I am a new nurse and this past week was my first on my own and also my first 4/4. I work at a very busy med surg floor and needless to say I feel very stressed/overwhelmed being on my own.
I am so scared of making a big mistake. I usually end up giving some meds late like very late (. Even though I try really hard it is very difficult with 9 patients. I had two patients with PEG tubes so those really made me late for meds for all the other patients. On top of that, doctors want me to round with them, management, new orders, critical lab value reports ughh just remembering it all makes me hypertensive lol. I have stayed very late until 10 pm or worsee 12 am (that day was crazy).
I absolutely LOVE my job and my patients, but it is too much. I usually end up thinking of little things that I should have documented but didnt. I stay up late documenting but even then I feel like my documentation is not very good. I am scared those four days I was on my own I made a mistake I didnt catch.
There are a lot of things I could have done better for my patients but could not since I was very busy. I don't know if I should talk to my director and ask her.
Time management with meds and documenting is my big issue. Anyone have any tips to keep up with documentation/passing meds on time/ provider notification? I also give meds one by one so I take out the mediction for one patient and then go give it, then I return to the med room take out medications for next pt. and give them. I dot he same for insulins but I am beginning to see not everyone does that. How do you all pass meds? one by one too?
There is a reason why your unit doesn't have enough staff. Those four nurses that are coming aren't going to solve the problem when other staff continue to leave.
Are there other health systems in your area? Because being labeled "do not rehire" doesn't seem like a bad thing if your administration considers 9 patients acceptable. I know certain areas of the country have higher nurse-patient ratios - is this normal for your area? Do other hospitals nearby have similar ratios? If you don't know, find out. Sometimes the grass isn't greener, but sometimes it is. If I were you, I would be looking and applying. I have never and will never accept more than 6 patients, but I can afford to be picky.
In terms of pulling meds, doing it one by one is absolutely the safest way to do it. However, that is a corner I cut when I have 6 patients. I don't do them all at once, but I group them a few at a time. I feel comfortable doing this because I double check everything. If you are not comfortable doing this, you should not do it. I'm sure you haven't been charting in real time, so when you assess a patient, write down the abnormals on your report sheet so you remember that for when you can chart. If I were you, I'd get report and go in each room with the nightshift nurse. You need to do this because you can't assess them all in a timely fashion, and you need to be sure they are at least breathing. After report, pick a couple walkie talkies to assess and chart their assessments before pulling meds. Do any immediate meds first, then whichever are fastest to get done, then the rest. Delegate as much as you can to your aides and if you have a free charge (you better not with those ratios) and they ask how you are doing, be honest, and ask for help. Do not chart things you did not see, even if it means your assessment is not as comprehensive as you want it to be. You can only do what you can do. With 9 patients, getting out on time is unrealistic, but as you get used to charting you will get faster.
So in Texas we have something called Safe Harbor. I am not sure where you are located but if something like Safe Harbor exists, it would be worth looking into. I have taken on six high acuity cases and have been overwhelmed in the past. I couldn't imagine 9. In that instance, I would declare Safe Harbor to protect my licence. If you are asked to take on unsafe assignments, which I believe 9 patients is an unsafe ratio on a med/surg floor, then you need to protect your licence.
"Safe Harbor is a nursing peer review process that a nurse may initiate when asked to engage in an assignment or conduct that the nurse believes in good faith would potentially result in a violation of Board Statutes or Rules."
So in Texas we have something called Safe Harbor. I am not sure where you are located but if something like Safe Harbor exists, it would be worth looking into. I have taken on six high acuity cases and have been overwhelmed in the past. I couldn't imagine 9. In that instance, I would declare Safe Harbor to protect my licence. If you are asked to take on unsafe assignments, which I believe 9 patients is an unsafe ratio on a med/surg floor, then you need to protect your licence.
"Safe Harbor is a nursing peer review process that a nurse may initiate when asked to engage in an assignment or conduct that the nurse believes in good faith would potentially result in a violation of Board Statutes or Rules."
Safe Harbor doesn't exist but here's the thing - every single state has somewhere in their laws that hospitals have to provide safe care. It's just one of those things. So when hospitals don't? You can do something about it.. it's just hard and it sucks and it takes every nurse standing up. There was a hospital in Florida not too long ago - they tried to make a med surg department go to 10 patients per nurse. The nurses refused on safety grounds and they were fired. A major nurses union stepped in (not theirs - the hospital didn't have one) and offered to sue on behalf of the nurses using safety as a rationale. They won the lawsuit. The nurses got their jobs back and back pay and the hospital couldn't flex that far again.
Am I recommending going that route? Not for a new nurse without contacts in the hospital. But what I'm saying is - it's possible. Its just hard as heck.
The hospital is called Monroe Regional if you want to google the case.
Specializes in Tele, Interventional Pain Management, OR.
DO NOT pull meds for all pts at the beginning of your shift.
You significantly increase your risk for med errors by doing so. A pt's MAR is a dynamic thing that can change with meds added/DC'd at any time. Also may be easy to mix up meds and pts. The scanning system is great but imperfect. Don't rely on it to be your nurse brain.
Most importantly...you are not there just to push meds. ASSESSMENT is the most important function of a nurse in any care setting. Is the pt better, worse, or the same? Ask that question for every body system as you complete your head-to-toe assessment. Hold that question in your mind each time you enter that pt's room.
I really thought I was the problem not moving fast enough, but now I see 9 patients is really not safe.
I dont think that you are the problem. 9 patients is unsafe. The most I have gotten on a med/surg floor was 7 and I called the supervisor to say that is was unsafe, she said that she didnt have any extra float nurses to send us, within an hour another nurse was sent. Just curious...do you work in a connecticut hospital?
RNperdiem, thank you for your response. Honestly, I woke up, read the responses and cried for a little bit. I did not realize my situation was that bad. The last thing I want to do is to hurt my patients. We are short staffed right now, and my manager says by October there will be four more nurses in my floor. So we would each get 6-7 patients. I will look into other jobs in my area, but I need to stay at least a year in my facility since I already got the bonus and signed an agreement. I do delegate to my nursing aide but they are also super busy. They get 10-15 patients
They will take the bonus back. Safe = no more than 5 or 6 patients. 4-5 is better.
Talk with a couple of attorneys re: breaking a contract.
Oh my goodness... in subacute we had 10 pts, and some days that didn't feel safe!! 9 pts is never ever reasonable for med-surg. EVER.
Ok so your manager can't get staff until October... 1) well yeah, nobody with experience would be willing to care for so many pts! so 2) for the love of Florence Nightengale, get agency staff!!!
I am willing to bet that your colleagues are cutting some serious corners to finish on time. And even with 15 yrs' experience and TWO pts -- no I don't pull meds for more than one pt. It's asking for errors.
The docs want you to round with them... yes in a perfect world that would be great; particularly for communication. But you cleeeeeeeearly don't work in a perfect world. You have your own rounds to do, and you can't have them interrupted more than they have to be. If they have questions absolutely they should feel free to ask -- but with 9 pts you DON'T have time to follow drs around.
On point about rounding with doctors (everything else too but especially that). That minimum, what, 45 minutes is valuable time. Yes, it'd be nice to know the POC but if the doctors are writing notes you can read it in less than a minute. There's absolutely no need for you to be there with them for that many patients. I can't believe the other nurses haven't gotten that changed. Is it your choice to round with them or required? Start there.
Exactly why I couldn't leave the bedside quick enough! Nine patients is ridiculous...I wish I had some advice for you, but I don't. You will eventually with time get a good rhythm and feel more confident, though. It really is just a struggle in the beginning for all of us. Hang in there!
You need time management help, I have had as many as 21 subacute/Pacu and 26 LTC. Be glad mgmt has not fired you. Today mgmt wants you done on time and when they see 9 patients that insanely low. Good Luck
Specializes in Physical Medicine & Rehabilitation.
Being a California telemetry RN, we are definitely pampered with our ratios of 1:4 in telemery, 1:3 in PCU, and 1:5 for medsurge. There are few work days where 4 patients it's tough; however, I cannot fathom having more than 4 patients, let alone 7+ from what I hear from many medsurge nurses across the states that don't have mandatory ratios. It's insane that those states still not have adopted mandatory ratios.
@ OP
In regards to both medication management, you must find a way to cluster your meds and your nursing skills. Depending on the acuity of the patients, I generally do the "more manageable" patients first (such as patients who are healthy for the most part and only have a few meds to none) and then go down the list. While the patients that will require more time, can possibly go last. Not sure how your place is, but at my place we can give meds up to 1 hour early and up to 1 hour late without it being charted on the screen as "late." This is another way to cluster your 8 am and 9am meds. Give both at 0830 or somewhere in between that time. If you know you need to maybe change out IV tubing or clean a patient up or do some sort of nursing task for that patient, cluster those tasks with your medications as well. Try to do everything that you have to do for each patient in 1 or 2 walk-ins. It saves you so much time instead of having to run back and forth between patients, charting, getting supplies, meds, etc.
In regards to charting/documentation, that can be clustered as well. Remember, getting your meds and nursing tasks are most important, documentation can always be done in the end as long as you don't forget. For us tele nurses at my hospital, we do Q4Hr assessment chartings where the 1st is a full assessment, while the 2nd and 3rd are focused in regards to chart. For the most part, your assessments should be the same throughout the shift. If there are changes, add in those changes. Key is to chart on one patient at a time and get all the charting done before moving onto another. For example, I chart my 8pm and 12am assessment chartings together for each patient (as well as complete all the others in between). Saving yourself several clicks on the computer saves you time. It all adds up. Many computers have shortcuts that will help you speed through charting the "normals" of the patient, try to find out what they are.
Specializes in Psych, Corrections, Med-Surg, Ambulatory.
Being a California telemetry RN, we are definitely pampered with our ratios of 1:4 in telemery, 1:3 in PCU, and 1:5 for medsurg.
That is NOT being pampered. That is being safe and being able to provide appropriate care. Your staffing should be the industry standard. Do not undermine yourself (and the rest of us) by using words like "pampered". The suits have been pushing that disrespectful narrative long enough.
(. Even though I try really hard it is very difficult with 9 patients. I had two patients with PEG tubes so those really made me late for meds for all the other patients. On top of that, doctors want me to round with them, management, new orders, critical lab value reports ughh just remembering it all makes me hypertensive lol. I have stayed very late until 10 pm or worsee 12 am (that day was crazy). 
Swellz
746 Posts
There is a reason why your unit doesn't have enough staff. Those four nurses that are coming aren't going to solve the problem when other staff continue to leave.
Are there other health systems in your area? Because being labeled "do not rehire" doesn't seem like a bad thing if your administration considers 9 patients acceptable. I know certain areas of the country have higher nurse-patient ratios - is this normal for your area? Do other hospitals nearby have similar ratios? If you don't know, find out. Sometimes the grass isn't greener, but sometimes it is. If I were you, I would be looking and applying. I have never and will never accept more than 6 patients, but I can afford to be picky.
In terms of pulling meds, doing it one by one is absolutely the safest way to do it. However, that is a corner I cut when I have 6 patients. I don't do them all at once, but I group them a few at a time. I feel comfortable doing this because I double check everything. If you are not comfortable doing this, you should not do it. I'm sure you haven't been charting in real time, so when you assess a patient, write down the abnormals on your report sheet so you remember that for when you can chart. If I were you, I'd get report and go in each room with the nightshift nurse. You need to do this because you can't assess them all in a timely fashion, and you need to be sure they are at least breathing. After report, pick a couple walkie talkies to assess and chart their assessments before pulling meds. Do any immediate meds first, then whichever are fastest to get done, then the rest. Delegate as much as you can to your aides and if you have a free charge (you better not with those ratios) and they ask how you are doing, be honest, and ask for help. Do not chart things you did not see, even if it means your assessment is not as comprehensive as you want it to be. You can only do what you can do. With 9 patients, getting out on time is unrealistic, but as you get used to charting you will get faster.