New RN - First nursing job in LTC and I feel like I'm drowning!!

[knitnurse72]

I have been reading some other posts on this topic and I'm realizing that my story is not unique, but I could certainly use some advice! I am 40 years old and just finished school in December, took the boards in January, and got hired at a nursing home in February. I am a brand new nurse but I have worked in healthcare for almost 20 years in some capacity, including being an activity director at a nursing home for 5 years prior to having children, and most recently as a unit secretary on a med/surg floor at our local hospital. When the time came to start job hunting, I thought about it a lot and decided to go back to LTC because I had really loved my job as an activity director and I really love that population. Also, having worked on a med/surg floor for 5 years, I realized that med/surg was not what I wanted to do. I applied to a few nursing homes, and also a few hospitals as well (who all wanted experience or a BSN), and I accepted a job at a small, 33 bed LTC facility. It's a full-time position and I work Friday through Monday, doing 7A-7P on the weekends, 7-3 on Fridays and 3-11 on Mondays. Definitely an odd schedule, but it works out for my family and I actually really like having those 3 days off during the week, every week. My job is to be the charge nurse, which in the beginning sounded great, but now I'm having second thoughts!!

Because I'm a new nurse, my DON had me do 5 weeks of orientation, M-F, at another of their facilities to get some practice and become comfortable with things, which was great. I was on a sub-acute floor at a larger LTC facility and got lots of practice hanging IVs, had 2 G-tubes to take care of, had a huge wound to take care of, and I finally got pretty good at doing the med pass by the time I was finished. There were 40 patients on the floor with a charge nurse, 2 med nurses, the unit manager, plus the DON in the building, so there was always someone to help me if I needed it and they were all wonderful to me. The evenings had a charge nurse and 2 med nurses, plus an admissions nurse if there had been any admissions that day.

My 6th (and final week) of orientation was at my home facility, doing M-F 7-3 with 1 3-11 shift, then I started my first 12 on Sunday, by myself, and I feel like all Hell broke loose. The nurses I oriented with during the week are great - they've both been there a long time, but they also think I should have had more orientation because this facility is a lot different than where I oriented. They have also begun to tell me about the DON, which apparently noone likes very much and has a reputation of not being very helpful to staff. The first thing that happened on my first day alone in charge was that a CNA burnt toast in the staff room toaster, setting off the fire alarm and summoning the fire dept. No one had gone over fire alarms with me (other than what I already know about RACE), and no staff was to be found on the first floor, where the majority of residents were sitting in the dining room, no staff supervision, and one was trying to rearrange furniture. I'm lucky she didn't fall and break something in the middle of the fire alarm. I finally found all of the staff, including the med nurse, down in the breakroom, looking at the toaster. Oy vey.

A few hours later, a resident came back from the hospital and I had to do all of the readmission assessments and paperwork, which I had barely gotten any training in, and at the same time, I had a resident who seemed to be getting sicker by the minute - very lethargic, congested, fever, etc., etc. The DON had happened to come in and I went up and said I needed help! She helped a bit with my patient who was declining (who is doing much better now), but no help with the readmission or anything else. I felt so swamped with paperwork that I just wanted to cry. The med nurse was only there until 1, so I was all by myself from 1-7, when all of this was going on. When the night nurse came on at 7, I was still doing paperwork and hadn't given any afternoon/early evening meds like I was supposed to, and I felt like a total failure. Granted, most of those meds were supplements, but I just didn't have the time. The next day the charge nurse said if it happens again, do the meds and forget about the paperwork, the meds are more important and the nurse coming in at 7 can't sign off on 4:00 meds. The DON also told me the next day to make sure there were "no holes in the med book" from the day before, so I went through and circled everything because I didn't give them. The state is due in any time, I guess, and I don't know if she wanted me to lie that I gave them and just sign them off or not - she said it again later - but I couldn't, in good conscience, sign off that I gave them when I didn't, so everything got circled. Luckily there was nothing super important that caused a problem by being missed at 4:00, because then I would have felt even worse.

So I went home Sunday night and crashed, and returned Monday for my 3-11, again as the only nurse in charge, and also responsible for meds and treatments. They had also gotten 2 admissions that day, so I also had to do 2 skin checks and document those, plus go through all the INRs that didn't even come back until about 7 pm and call and get new Coumadin orders, plus verify all the orders on the new admissions because the day shift didn't have the chance to, plus do all the meds and treatments for 33 patients that I'm still getting to know. I was there until 12:30 in the morning (I punched out at 12 because everyone has told me we are not supposed to do any overtime), but there was no way I could have left at 11. The night nurse was actually about 20 minutes late because she overslept, so I would have had to stay a bit anyway, but I sure had enough to do while I was waiting.

I am feeling so overwhelmed and don't know if it's just new nurse jitters, or LTC, or this facility in general. Having worked in a hospital where each nurse only has 5-6 patients, plus a secretary, plus a supervisor, and having oriented at the other facility that always has at least 3 nurses on the floor for 40 patients, I am kind of feeling like things might be unsafe, but having read a bunch of posts on here, I'm finding that it seems to be the norm at LTC facilities. I am already super stressed out that I've missed things, and what if I miss something and get written up and end up losing my license - I was so stressed out yesterday that when I got home from doing some errands, I half expected a call from work saying to not come back because maybe I had totally messed something up!! But that didn't happen. I'm trying to take some nice deep breaths on my few days off, but am already kind of dreading going back to work on Friday and trying to get through the weekend. Will it get better? Should I look for another job? I don't really want to look elsewhere yet because I do really like the residents already - they are all very sweet for the most part, and the staff has been really nice, but I personally feel that the job is too much for one nurse to handle, whether or not she/he is a new grad. Help!!

[richnurse828]

Welcome to the wonderful world of ltc. Try not to beat yourself up too much bc their expectations really are impossible. Basically the number one thing that the mgmt cares about from nurses is documentation. This is the only thing keeping them from getting sued, so whatever you do, make sure your documentation is good. Don't try to be perfect bc your just going to tear yourself up inside. The horrible truth is that there really is no one holding you accountable. You could easily get thru a shift by providing substandard care, not even passing your meds but as long as you can document you did everything you are required and didnt get any overtime you'd be fine. Hell, you'd probably get promoted. But I'm sure your not likely to do that. My point is that's how the systems set up. There's no incentive to provide good care in the for-profit ltc environment. The nurses that care too much are the ones that get reprimanded. So just do what's required as quickly as you can and go home. I suggest you find a facility that's a notforprofit bc there you will be properly trained and develop good habits and its much better for your soul too.

[VANurse2010]

You're not going to lose your license because you miss somebody's Os-Cal or didn't get to a treatment. It's just not going to happen. I call BS on the nurse who can't sign off 4PM meds - this is a common saying in LTC but it's just lazy non-use of critical thinking. You'll have these nurses not give the med at all rather than 3 hours late when it is most likely perfectly safe and acceptable to do so. The doctors don't schedule med times - just frequency - and it's up to nursing/pharmacy/facility policy to determine the exact times.

Now, don't get me wrong, if I were the 7PM nurse I'd be ticked if you left me with a bunch of 4PM meds, but they need to be a little more accommodating of the residents' needs.

Do NOT CHART OFF THE CLOCK. If you're working, then have to pay you and you could liable for looking at personal health information without being on the clock.

You could look for another job. Not all LTC are created equally, but most are more like the facility you describe than a good facility. You can always check the facility ratings on medicare.gov. You are far less likely to run into problems at four and five star facilities than at 2 star facilities.

[sunmaidliz]

The comments on this post really has helped me. I'm a new nurst on an LTC and my boss apparently is really picky about documentation. And RICHNURSE828 said it right that you can give sub-par care if everything is documented right. It's all CYA until you find your groove.