I'm a new grad, new LPN, on my very first job, at a LTC facility. I love the people, like the facility, but I feel so unorganized & after my first stab at the med pass I am terrified.
I know it's going to take some time to get familiar with the names & faces of my residents & get to know who is up first, whose meds I can knock out quickly, & who I will have trouble tracking down or getting to cooperate, etc.
I'll be on day shift 7am to 7pm, with about 20 residents. My very first preceptor has been a LTC nurse for a really long time. She is great - she makes everything look so easy, she's so light on her feet, such a bubbly, positive attitude, great with all of the residents & all of the other nurses & CNAs. I call her the "people whisperer." She is so efficient, she seems to whiz through her morning med pass, do some treatments, takes time to stop & interact with her residents, helps other nurses when needed, & even has time for breaks & lunch.
I guess all of this comes with her many years of experience. I'm learning a great deal from her, but after my first test on the car myself, I felt like an utter failure. Like I was spinning my wheels & ended up 2+ hours into my med pass, missed some treatments, & two other nurses ended up helping me. Thank God for them!
Would any of you have any advice/experience to offer on time mgmt, tricks to help a new nurse be more efficient, etc? I feel like I just can't hurry any more than I already am or I'll risk med errors. Any advice for taking/giving report? I don't seem to know enough about my residents to give a full report & not just read off of their chart, but the oncoming nurse seems to look at me like I'm a moron if I tell her there were no changes, vitals were WNL, a certain issue has been resolved, or just report the MD orders that were given during my shift & changes to care plan.
Also, any tips for dealing with CNAs who are testing to see how little they can get away with while the "new nurse" is on?
I meant at our facility they have told me not to ask the CNAs to get vitals if I need them. Like on a patient who has had a fall, I may need vitals every 30 minutes, every hour for so many hours, & then so on for 72 hours. If 3 or 4 patients have had a fall, which did unfortunately happen, it gets very overwhelming trying to accomplish my med pass, treatments, accu-checks, & vitals in the midst of all of it. I feel like I can't keep it all straight, like I'm doing too many things at once. I guess I just have to learn to organize myself, but I didn't foresee not being able to depend on my CNAs to help me with that.
That's not uncommon in LTC. Where I work, the CNAs don't get vitals either. I think your facility should reevaluate their fall protocol. If they didn't hit their head, vitals q shift x3 days is what we do. The every 15 min x4, then 30min x2, etc. thing is unreasonable.
Brandon, they're called med techs or med aides. They take a class,pass a test, and can hand out meds. Here's the thing....they make fewer mistakes than nurses because no one bothers them with 18 different things while they're passing meds.To the OP, take your time and find your own rhythm. Those of us who've been doing this forever think 20 is a cakewalk, but I can guarantee when we were as new as you, we were freaking out, too.
Ok, I'll be honest and admit that opposition to med techs is based entirely on instinct to preserve my job. Any reasonably intelligent adult is probably capable of safely passing meds, as long as there's a nurse they can consult with.
I think it's a slippery slope, though. These facilities are employing med techs cause they're cheaper than LPNs, not because they think it will result in better care. Now it's med techs, but what's next? Cross training CNAs to be "wound techs"? CNAs with a couple days training who can now "gather data" (ie assess) for the RN? How long until almost EVERY nursing task is delegated to unlicensed staff with only one nurse to hold the fort?
I can't get the link to post, but try to look up this article in Nursing 2000 March issue;" Better time management: A matter of perspective" by Sharon Cox, RN, MSN. It is not at all what the title led me to believe! I call it my "Just Say No" article, & have had it posted by my desk at home since I first read it.
CNA's and their duties are usually per facility policy and some are regulated by the state. First, as mentioned before, stock your cart, on top and in your drawers. Insulin needles, diabetic supplies, alcohol wipes, and any generic drugs that may be supplied by the bottle, i.e. APAP, ASA, Colace, etc. We have a "shift to shift" report that can be printed from the computer, that has all resident's names and room numbers. Noting how they take meds is important. Check all tube feeders and make sure your set-up is infusing properly. I have a cheat sheet that I made on my computer, actually I have a couple. One is ASSESSMENT for admissions, head to toe, so I don't miss anything. Another one is Shift Duties, which includes: who must be charted on, all ALERT charting, Labs, Phys. Orders, etc. As you go along you will figure out what YOU need to have on YOUR
cheat sheet. Also, never take these out of the facility, HIPPA violation, since resident names and other info. are on them. Put them in the shredder at the end of your shift. Charting is different in every facility. We have ALERT charting=those on ATB's, IV's, Isolation, New Meds, etc. And we also have weekly updates, and of course, change in condition charting. Give the best report you can give. Sometimes, nothing does go on with a resident. If someone is giving you grief about your report, they should be ashamed. They were new once too. Most nurses are friendly, and if they have the time, will answer questions and even help you if you're in a bind. We do not eat our young! Hang in there, you'll get the hang of it. Wait until you have 30+ as I do, along with the rest of my co-workers. You have to have a system of your own, that works for you. I'm sure if you ask, others would be willing to give you some ideas! Good Luck!
I have been a CNA for years and just recently got my MA so I know both sides of the fences. I have been a CNA longer and know that as a CNA we all feel out our bosses to some extent. Dont be one to let them get away with slacking and then one day boof, your a b**** u know? Be who you are from point A. You are also feeling them out as well because without each of you things would not run smoothly. It takes both. A CNA's job is hard enough without a gripy nurse. As long as they are getting their job done it doesnt matter and if you make that clear the two of you will make an awesome team. Thats all that a CNA wants, is a nurse who sees their potential and recognizes how hard their job is. Afterall they do have one of the most stressfull jobs out there. I have found that when the nuse gets along with the CNA that both of them benifit so stand firm from the start without seeming like a nurse who doesnt seem to care about no ones job but their own. Does that make much sense? But don't let them slack with patients either because they deserve all we can give and some :)
Specializes in Care Coordination, MDS, med-surg, Peds.
BrandonLPn: I hear what you are saying, but I just have to say that in the 70's as a CNA, I not only was the wound "nurse"(yes, I know I was not a nurse, but that's what the residents called us). I inserted caths and removed them. In some hospitals, now, CNA's are trained to insert foley's as well.
OP..speed will come with time. You will learn time management skills as you get a routine down, of course, there are shifts when the routine goes out the window, but as long as you have a good basic routine with tips and tricks to help you, such as the report sheet, marking or names as dones, etc.. you will do fine on the crazy days, too. I do agree that your fall policy needs to be looked at. A head injury needs more intense monitoring, but a fall without head injury does not.
I know that as you and your CNA's build into a co-hesive unit the respect for each other will be there. It may take some time for this to happen depending on the individual people. It seems that they should respect the position, but that doesn't happen generally.
Specializes in UM,Psych, Military, Substance Abuse, SNF.
My first job as an RN was at a SNF. 30 patients but I usually had someone to do meds and then I had everything else. You learn tricks as you go. 20 shouldn't be too bad once you get the hang of it. Re: troubling CNAs. You have to establish authority early on (difficult for me because many were as old as my mother!) but you also want to show that you're fair and there to help support them. Also, it's not quite fair to say they ONLY turn, dress, bathe, etc. That's extremely time consuming crap (esp with certain residents). I told my aides all the time: "Don't ever let anyone tell you you're 'just an aide.' That's ********. You fill a vital role and nurses couldn't do it without you." Its not like you have to get vitals on every resident...unless they're ALL Medicare which is unusual. I finally broke free of the SNF life after 2 1/2 years. That was enough for me. But your facility sounds nice so I wish you luck.
I am right there with you. I am working at a LTC facility and this is my first nursing job. I have been working there for about 10 months and I have gotten quicker, mostly because I have become really familiar with the residents on our floor. I have learned a few tricks that have made me a little quicker. Our CNA's don't do our vitals for us either, so I would say before you start your first med pass and do your accuchecks, take as many vitals as you can so that will be out of the way. Also, cluster your tasks together, this really helps. Keeping your med cart stocked so you won't have to go back and forth for supplies will help also. Also, if I know a patient will be difficult, I usually try to get everything done with them in one shot..like morning accucheck, morning meds, and vitals. But don't feel the need to rush. Like you said, you don't want to make a medication error. Like my trainer told me, speed comes last. Accuracy is the most important:) Hang in there!
I wonder if the amount and timing of vitals after a fall is "common" to most LTC? We have two different agendas based on whether it was witnesses that the patient did not hit their head or if they did/may have hit their head. We have to do neuro checks and vitals each time. Possible head injury, vitals and neurs q 1/2 hour times 4 after the first set (total of five 1/2 hour checks) then q 1 hour for four hours then q 8 hours for 72 hours.
Whenever I have a fall I keep the patient in the hall with me and if at all possible keep a dyna map attached to their arm for the first couple of hours after the fall. It helps to save time, patient less grumpy from being attached/reattached over and over and catch any developing issues more quickly.
As for the CNA's getting vitals for you that is not simply matter of facility policy. Even if the facility says you can you still may not want to do that. As the LPN we are responsible for EVERYTHING that happens on our shift. If the aid gets caught up with a persnickety patient and forgets to get the vitals on time or at all, it's your butt. (yes happened) If the aid gets any "strange ideas" that it is okay to just make up numbers and hand them to you, it is your butt. (yes happened) Even if you do have an aid you can trust and a situation that makes it less likely they would get tied up to long you still have to do the neuro checks for yourself because the aids aren't allowed. Just some things to think about on that one.
I know how hard it is to be a new nurse trying to learn all your own job and then being responsible for what your CNA's are doing and not doing just piles on the stress. I sincerely hope you have strong professional aids working with you while you get used to your own new job. It makes such a world of difference.
Just make sure you take the time to tell them how much you appreciate them. Tell them when a patient makes positive comments about them not just negative. Tell them when you overhear them being extra patient and supportive to a patient that you appreciate their kindness towards the patients. Things like that.
In time you can decide other things you can do to let them know you appreciate and respect them. I personally also keep "goodies" in my bag and if the girls need a piece of candy, mint or gum or something to tide them over I have it on hand for them. I know it seems like such a small gesture but it has a lot of impact on the aids. Sometimes we nurse's all go together and get the aids pizza brought in or something to show our appreciation. It may not seem like much but it gives the aids a "boost and builds team spirit". Christmas I baked them all a pile of different cookies and candies. Stuff like that.
Everyone as their own leadership style. I had the advantage of working as an aid in the same facility while I was in school. I was watching every single nurse I worked with, listening to all the other aids and how they responded to the nurse's. Even how the patients responded to the nurse's and their leadership style.
As long as your CNA's do not try to push their luck to far while you are getting used to your new job you may be able to take a little time to simply watch everything for a while so you can decide what is best for your individual situation. If not maybe you're lucky and there are other long term nurse's there that can help you.
When I first got put down my permanent hall it was a nightmare for me. I was scrambling every day just trying to "clean up" everything left from the day shift nurse, trying to organize the hall so I could even find anything due to far to many "fill in nurse's" not caring if people's meds ran out or if we even had the right meds in the right drawers etc, creating my own "system" for dealing with all the particulars of that hall etc.
Having an unprofessional, lazy aid that would bold face lie to me was NOT helping me nor her poor overburdened partner! Sadly this aid had been doing this since day one and although she has been "remodeled" and is doing much better it was still to late by the time I took over that hall and I lost a wonderful aid that quit because she was burned out from carrying most of the burden alone way to long. That really upset me to see her go. The patients loved her, families loved her and I loved her:( Wereally need to keep a close eye out for that too.
Other nurse's that were there long term saw what was happening and stepped in to help with the problems with this particular aid. We have three halls on our unit so there are three nurse's. We all collaborate on how we need the UNIT to run and back each other up when something is wrong.
We "swap" aids sometimes to build teamwork and so the aids and patients will be less upset when emergencies happen and they are "forced" to work other halls/ have "strange" aids tending them.This also helps the aids not to say "You are not my nurse" when one of them sadly does need corrected on something and we just happen to be the nurse that is there at the time. This has worked out much better for everyone than the old way we did things that is for sure.
One of the nurse's transferred to a different unit and we have another newer nurse down that hall.. Now it is my turn to help her until she says she is ready to fly solo with each thing. Team effort makes for a stronger unit all the way around.
Starting out at a LTC facility, what you are experiencing is normal. Only start to worry if in 3 weeks, you haven't noticed a noticeable improvement in time management.
The only thing that worried me was when you said, "The overwhelming part for me is having CNAs who do not really do anything but change, turn, feed, & bathe/shower patients." That is A LOT. Not only is it physically demanding, it is emotionally demanding too. Those girls (and guys) are literally elbow deep in **** on a daily basis, transferring people who often times weigh twice as much them, and take a ton of verbal, physical and sexual abuse from residents. (Not to say that you shouldn't expect that yourself, but aides tend to get the worst of it). Their focus is patient care and ADLs. They main way they are going to help you is by communicating important changes in your patients. They will be the first to notice blood in the urine, the beginning of mental changes, and many other things.
RESPECT your aides and they will respect you. Respect your resident's needs first though, if you notice someone has not had oral care, not been turned, etc, find that resident's CNA tell them "Hey, I noticed that so-and-so is still wet or that mr such-and-such has not been turned yet, please make sure that it gets done." They will respect you for caring about the residents and holding them accountable for their job...there are always a few bad eggs, but it will get you pretty far.
As for vital signs, I already made the point that CNAs are also very very busy and overwhelmed. In my facility, CNAs are only obligated to take vitals on 3rd shift, where they have more down time. After about 6 months of working 3rd shift, I started doing most of them on my own after realizing that most CNAs do not have the proper skill set to be able to interpret critical vitals, and some of them do not even have the proper skill set to even take them.
I've had CNAs leave papers for me that listed someone's o2 sats as 78%. They just dropped it off in a long list of many vitals that they began to take hours before it was delivered to me. It has happened more than once too.
Also, many CNAs do not know how to accurately take BPS and only feel comfortable with a wrist cuff...I've had people "make up" BPs because they could not get a reading or did not have a digital cuff and were too embarrassed or scared to tell me that they didn't know how to use a manual blood pressure cuff.
I could go on and on. I could write a whole damned volume of books about relationships between CNAs and LPNs. Be thankful for your CNAs, unless you'd really rather be changing diapers and washing yeasty skin folds all day. If they don't do their job properly, let them know what you expect. Be friendly and be confident in yourself.
You sound like you are going be Just Fine in LTC. Always remind yourself to keep up the pace, don't take shortcuts that put either you or your resident in harms way, and ask every single question that pops into your head. The first few months will be scary, but it will be so worth it when see how much you can grow as a nurse!
20 residents! and 12 hour shift. U need to thank God and stay in the position as long as you can and until u get your B.S You will learn those residents in no time. Keep a notebook for yourself. Keep track of what you do daily use initials or rm # . This will show you where you can be more effective. It will also help you keep track of your patients likes , dislikes and info on family interactions.
LPNKY2012
14 Posts
I meant at our facility they have told me not to ask the CNAs to get vitals if I need them. Like on a patient who has had a fall, I may need vitals every 30 minutes, every hour for so many hours, & then so on for 72 hours. If 3 or 4 patients have had a fall, which did unfortunately happen, it gets very overwhelming trying to accomplish my med pass, treatments, accu-checks, & vitals in the midst of all of it. I feel like I can't keep it all straight, like I'm doing too many things at once. I guess I just have to learn to organize myself, but I didn't foresee not being able to depend on my CNAs to help me with that.