New NP @ post acute care setting---need advice!!

jgamom · May 14, 2014

I'm currently an FNP student. I see that this post is quite old, but your concerns were definitely disheartening knowing that I might have to face some of the same issues in the future. I'm curious to know how it all worked out for you. Are you still working at this site? I'd love an update and any advice you might have. Thank you.

zmansc, ASN, RN · May 14, 2014

two days is quite old?

jgamom · May 14, 2014

I'm sorry. I must have read the date from another post that I was reading right before this one. I thought that you wrote it over a year and 1/2 ago. Sorry. I look forward to the responses you get.

Trauma Columnist · May 15, 2014

1. If the DON doesn't have "much of a presence" then you must set the tone: don't accept a nurse/CNA, etc just plopping stuff down on your desk. Firmly inform them that you will take care of that issue when you have time and request (sternly) that they place the paperwork on the labelled clipboard.

2. Get the nurses buy in on your treatment plans. When you place the orders, briefly explain why you are doing what you are doing. Emphasize what' in it for them: improved pt care, quicker discharge back to their baseline skilled or intermediate units or home if that is the plan.

3. If you conduct care conferences, ensure the nurses, aides and therapy staff sit in too. Again, smile and bring in the staff to get their buy in.

4. At some point, you do just have to set the rules of engagement. My job is similar: I round on 150 dialysis pts and manage all their care as well as any acute issues. I go to four different units with four distinct personalities. However, what I do is the same: the nurses/staff know where to put paperwork they want me to complete, they show me results either visually when I'm at the unit or via secure email.

5. Use technology: use the EMR at the NH, get credentialed at the hospitals where your pts go - this will save you tons of time because you can just look up all the results as well as check on your pts progress when hospitalized. Also, use secure email and texting when possible.

Good luck.

lvan0904 · May 19, 2014

Thank you traumaRUs. I appreciate your feedback. I am coming from a hospital background and the post acute care setting is managed quite differently. They use paper charting and the rules and regulations are loosely held in place by the DON. One staff mentioned that another NP doesn't mind having multiple labs delivered all at once to review. Well, I feel it is not safe as a new grad and I don't know when I will reach that comfort level. So, I will sternly remind staff about the clip board. I imagine every new grad faces challenges. How long did it take for staff to follow through with your requests?

I know it is a different culture from the hospital, but basic practices that should be in place are lacking (ie- hand washing/sanitizer, reporting falls, leaving call lights unanswered). I guess I am having culture shock and I don't want to become desensitized and lower my standards. I was wondering if other NPs in nursing homes have similar experiences, or if this is unique. I will continue to set limits, integrate positive change, and uphold safe practice. I will meet w/ the DON and discuss areas that need addressed in order to provide safe, quality treatment for the residents.

A meeting was held this past week with my supervisor, and with some staff from the hospital that I am employed through (I am a hospital employee stationed at a nursing home). They seemed a bit in shock and agreed that policies need to be enforced if I should continue to practice at this site. A follow up meeting will take place in 1-2 weeks. If this situation does not improve, I will begin looking for another job. I will not risk my license and I will not be a part of practices that endanger the lives/health of patients.

No big deal about the date, [COLOR=#003366]jgamom. I'll report on how things turn out.

Please give more feedback/input. I really do appreciate any helpful advice.

Thanks and have a good week.

Trauma Columnist · May 19, 2014

The post acute area is very different environment. I went from level one trauma center ER to chronic hemodialysis units. I get the culture shock. I was very frustrated with the perception that I wasn't giving or seeing good care. It's not that you lower your standards, it's a different set of standards. For me, I had a huge learning curve and I found that the extra stress of being a new grad APN made thing far worse. I go to four different clinics each with their own culture. I had to get buy in before they would listen to me. The RNs set the tone. Or LPNs if that is what you have. Convince them that you want to provide good care and make their lives easier. They can help you by alerting you to changing conditions, new developments, etc.. I also brought in articles I found interesting to share. I talked with the nurses one on one to ensure that I was perceived as a team player versus a boss.

OregonGNP23 · Oct 26, 2014

I did subacute in a nursing home/SNF setting for 2 years. This is pretty typical, and nursing home staff is all of the above. Lazy, poor knowledge base, lack of training and education, inability to critically think. However, there are also some really good nursing staff members amongst them as well. Remember that their pay is awful, staffing is poor, and they are overwhelmed with this work.

I worked between 3 care homes and the staffing culture from the DON to staff RNs and even admin and social workers were different.

I just left this job, as 3 care homes was too much to juggle this in. Thankfully going to a position in just one SNF/nursing home, which will simplify things considerably. And it should just be this way. Balancing more than one invites problems and errors and is way too much work for one NP. As you say, these patients oftentimes are complex. That's an understatement.

You will ALWAYS be dealing with interruptions. It's the environment of subacute. I compare it to being a firefighter-putting fires out all day while doing your assessments throughout the day. It's quite typical. Until nursing home staff is better trained (which I think is coming, just slow going), you will have to adjust and be very vigilant in your work. It's the nature of SNFist work.

lvan0904 · Oct 26, 2014

Thanks for the input OregonGNP23!!! It's comforting to know that someone else can relate to my concerns. I was starting to question whether or not I had too high of expectations for staff & for the manner of which care is delivered within the post-acute setting. The organization that employs me just merged with a larger institution with an extensive history of NPs in sub-acute care, so I am hopeful that we will soon see more staff training and also initiate use of an EMR. I do feel like a firefighter some days!!! (actually most days!!!) Hospital re-admissions have gone done significantly since I began, so that is a promising sign that all work is not in vain. Most staff have become more receptive to my approach, and I have started meeting w/ the DON & administrator monthly to check in and discuss concerns & brainstorm ideas. I want this program to succeed and I want to see that residents are obtaining the care that they need. If you have any suggestions, please feel free to pass them along to me, and again I thank you for your input :)