New grad, 52 residents, anxiety through the roof

[BobbyDigitalis]

Hello everyone,

I hope it's okay to soundboard here. 

I passed the NCLEX in CA on April 1. I've now been ward clerk for 3 days "orientating", and while I did get some experience (first foley!) and learned the MAR/charting a little more, I'm still far from prepared, confident or being stable. I'm on the schedule for NOCs starting May 1. There's 2 halls: ST1 has 52 residents. ST2 has...2, one nurse per hall. I'm slated for ST1 because I'm new and I guess everyone wants the kush hall. 

My anxiety and SSRI is playing hell on my memory/metabolism of things. I'm having trouble remembering names of aides/residents, how to navigate the system, which charting is needed when, when to write clinical notes, etc. I'm not worried about med pass, I'm worried about remembering stuff and doing the right things/steps. I'm worried about mistaking something in an assessment for something else (wrong lung sounds, missing edema, etc) and not knowing how to deal with and chart it.  

The other nurse on ST2 with their 2 residents are mostly registry, so they're not exactly familiar with the facility protocols either (nor do they ever venture outside their hall). I'm running so short on time and panicking every second.

I'm just very scared, my mind is wandering all over the place, I'm not receptive to learning this much, this quick. Any thoughts, pointers or advice? Anything would help.

[TriciaJ, RN]

Take a breath.  Do not expect your brain to remember anything.  Get yourself a little notebook for the permanent things and use sticky notes to index it.  Use a nightly worksheet to keep track of things on your shift.

Get a census list of the residents and find a way to make a worksheet out of it.  Use a 3-colour pen so you can prioritize things with different ink.  It will probably take a few weeks to develop your "system" to your satisfaction.

If you can't remember proper words for charting, then just chart your observations.  For breath sounds, you can chart "crackles" or "moans" or "squeaks".  You might feel a bit idiotic at first, but it's really about conveying the pertinent information for the most appropriate intervention.

When you're feeling anxious about minutiae, bring yourself back to basics:  is everyone breathing?  Do they all look safe and comfortable?  Okay.  Take a breath and move on to the next thing.

Don't be afraid to ask questions.  Ask the CNAs about routines. (Be careful not to let CNAs give you nursing advice; that is a liability issue.  Use the registry RN for a nursing resource.)

Ask for more orientation time.  You probably won't get it, but get good at asking for what you need regardless of result.

Of course you're scared; it means you're conscientious.  You've got this.

[BobbyDigitalis]

Thank you so much for this, TriciaJ! That all, really helps me...breathe. The worksheet tip is genius! Thank you, I will implement that! 

Last night I did both halls, all 52, and my med pass took around 4.25 hours. I went in adamant on setting a good pace, I started out so good and on par with my orientating nurse, but then somewhere it just all slowed down. I was discouraged when I saw all the meds flashing "late" on the MAR. I honestly don't know how I could've gone faster.

The nurse from the other station did my morning pass on one hall, even though I wanted to sink on my own, but I wouldn't have been ready for AM shift without her help. 

My biggest thing, next to first pass, is remembering stuff and being "sharp" when AM rolls around. I struggle with report, even though I write down PRNs and BM list, etc. I cant remember most of my interactions with the residents, my recollection is very hindered, so my report tends to include a lot of "she's fine, nothing with him". It makes me feel horrible, I don't want to be "that" nurse when it comes to handoff, it makes me look like I don't care. 

After these last 3 orientations I feel a little better but am prepared to get destroyed when I'm solo, and, that's expected. I just hope I can learn from that and get to a point of competency, I'm nervous that some things just one stick, I don't want to always use the "I'm new/learning" card (I'm a slow learner, especially at 3am).

Thank you so much for responding. It means a lot. 

 

PS: 40 years experience?! My goodness. I'm glad burnout didn't get to you, it's both inspiring and reassuring to me.

[TriciaJ, RN]

Actually, I retired after 36 years.  AN  keeps adding  years of "experience" even though I am no longer acquiring any.

I did some agency shifts in long term care and it was certainly med pass heavy.  You'll develop tricks and techniques to get through.  But beware of any workplace that requires a lot of corner-cutting to get through.  If something isn't feeling right in your gut pay attention.

Right now it looks daunting because there's so much to process all at once.  When things start finding their own slot in your brain you'll be surprised at how proficient you become.

Don't be afraid to ask questions if there's anyone around to ask.  Patient safety trumps what anyone thinks of you.  We're all slow learners at 3 a.m.

[amoLucia]

Bobby - even we 'oldie but goodie' staff are/were slow whenever we started new jobs. Even with my 36 yrs pre-retirement yrs, I would flub-dub when I floated off my unit. But I developed a neat 'cheat sheet' for myself (a pencil master copy that everyone on my unit eventually adopted) and my nitely 'working' cheat sheet.

PP TriciaJ hit the nail on the head re the 'minutiae'. At the end of the shift., I would know #1 ALWAYS KNOW YOUR BED CENSUS COUNT!!  #2 nobody died (unexpectedly).  #3 nobody fell.  #4 everybody breathing OK.  #5 IVs/GTs all OK.  #6 pain managed as well as poss.  #7 diabetics OK.  #8 everybody peeing & pooping OK. Anything that deviated from my 'minutiae' list was reportable.

Special attn was made for new admissions. Dialysis & doctor appts mentioned too.

Just remember that LTC/NH is NOT the ACUTE care setting of the hospital. I think this is THE HARDEST thing to absorb as a newbie nurse or acute-to-LTC nurse.

As a newbie, you will have an on-call person if you're really stuck. Believe me when I say that even with all my experience there were times I felt the need to call for something beyond my control. Do so WISELY!

Med pass speed will improve with time - I was sooooo slow when I floated!

I am going to alert you to make sure you have access to EVERYONE'S phone numbers, incl DON, Admin, doctors, lab, xray, dialysis, other dept heads, etc. You ever know when you might need them. I usually made my own personal copy.

Also, find out how shift call-outs are handled. Very serious!

Final rule - when in doubt, ALWAYS, ALWAYS err on the safe side for pt safety/care.

[BobbyDigitalis]

On 4/23/2021 at 8:49 AM, TriciaJ said:

 

 

On 4/23/2021 at 12:36 PM, amoLucia said:

 

amoLucia, I made my own cheat sheet with resident preferences and info (the facility have some incorrect things on them). I've fully taken to heart the "don't sweat the small stuff". Last night a resident was complaining she couldn't breathe and I kinda froze. I took her sat and raised her HOB, panicking on the inside, then another nurse asked if she had PRN atavan (to which...what about her breathing issue? Does a panic attack really take precedence over breathing? I don't think it should. She's been an LVN for 5 yrs and is quite proud of that, I believe some become jaded after a while). We then found that her O2 was disconnected. I still feel bad I didn't act more like a nurse (but at least I wasnt focused on AtavanBreathingCirculation). Furthermore, I know the O2 was connected when I was in there earlier, but she insinuated (playfully aggressively) that I missed the O2 disconnection. That both hurt and pissed me off. She told me that I should ask for more time in orientation; she doesnt know me and didn't watch me at all. My hall pass took 2 hrs, which is improving already, and I am going very fast (and safe, no med errors). She said things to bring me down and bring herself up, while talking my head off about gossip and inappropriate questions (asked me my sexual orientation, which made me feel very uncomfortable. She's the 2nd nurse there to ask that. Why? I'd never ask that of a co-worker). I've always been told to develop a thick skin, I don't know how, I guess I need to really start trying; holding stuff in is toxic. 

Thanks again for listening and advising. The cheat sheet seems to help.

[BobbyDigitalis]

TriciaJ, I'm certainly not afraid of asking questions, though sometimes it just doesnt stick and I'll have to ask again, even after taking multiple notes. This assimilation of everything at once, especially for an older fella like me, it's hard. I do believe I'm getting better at things, knowing (and remembering!) routines, slowly, albeit surely. The corner-cutting is real, my god; things like giving meds 3 hours early, simply not giving meds for whatever reason, giving PRNs without the residents asking, because it, "makes my night easier". I'm a good person, and maybe not a good (fast/capable/confident) nurse yet, but seeing some of this stuff and how it passes muster...it breaks my heart and is frankly scary. 

Not focusing on the minutiae is helping. I just want to be safe, the residents healthy and be ready for AM on time, not to make their day harder. It's still the what-ifs that get to me, the resident emergencies that I haven't had and would panic in that situation.

They took down my days from 3 to 2 next month (without telling me), which I'm okay with, a lower workload will be nice for a minute. Just kinda brings me down in some regard, I guess they don't think I'm ready yet, but they've done this with none of my fellow recent grads. Admin has been nothing but complementary and confident and encouraging. They live by the whole 'trial by fire/get on in there' thing, I've rarely seen them adjust to slower pace with someone. I tell myself "you're doing fine, you're not doing that bad at all" and it's hard to maintain when I ponder the reasons for already cutting my hours. 

Thanks for your encouragement and advice again! 

[TriciaJ, RN]

Sounds like you're getting the hang of things and developing your own style.  Next time someone asks you about your sexual orientation "I'm sorry; I'm not available for a relationship."  They'll protest all over the place that that isn't what they meant but hopefully they'll learn not to ask inappropriate questions.

Sounds like you kept your wits about you when the resident was having trouble breathing.  We all panic on the inside when things happen; it's an art to maintain a calm exterior.  

Your employer seems to be happy with you.  I do hear you about the corner-cutting.  It's concerning, expecially if doing your job depends on it.  If it becomes a problem, you might let management know there are some corners you're not willing to cut.  Hang in there.

[BobbyDigitalis]

15 hours ago, TriciaJ said:

Sounds like you're getting the hang of things and developing your own style. [...] Hang in there.

TriciaJ, 

I think I am too! Finished lastnights pass by 10, which is a big improvement for me, you get in a rhythm and you get hyper focused. My DON asked me to pop in before I lest and told me I was doing really well, she's read my charting and I have no issues. I told her my medpass time and she got wide-eyed and said she usually goes 30 mins past that. I almost cried. I put a lot of pressure on myself to try and be perfect and...it's not a good thing. 

Only thing aside from time management, the computer system and lethargy come 0300 I need to develop is managing the aides. I'm new and most of them are very young, lazy and walk while looking at their phones, so they don't miss something. I'm new so they think they can push me over (which is kinda my personality) and take advantage of me, so I need to assert myself very quickly. I shouldn't have to take my own premed vitals, and even my DON told me that there's some bad eggs and "if you don't trust your aide taking vitals [because some of them write fake vitals] then you can do it yourself". Guess I'll have to start throwing down the hammer, which, my god do we wear a lotta hats, LOL. 

Thanks so much for making me feel confident and happy! Not every nurse is as kind and experienced as you. It's a warm blanket and a full moon. 

[downsouthlaff, LPN]

OK first breathe ! This is what you need to do and what helped me tremendously as a new nurse in LTC. One, realize that LTC is very hard. Until you have the advantage of knowing the routine to a T. And it’s still challenging. Next make a check list of every task that you’re responsible for (Medicare charting, weekly room charting, ABX progress notes, chart checking, pharmacy reorder, Glucometer control) make copies of this, check them off as you complete them. Also, make a binder of your facilities step by step processes like sending to ER, a new admission, entering new orders and refer to it each time the situation arises. Just remember the basic nursing practice rules when it comes to nurses notes and when to do them. 
 

1. your facility policy for notes (skilled, Part B, weekly, ABX)

2. Anytime a resident leaves and returns 

3. Anytime a NP/PA/MD rounds and or gives new orders by telephone or anytime you notify. 
 

4. any change in condition and prudent action you took (PIE) 

5. refusals of care 

best of luck 

[AZNurse13]

Bobby, run don't walk out of that situation, there will be other places to gain work experience and where you won't be in danger of losing your license once the company throws you under the bus or reports you to the state nursing board. It's ridiculous to believe the ratios between nurse and patients. 

[BobbyDigitalis]

22 hours ago, AZNurse13 said:

Bobby, run don't walk out of that situation, there will be other places to gain work experience and where you won't be in danger of losing your license once the company throws you under the bus or reports you to the state nursing board. It's ridiculous to believe the ratios between nurse and patients. 

When I first thought about this, I didn't really seem motivated/worried. The DON seems amazing and supportive, I like her a lot. Get along with most of the nurses. I know the residents now. It's getting more "comfortable". And yet...what you say speaks to me. I wish it were that easy to leave and find a new-new job. 

I still don't know many of the important procedures (like sending someone out, which we had to do a week ago, on the medicare wing with 6 residents, with the registry nurse that doesn't know anything or care at all. Fun fact: she makes exponentially more money than me, is incredibly lazy, takes multiple smoke breaks and steals my aides to go with her, she's a bad nurse). I did most of the paperwork that I don't know how to do for her, as she sent him out. She proudly didn't know the procedures much more than me, nor was she caring that she didn't. She was told to help me with my 2000 pass (which I don't love, you cant have 2 nurses on a cart, just let me learn and gain my efficacy). The last 2 days there was a narc count error on the side she passed on. I told her I don't want her help, now she's very pouty. Another nurse on that side, RN, helped on a pass a while ago, and he also forgot to sign out a med. They act like it's no big deal. Nobody cares. It's like it didn't happen. 

The only 2 nurses I know (from school), trust and rely on just put in their notice last night. They're going to a bridge program. Not 24 hours later the ADON texted me asking if I could pick up days in July. I was gonna ask for time off, because Im getting burnt out. I told her "we'll talk",  and she gave me a thank you reply, as if I agreed to something. Snuck on 2 days for me last month already. With the departure of these 2 nurses, we now have...4 NOC nurses, 2 of which exclusively work the Medicare side (because of preference). 

I have learned things though and I'm thankful I can at least walk the walk in many regards. But...and it scares and saddens me to think about this, I realize I need to take your advice and seek another avenue, fast. I'm a hard worker and a good nurse, I know that much, yet there's bad nurses (and aides especially) that don't work and the difference between us types is nothing. No praise for work ethic and devotion, no shunning for the opposite. It's so depressing. It's turning me off to nursing in general, if I may. I originally envisioned an RN in pedes, not this, and yet I know I'm so far away from that, wondering daily if it's worth it to try to get there. 

Sorry for the diatribe. Just wanted to get some stuff out. Thanks for the advice, I read you 5 x 5. Just wish it wear easier/quicker to implement. It's nice being employed and having the LVN badge, and honestly, from what I've seen, I'm not too worried about them throwing me under the bus or anything (we already had state survey, where things went amazing for 3 days and then were quickly back to a joke). I'm more realizing how much it burns you out and how little respect I get, and am taken advantage of, as a new, enthusiastic, hard working nurse. It really saddens me.