Unreasonable expectations?

[eggyweggy, MSN, RN]

I've been working the subacute rehab floor at a skilled nursing facility for almost a year now. I float between several different units and work, at most, two consecutive days on the same unit. I am responsible for all medications and treatments for up to 13 residents with one CNA on the unit with me. Management will occasionally step in and help with the more time-consuming treatments (like wound vacs or complex dressing changes), but this is not guaranteed. We do not have a HUC, so the majority of the orders are entered by nursing. We are still using paper charts and MARs, which is incredibly inefficient. I am required to do vital signs and daily charting for half of the residents on the unit during my shift. Here is a typical patient load:

1. s/p TKA with Type 2 DM, daily dressing change and PRN narcotics Q4H, which they ask for q3h. Has a CPM machine that nursing is responsible for setting up and taking down twice per shift. Morning med pass includes 20 (!!) different medications, one insulin injection and a nutritional supplement.

2. Hospice patient. Hit or miss with taking meds, history of frequent falls since in our facility.

3. Non-healing wound with wound vac. Type 2 DM with insulin ac. Min assist with ADLs, but has scheduled narcotics q4h and also has about 15 different meds during the morning med pass. Oh, and his wound vac alarms about ten times a shift, but usually corrects itself by the time I respond to the beeping.

4. s/p arm fracture. Chronic pain, on scheduled narcotics TID and asks for PRN narcotics q4h on the minute.

5. Dementia patient with schizophrenia dx. Has a stage 2 pressure wound that is finally healing. Requires 2A for transfers. Type 2 DM with QID accuchecks and oral meds. Morning med pass is about 12-15 pills, and this is after the MD d/c'd a few of her diabetic meds after she kept going hypoglycemic on them. On abx for pneumonia.

6. Ambulatory, independent patient on IV abx for a wound infection. Daily dressing change, plus he's diabetic with QID accuchecks and a boatload of insulin before every meal.

7. Bedbound patient with multiple large, bleeding wounds that require BID dressing changes. On supplemental O2, has a foley cath, but is remarkably low maintenance otherwise.

8. 95-year-old dementia patient with only four medications patiently waiting for a bed to open up in our long-term care unit.

9. Mostly independent cancer patient with mercifully few medications and treatments.

10. s/p CVA with hemiplegia. Requires 2A for all transfers. Requests PRN pain or nausea meds 1-2 times per shift. Has a G/J tube for nutrition and I have to turn off the tube feed and flush the thing twice during my shift. But I can't do it too close to a meal or the patient barfs.

11. Sepsis patient with IV abx plus fractured vertebrae from a fall. On the call light like crazy. Forgets that the call light was pressed most of the time. Requires frequent linen changes due to urinal spillage. Rarely gets out of bed and has a pressure ulcer.

12. Deconditioned patient with BLE weakness. Few medications, but quite anxious and experiencing stress due to being unable to smoke.

While I know most of these patients from my last shift a few days ago, I have to orient myself to the other half. I work the 6-2 shift and I spend the first hour getting report, organizing the med cart and gathering supplies, second-checking orders that haven't been done yet, putting away paperwork left by previous shifts and organizing my day. I generally start my AM med pass at 7:15/7:30, breakfast is at 8:30. Without fail, I get interrupted multiple times during my med pass to assist with transfers, give a quick report to the unit manager, answer questions from therapy or other staff, or answer the phone. I'm lucky if I can get my blood sugars and insulins done before breakfast trays are served. Once breakfast is out, I am required to stay in the dining area to supervise. I can sometimes get a few patients' meds done while they are in the dining area, but I'm constantly interrupted there as well. Breakfast ends at 9:15, then I'm usually scrambling to get the rest of my meds and vital signs done before 10 am.

I try to cluster my meds and treatments when I go into a patient's room and ascertain if they are going to need a PRN before I pull their pills for the med pass. If a patient has a scheduled IV or scheduled med (at a specific time) I do all of their meds at that time if possible. The combination of interruptions and passing meds from a cart that isn't "mine" makes for a very slow med pass. After I get through the beastly AM med pass, I try to take my 15-minute break and at least grab a snack and/or pee. Then I come back and get all of the treatments done.

If I have time after that, I will sit at the desk and enter vitals into the chart, return phone calls, and take care of other paperwork. This is also the time that everyone seems to have some sort of an issue, either a wound vac alarming, or a fecal impaction that I have to deal with, emesis, or a soiled bed that requires 2A to remake. While the CNA is taking their lunch break, I have to answer call lights and assist with toileting or other cares until they return. If I can squeeze in my lunch break before I have to start my lunch accuchecks and insulins, I will.

The noon med pass is usually a lot shorter, but I still have the same issue with constant interruptions, everyone's q4H PRN pain meds being due again, and being tied to the dining room for 45 minutes while the patients eat lunch. If I can, I do my daily nursing notes during that time, but it seems like every time I open a chart to start writing, someone needs something from me. I'm lucky if I can get one patient's charting done during lunch. By the time lunch is cleaned up and I've passed the last round of PRN meds I'll probably give on my shift, it's already 1:45pm and time for me to get my stuff together so that I can give report to the oncoming nurse. After I give report and we count the narcs, it's almost 2:30 and I still have 5 or 6 more notes to write, plus whatever other paperwork I couldn't get to between med passes (usually admissions paperwork, assessments, or orders).

So here's the rub: management has been on our backs for not completing assessments, getting consents, charting properly or catching orders that need clarifications or corrections. Management is also on our backs for staying late and racking up overtime. I can occasionally get out on time, but most days I am there for an additional 15-45 minutes past my shift end to complete my charting and other paperwork. If I get an admission during my shift, it's even worse because the paperwork for a new admit is so tedious. On days that the MD is in the building, the interruptions are even worse and then there are multiple new orders that have to be transcribed and second-checked.

I'm tired of being pressured to get out on time and simultaneously getting reprimanded when the little stuff isn't getting done. Yesterday, at my manager's insistence, I passed off multiple paperwork tasks (other than charting that was my responsibility) to the oncoming nurse. When I returned to work the same unit today, it wasn't done and there were additional tasks that were then passed on to me, which I ended up staying late to complete today.

I know that part of the issue is that I don't have a set unit that I work on each day, so I'm not as efficient as I would be if I were passing the same meds to the same people from the same cart every single time I show up to work. I'm not the only nurse working on subacute rehab who ends up staying overtime to get the job done -- even seasoned nurses who work the same units regularly are staying late more often than not.

I guess my question here is: does management has unreasonable expectations of nursing staff in terms of what can actually be accomplished in an 8-hour period? Honestly, I've been feeling a little overwhelmed by the acuity of the patients that have been coming our way lately, especially with 12-13 all to myself. Even if there is nothing unexpected that happens, it's tough to get the bare minimum done each day. Anything "extra" turns an almost manageable assignment into an impossible one. Some days I feel like I'm drowning, even though I've been in the job for nearly a year. I really like the population and rehab nursing but the subacute nurse-to-patient ratios and management's recent focus on the bottom line over quality of care is starting to wear me down.

Thanks for letting me vent, I feel a little better after another crazy day.

[jadelpn, LPN, EMT-B]

I would advocate for another CNA. Then they can go down the line and do turns and repos, FBS, and morning vitals. Then, while you are organizing your day, they can come to you with that information, and you can prepare meds accordingly.

I have not a clue how you would get anything done in an 8 hour shift with such complex wound care needs alone. If therapy is in with a patient, can they set up the machinery that would be needed for passive motion?

I would take some charting with me in the dining room if you can. Perhaps a desk can be set up in a corner for you to be able to see everyone, but still be able to chart?

It is a general theme that encompasses all kinds of nursing specialties that the expectation is to do a lot more with a lot less. Usually, the people who are mandating all of this have spent no time on the floor, are either not nurses or have not been in multiple years, so they do not have a clear understanding of the time it takes for patients with complex and multi-tiered needs.

Another thought process is to advocate for team nursing. If you had a treatment nurse, a medication nurse, and 2 CNA's, life would be golden. (or more rosy than at present). Throw in an admissions nurse who floats to help where needed, and you would hit paydirt. Easily, nurses can be hired for probably less than what they pay you all for OT.

But to answer your question--YES, management is asking for more, giving less, and we all need to buck up and be happy we have JOBS. (