RNjuice

Thanks so much for your detailed response! You make a great point about how a quick assessment can be done without taking away too much time from med pass / tx for existing patients. I also respect and appreciate the fact that you take full responsibility for the patients you admit, as in my brief time working in this setting, I have on several occasions been left to perform the initial assessment on new admissions from the previous shift as 1st shift tends to try and leave ASAP. It's not unusual for me, as you've stated, to stay an hour or more after to complete paperwork in these cases. As I've thought about it since posing the question, it's important to ensure that the patient is stable and establish an objective baseline for them as soon as they arrive. As a newly practicing nurse with little experience that graduated years ago, I'm having to reshape my thought processes and return to thinking like a nurse. Also having to redevelop my assessment skills to be as efficient and useful as possible. Continuing to work at it!

In the past year, I've worked in two radically different Long Term Care / Rehab settings. One thing the two facilities share in common, however, is that admissions tend to come in right before shift change, and the responsibility of who is to perform the various assessments becomes diluted / is otherwise unclear. Furthermore, I have found it to be challenging to find the time to fit in a timely, thorough admissions assessment in the midst of providing the necessary care for the patients already present. Does anyone have advice, suggestions, or perhaps something that has worked in your facility that ensures that neither new admissions nor existing patients are neglected when a new admission arrives?

Thanks, cin, for the response. It turns out you were right. I had to make the decision to resign immediately from the facility when I finally realized this. While two weeks is the professional standard, I also have a legal obligation not to accept assignments that aren't safe or reasonable. And if I'm not accepting any more assignments, then what I am doing? What's frightening to me is that this is my second nursing job where the nursing staff routinely falsifies the medical record to make it look they're doing things that they did not do. If the nurses would simply be honest about the fact that it isn't possible to adequately perform all of the tasks that were being asked of them, at least the corporate owners and nurse leadership wouldn't have plausible deniability and might be forced to take some sort of corrective action to help enable nurses to complete their work. Instead, it seems like much of nursing staff was content in lying in their charting to make it appear as though they were capable of completing the necessary tasks as ordered. I know this because during my orientation and training, those same nurses encouraged me to do so as well. As a result, corporate and nurse leadership get to claim that they were unaware of the problem, and the nurses who are being misleading will take the fall in the unlikely event that they are caught or they lie about the wrong thing and it causes significant harm. It seems like much of the nursing staff treats the job like low-risk, high-return gambling. Lie in the charting about things that it's extremely unlikely you'll ever be caught for, continue to keep a $60,000+/yr job. Maybe you get caught one day, but until then, you're still getting a decently sized regular paycheck. My only other major nursing job was at a state Psychiatric hospital where, once again, nurses were writing entirely fictional accounts about a patient's day because the patients were off the unit and the nurse charged with charting the events of their day was confined to the unit. Instead of bringing this conflict up with leadership and attempting to resolve it, nurses would simply falsify the medical record. Most days, it made no difference because unless someone died, it's highly unlikely anyone would read or question it anyway. It's frustrating for me in particular because every time I try to make my way into nursing, I find myself being pressured to participate in these criminal practices. Worse, I find that I seem to be the only one concerned, and am usually discouraged from speaking up or disregarded because of my lack of experience. Now I'm forced to ask ... is this the norm? Falsification of medical records? Aversion from fixing systems and acceptance of a status quo that fails our patients? With no job lined up, I'm in a precarious situation. But my responsibility to provide an acceptable level of care to my patients is more important than my ability to get paid a lot of money. I'll find something to do for money, even if it's minimum wage. It's why I keep expenses very low. Are there clinical/bedside nurse roles with employers who encourage fixing broken systems so that nurses are enabled to practice within the confines of the law? Are there places where nurses come together to fix situations like what I described rather than lying to avoid rocking the boat?

Before I go on, a disclaimer. As a novice nurse, it’s entirely possible and even likely that my problem lies in my own ability to manage time or tasks. I accept that, but I will also stand behind the effort and thought I put in to solving for those issues on a daily basis. I work as a Rehabilitative RN and am responsible for up to 15 patients per shift. I have found over the past 2 months of working here that the morning and afternoon med passes plus basic nursing skills (draining an abdominal Pleurx catheter, draining a Billie tube, changing colostomy bags, etc) take up the entire 8 hour shift, even when walking up and down the halls at full speed just shy of breaking into a sprint and when administering some medications earlier than scheduled when possible. That doesn’t include charting, which requires staying past the end of my shift to complete. That also doesn’t include admissions, which may add an extra 1.5-2+ hours of overtime to a shift. Finally, that doesn’t include weekly skin checks, which sometimes requires checking multiple patients on the same day and, to be done properly, requires time to be carved out of a day of doing med passes where barely enough time exists to begin with. I imagine some of you may be reading this and thinking “yeah, that’s nursing.” Some may even think “suck it up, if you can’t handle it, get out.” My concern is with the patients. If we have created a system where our patients have to compete with our own families for time (which is what overtime really means), our patients will eventually lose. Are we ok with this? Is this normal? If, for example, a facility can scrounge up the cash to make sure a nurse is present, why can it not scrounge up the cash to make sure enough nurses are present to provide patient care without being in a constant state of full-bore rushing around and having to stay hours late regularly to catch up? Is there an evidence based process for providing staffing based on patient care needs rather than census? If we push our nurses to do more than is possible, the ones who make a good faith effort to try are the ones you will lose to turnover. The ones who don’t do the work will be unaffected. How do we create a system that rewards nurses who make a good faith effort to care for their patients without making them trade between time with their family beyond their shift and providing adequate care to their patients and fulfilling their professional responsibilities? Does anyone have any positive experiences to share from their work places regarding this sort of thing?

Thanks, everyone, for continuing the discussion. The topic seems to have touched a nerve, which is why I thought to bring it up here in the first place. As a new nurse, I don't have the instinct, wisdom, or experience that some of my peers possess. Nevertheless, I am sometimes placed in the same situations as my peers and have no choice but to approach each situation from my own perspective - which is as a novice nurse who is dealing with everything for either the first time or the second time since reading about it in a book for perhaps a week some years ago in nursing school. There are some situations where I can simply study up on a patient's diagnoses on my own time to refresh my memory or to learn about what nursing considerations are appropriate, and I do that. But this is indeed a gray area. It is absolutely open for debate about what consent means when you have a patient who arguably does not possess the level of cognition necessary to make decisions regarding their own care. For example, we don't "allow" people to commit suicide. But I recently had a patient whose wife died. Grieving, the patient made a decision to stop taking his antibiotics until he became septic. I sent him away to the hospital, where I later learned that he was placed on hospice and passed away a week or two later. Prior to his being sent away, psych and the care team were both aware and involved. One of the responses referenced a law in the UK that helped to clarify what should be done in the event that a patient does not possess the cognitive ability to make decisions regarding their own care. As I practice in the United States, this legal mechanism does not apply in my situation. That said, given the unclear nature of my initial question as evidenced by the passionate and varied discussion which followed, it seems like a standard that we can all follow would be helpful so that the decision doesn't fall upon a nurse who is new to the practice and only has about 10 minutes to spend with that patient per day in an 8 hour shift to begin with. I don't mean this as a complaint, but simply that the cumulative knowledge of many experienced healthcare professionals deciding upon a standard of care that novices like myself can follow would benefit the patient more than it would benefit me. As I work in a Rehabilitative setting, many have suggested that I involve the patient's care team. Members of the care team have been notified, but aside from experimenting with changing the resident's medications and supplements, the specific issue of medication concealment or the resident's right to refuse have not been specifically addressed. As my facility has been in a transition process, there hasn't been a hierarchy of nurses to address the issue with, either. I will continue to pursue the issue as the situation evolves and, once again, I very much appreciate everyone taking the time to share their different perspectives on the issue. There are valid points on both sides of this argument, and by referring to it as an "ethical dilemma," I'm not trying to assign judgement upon anyone for making the decisions they thought were best in their particular cases. It's simply a reflection of the scrutiny with which I am subjecting myself as the individual who has to make this decision. Thanks again, everyone, for your input.

Thanks everyone for your sharing stories, your advice, your perspectives, and your expertise! This is exactly what I was looking for when I posted this and you did not disappoint. I've been reading your responses over the past few days and have been taking them into consideration. The Nurse Practitioner has already implemented some of your suggestions. She is now on liquid supplements ("Vanilla Shake") that she is happy to take and that will help with healing her many wounds. The Care Team and family are aware of the situation and we are all trying different methods to get this resident to be compliant with medications. I always plan to spend extra time with her during her med pass and bring vanilla pudding in addition to her supplements and some of the most important medications. I've begun to have success getting her to agree to take up to 4 at a time, and she has even begun to spontaneously request certain ones. I find that she is more likely to agree to take her medicine if I sit at the bedside and feed her pudding, "shakes," or a cookie. It takes an extra 5-10 minutes of my very full day, but it's worth it. I've been sharing my tricks with my colleagues in report and have been documenting my actions thoroughly. I'm hopeful that the situation will continue to improve. In talking to the resident, she often expresses a need or desire to have control in many situations unrelated to her medications. She talks about past events where family members pressured her to take medicine, or to go to churches she didn't want to go to, among other things. Although she is frequently unaware of where she is, what year it is, or even what she is physically capable of (she'll often request that we put things where she can get them, saying that she'll do things herself - at this stage in her Parkinson's, only an extremely limited ability to move her arms and neck remain, with no finger control), she seems to remember and be entirely fixated on events where she did not have control. Which makes a lot of sense given the circumstances, honestly. Thanks again, everyone, for taking the time reply.

I’m a new nurse working in rehabilitation and I have a resident with Parkinson’s and dementia. The resident also has wounds and has lost all mobility except in their arms (barely). She takes her Parkinson’s medicine (Sinemet & Neupro patch) without issue, but consistently refuses all other meds (muscle relaxer, steroid, APAP, nerve pain med, and vitamins for supplementation and wound healing - a total of 8 pills every morning), stating that she takes too many pills (often arguing that we try to give her more than 8 at a time). She is not completely oriented to time/place, but she is always consistent regarding her medications. Her family has tried to pressure me to administer her medicine without being forth-rite about it. For example, administering the meds in pudding without mentioning that there are pills in the pudding. The family wasn’t pleased that myself and the other staff comply with her refusals. It seems wrong to ever be misleading to a patient or resident about the care that they are receiving and we know that our patients have a right to refuse. But what do you do when they potentially have altered mental status and their noncompliance puts their recovery in danger? (I’ve notified the provider already.) I’d be interested in hearing stories and advice from other nurses.

Thanks for the tips, everyone. I knew from the beginning that being a new nurse would be a serious challenge. It’s further complicated by the fact that I spent a number of years not working as a nurse after graduating, so my knowledge base and skills are very rusty. One of the really scary parts is that the facility I work for is struggling to find nurses to staff it. The Director Nursing and the Administrator have both left and not yet been replaced, and there isn’t usually a unit supervisor working on my shift, so I feel very alone, especially when the wound treatment nurse is pulled to work a cart because of a call out and I have to do dressing changes in addition to my current responsibilities. It’s overwhelming. But what is the most stressful is the fact that I am inexperienced and out of practice. There is so much I don’t know, so many things I am not sure about how to handle. I have signed up for an RN Refresher course to try and restore some of that knowledge. But it makes me wish mentorship was more feasible. An experienced nurse to help me deal with these experiences so I can begin to sharpen my skills and build a knowledge base. They gave me a 4 weeks training period, but most of that was spent shadowing someone on relatively routine days. Only the last week or so was spent with another nurse available to help answer questions and concerns as I worked independently. For now, I just keep pushing forward. I made a commitment to myself to work here for a certain time frame no matter what to develop my skills. So I’ll keep going with it!

It’s ok to be frustrated that your spouse doesn’t earn as much as you, especially if they’re not covering their own expenses that might be considered excessive or unnecessary. That said, I disagree with the rationale that having equal incomes is somehow standard or normal and using that the justify your stance. You don’t need that to justify your stance. Your feelings are your feelings and when it comes to your relationship with your spouse, they matter based on that alone. I believe a major part of relationships is accepting the people we love or to whom we have made a commitment such as marriage. After all, if we love them, then we would want them to happy and live their lives in the way that makes them happiest. And if we are truly committed, then we accept their decisions anyway, even if we disagree. Barring abusive situations, I think this mentality can help get through this sort of thing. If you are struggling but your spouse doesn’t seem concerned, then that could mean that your standards aren’t being met but your spouse’s are. You can be happy that your spouse is satisfied and you can make an effort on your own to meet whatever your own financial standards may be rather than demanding someone else to live in a way that makes them unhappy so that you can be happier. Additional education or a job change could also get you more money in the same way that it could get your spouse more money, and that would mean that you’re pursuing what matters to you and your spouse is doing what matters to them, which is a win win. Anyway, I wish you the best of luck in resolving this issue with your spouse. Finances are tricky and some people never figure them out. I supported my family (my autistic son and his mother) as the only income on $10 an hour with no help for many years, including through nursing school. In the process, I had zero debt and while it wasn’t luxurious, it was comfortable and it was as happy as it could be.

Thanks! I use my own "brain sheet" that I've come up with that keeps all of the information that I've determined over the course of the past 4 weeks that I need to know to get through a shift. It includes: Patient Appointment scheduleAM Med Notes & checklistPM Med Notes & checklistProgress Notes checklistNurse Aide Assignment & tasksAlerts - for things that need to be followed up on and notesOrder Confirmation checklistLab and Radiology Results requiring reviewI do struggle with following what some of the more experienced nurses do, however. I've witnessed practices such as: Documenting medication administration done or expected to be done by Nurse Aides (often prescription creams, which is outside of their scope of practice in this state)Administering medications before their scheduled time (between 2 and 3 hours early) and documenting administration later within the administration windowLying to residents and resident family members to cover for mistakesI want to follow in the foot steps of the experienced staff as you suggest, but I am deeply concerned about violating state / federal law and practicing or having others practice outside of their scope. I suppose my next question should be: is this sort of experience normal, or have I found myself at a facility that is engaged in unusual questionable practices?

This is so true, but the cycle is almost daily for me. I am also a new RN in an LTC setting. It goes one of two ways: I have an excellent day without major crises or I have what I call "learning experience" days where I identify 3+ areas where I could have handled things better. Every day is a blank slate, an opportunity to build upon what I have learned, and a chance to try new techniques for managing time and to experience and become more comfortable with patient care. Thankfully, no one has hounded me for being too slow, although I am slower than some of the other more experienced nurses, which is to be expected. They didn't have me start working on my own until 3 weeks in. Prior to that, I was shadowing other nurses and assisting. I'm now in my 5th week and have been working independently for a while. There are good days and bad days. I am open for advice though, and I've started my own thread for that.

Hi! I'm an inexperienced RN working in a Rehabilitation / Long Term Care setting. I'm looking for advice from experienced nurses because I haven't been working as a nurse for a long time, I graduated years ago, and I only briefly worked as a nurse around the time I graduated. I have already signed up for an RN refresher course and I'm trying to redevelop the skills I was taught in nursing school. Is there anything anyone would be willing to share that could help me to provide the best care to my patients? I am responsible for roughly 15 patients at a time. My responsibilities include medication administration, assessment of new admissions, and handling emergent issues / changes in condition. Although LPN's typically work in the role I currently fill, my lack of experience, the facility's strong desire to hire RN's, and a staffing shortage have placed me into this role. I find that the LPN's and Nurse Aide's are far more experienced and comfortable in their work than I am at this point, naturally, but everyone expects me to more capable because of those two letters: RN. And to think I spent years thinking no one thought my license was valuable because I'm an ADN and not a BSN! It turns out that in this setting, people think it means something even without that Bachelor's Degree. A true shock after my very unsuccessful job search after graduation. Anyway, any advice? (Besides "Don't work in Long Term Care" - I'm determined to give this job a minimum 6 months before I search for alternatives. I need experience and my old profession is being automated away so I can't go back to it.)