cake compared to this.

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Specializes in Geriatrics, Ambulatory Care.

I think three days orientation is ridiculous for a new grad.

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Specializes in LTC, Psych, Hospice.
So today wasn't so bad. I finished my 8am meds by 11am and didn't feel so overwhelmed. Its still a lot but I think I'll get a hang of it eventually. I just had a really bad day yesterday.

And for my pt. load. Its mostly subacute (about 50% require rounding at least every 2 hrs to make sure they are still stable with no resp or cardiac issues ) with some ortho and a few ltc pts...And I have no exp in a hospital or LTC as an lpn or RN. I was an EMT for a year but that's cake compared to this.

Sounds great! Hang in there.:clpty:

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Specializes in Geriatrics, LTC.
Many nurses think SNF/LTC is the place to start because it is often viewed as "easier" than other areas of nursing. This is a false assumption which usually results in many new nurses getting in over their heads.

Ain't that the truth. I cannot tell you how SICK I get of hearing, "oh, you *just* work in a nursing home? Did you try to go to any hospitals?" LOL. Hospitals have more acuity, but LTC is a different level of chaos in itself.

It doesn't matter if working with "only" 21 patients is considered favorable; the bottom line is, it's still overwhelming. I'm a new RN -- going on 5 months in LTC -- and I still have trouble always getting the medpass done on time, so don't feel bad! Anything can happen -- someone falls and the nurse has to complete an incident report, someone needs to be transferred out to the hospital, someone is being discharged or passes away, etc. It seems overwhelming to form organization skills in priorities, but trust me -- you WILL get there. I thought that my five days of orientation was short, but compared to what other people are saying on this forum, I suppose not.

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While this is the nature of LTC, 3-5 days orientation is rediculous! There is NO way a new grad would be able to get it in that short time. It is also very dangerous seeing that you are ina subacute unit. Thie subacute unit I worked had anywhere from 15 - 25 residents at a time. generally when we were over 22 we would get an LPN for morning medpass only. This frees up time for medicare and COC assessments and charting. A "normal" LTC unit has more number wise in residents but what many don't realize is that it is NOT the same! Good Luck to you. Maybe start looking for something new.

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