So, I have to be a bad nurse to be a good nurse?

roser13, ASN, RN · Aug 27, 2010

I don't think it's true to say that you have to be a bad nurse to meet your deadlines and get your work done.

You do, however, have to be at maximum efficiency. Speed and efficiency takes time and practice to learn. And probably more importantly to a new nurse, you do have to learn that what you were taught in nursing school doesn't necessarily work in the real world.

Some of the best nurses I know have evolved their practice over time to incorporate the fact that the real world of patients and nursing involves flexibility and being able to respond to challenges that nursing school never mentioned.

abooker · Aug 27, 2010

I feel your pain.

Could there be such a thing as a "good enough" nurse? Winnicott from developmental psych class theorized the "good enough" mother.

Good nurse, bad nurse is all-or-nothing thinking. Things appear in black and white categories, and if performance falls short of perfect, it feels like total failure. Passing meds on 40 residents absolutely cannot be done without rushing from start to finish. That is part of the job.

Are you taking breaks? My friends started dragging me off the hall for 15-minutes every morning, even though I didn't have time. This actually resulted in my finishing my med pass earlier, because I could think more clearly. (And the caffeine was a help, also.)

Assessment - Do you have everything you need before you begin? My NM was happy to buy my "neighborhood" a large blood pressure cuff when I let her know I was spending 15 minutes every morning playing hide and seek on our rehab unit looking for the one belonging to the facility.

Do you know where your residents are? I had to learn that on Tuesdays some of my people go out into the community in a van for activities. On Wednesdays and Fridays, the beauty shop is open. On Sunday mornings there is a church service. Before, I was all over the building looking for them.

The resident's rights of medication administration, can you honor those? Some facilities will avert their eyes if you pre-pop several med cups. At other places, this will get you fired. What are the "bad" nurses doing? Maybe something they are doing isn't completely naughty?

If there is an Employee Assistance Program offered by the workplace, maybe this would be helpful. It could allow you a place to vent, and they're already familiar with the environment where you work. And it's free.

eriksoln, BSN, RN · Aug 27, 2010

I always tell non-nurses that the specific challenge of nursing, what makes it uniquely stressful is what you are talking about:

When I was a teenager, I was a busboy. I was darn good at it. I enjoyed it very much. I know exactly what was important at the moment and what could wait. I could keep it to less than two dirty tables at a time during Sunday AM rush. That is with everyone leaving at once it seemed.

When it was busy, I simply did the same motions in a quicker manner. I wasted little to no motion.

Fast forward to being a nurse. Can't handle it the same way. People are not dishes willing to be thrown here and there as you rush through your duties. In fact, they will become more than a little resentful if they feel you are too rushed to treat them as #1. They like to take their time, milk it more than a little bit and force themselves into being your priority even when they are not.

When I bused tables, I never had to worry about if the dishes approved of how I was stacking them in the bus pan. I didn't give a second though to whether they felt they were being............treated like a part of a routine.

The time management skills of a nurse are different, you learn to rush without..........rushing. Its a difficult concept and its also very Zen'ish in nature. I can't give examples of how one nurse does it and another does not. There is no way to write a guide on how to do it. It just happens. Experience combined with a drive and desire to do better make it happen.

carolmaccas66, BSN, RN · Aug 27, 2010

eriksoln is right. People aren't dishes - it takes time to learn how to manage time - one of the most important jobs when being a nurse.

And no, you shouldn't be rushing meds just to please some management person who probably hasn't done meds in the new century yet! Also family members & patients come up to you and badger you to get meds done faster. I just explain the legal ramifications and if I do them fast I could make several mistakes, and/or kill someone. Sometimes you have to be harsh to stand up for your rights.

I did a shift at a LTC facility where I was, unbeknownst to me b4 I went there, the only RN on the floor. I had to do meds for about 50 patients and it was insanely busy. I had so many interruptions and rude, nasty patients and their families with all their complaints. I finished my meds safely (wasn't given any patient diagnoses either!), hardly had time for anything else and couldn't give a proper handover cos I hadn't been given one. I said I would not go back there - it was too awful for words. I finished late as well and wasn't paid for it.

I wouldn't work somewhere like that. You will hate it after a while, and I feel I was putting my license at risk. Remember if you make mistakes cos you are busy and rushed and hating every minute, no-one will defend you in court.

I would be looking for another position or maybe cut down your days if you can to try and stay sane. Maybe also tell the NM that you aren't coping and why.

This is a disastrous situation in my opinion. I would try my hardest to get out, b4 something really bad happens.

Finallydidit · Aug 27, 2010

I don't think its about good nurse/bad nurse, working hard/working smart. It is truely about time management and it will come, give youself 3-4 months though.

I work 3-11, 30 residents in 16 rooms (10 diabetics) -and I sort of break my shift up into time slots, and set goals within those time slots, and on a perfect night (HAHAHA) it works something like this.

3p-5p Report, count, stock, finger-sticks, (give meds with insulins to diabetics) and give meds to rooms 201-206. (these room consist of 6 of my 10 diabetics)So this point I usually have 16 of my 30 first med pass completed. (I then take a 10 minute break)

5-7 Finish med pass for remaining 7 rooms, (on a perfect night) I finish around 6:30-6:45. If so I will assist the CNAs with feeding.

7-8 Lunch or Charting (The other nurse on my unit and I switch lunch times)

I try and get my MC and alert charting completed at this time, call pharmacy, or return phone calls to family etc.

8-10 2nd complete 2nd med pass (This one is much smaller) and HS blood sugar coverage. 2 weekly skin assessments, and any treatments that are needed. (take another 10 minute break)

10-11 Finish any charting, (skin assessments) do any paperwork, fax Dr. orders, order meds, etc. Chart I&Os, BMs, Report to oncoming nurse, count narcs, clock out.

Now it doesn't always work-out perfect, but it does more often then not. I have found that setting the "goals" allows me to realize if I am getting way behind, or if I will have time to assist my CNAs a little more, or extra time to spend with a resident, or family member.

Good Luck to you

paacollins · Aug 27, 2010

I loved eriksoln's analogy. I really couldn't have put it better. I work in LTC and our hall nurses are so rushed it is not funny. They have 24 to 30 residents, many of whom are rehab patients and very needy because they are in pain, not used to being in a facility, confused, etc. We have tons of meds to pass, treatments to do, tons of charting, supervising of the CNAS; we answer the facility phone (no receptionist), handle questions from family members, chase down dementia patients who are trying to leave the facility, etc. There is no way you can get all your work done in the allotted 8 hours. We truly have 12 hours of work for an 8 hour slot. I know many of our nurses take short cuts and I hate it but you just can't get it all done. These aren't new nurses either. They are nurses with 20 years of experience who are doing it. Time management only works if you actually have the time you need to get it done. Sometimes you just CAN'T get it done in the time you have. It's really sad that our geriactric population gets the short end of the stick so often. I would love to have time to just talk to my residents some days because that is often what they need the most.

sistasoul · Aug 27, 2010

Trust me, the hospital setting is not any different. Too much to do in too little time. I hate the feeling that I am rushing in and out of patient rooms. It sends the wrong message to the patient. I love being a nurse when I am allowed to nurse. A bedside nurse's job is to be at the bedside. It is not behind a computer charting till their fingers fall off and the other various types of paperwork that must be done daily in triplicate.

I am late getting out almost every night. It is because I spend too much time at the bedside with my patients. I have been told that I need to get in and out of the patient's rooms (bedside) as fast as I can. To me this is not being a bedside nurse but a paper pusher.

guest2210 · Aug 27, 2010

with experience comes time management. you have to find what works for you.

i did a 4 hour shift in a nh through an agency. had never been there, didn't know patients or staff. got an admission, several calls from an md who thought his patient was the only one i had (35). only managed to stay over 30 minutes. i've also worked with nurses on 12 hour shifts who didn't finish their hs med pass until 1am-no emergencies, no excessive calls. just didn't know how to manage her time. :smokin:

cjcsoon2bnp, MSN, RN, NP · Aug 27, 2010

Please don't start cutting corners. Once you do it will be a slippery slope and you will never be able to come back from it. If the caseload is too overwhelming for you then talk to management about strategies to maximize your efficiency or seek other employment, for the sake of you (and your license) as well as your patients. Your a good nurse, don't let an unreasonable caseload turn you into someone who cuts corners in order to get the job done. I would suggest you use a journal to self-assess what you are doing everyday and how long it takes you to do it so that you can see what tasks are taking the most time and how your time can be better spent, this includes bathroom breaks and lunch breaks. For example:

0700: Arrive on unit

0710 - 0730: Taking report from previous nurse.

0730 - 0740: Bathroom break

0745 - 0800: Check AM Blood Sugars

0800: Begin AM Med. Pass

This is just an example. If you do this a few days you might see a pattern and it might be something you can work on or discuss with your manager and you could figure out the best way to help you get things done safely and on time. Please let us know how your doing.

!Chris :specs:

georgianurse89 · Aug 27, 2010

I am also a new nurse i graduated in June, started my job at the beginning of August at an LC facility.. I have never thought of the "journal to self-assess" that is a fantastic idea! I've already been doing that in my head but if it's written i can truly compare each shift. I have almost 50 pt. (2 gtubes, about 6 diabetics, ALL WOMEN [so UTI's and moods run rampant] In the short amount of time I've been nursing I've already learned how to maximize efficiency like during report make a note of all the supplies you need to stock for your shift and get it all in one trip so you prepared for the next 12 hours! then group pts together that you know are just "pill-takers" and the ones you know require attention and explanation and talking to. Things you'll pick up quickly. As for med pass it still takes me about 30-45 minutes longer than everyone else (we only pass at 9pm and 6am) but i know EVERYTHING is done by the book. so if Joint commission comes in or the executives of the organization comes in, all my ducks are in a row everytime. It's different to cut corners when you are going on a road trip but to me nursing is NO PLACE FOR SHORTCUTS! especially when you're dealing with fragile elderly people who sometimes can't stand up for themselves. THAT'S OUR JOB!

starletRN · Aug 30, 2010

I loved eriksoln's analogy. I really couldn't have put it better. I work in LTC and our hall nurses are so rushed it is not funny. They have 24 to 30 residents, many of whom are rehab patients and very needy because they are in pain, not used to being in a facility, confused, etc. We have tons of meds to pass, treatments to do, tons of charting, supervising of the CNAS; we answer the facility phone (no receptionist), handle questions from family members, chase down dementia patients who are trying to leave the facility, etc. There is no way you can get all your work done in the allotted 8 hours. We truly have 12 hours of work for an 8 hour slot. I know many of our nurses take short cuts and I hate it but you just can't get it all done. These aren't new nurses either. They are nurses with 20 years of experience who are doing it. Time management only works if you actually have the time you need to get it done. Sometimes you just CAN'T get it done in the time you have. It's really sad that our geriactric population gets the short end of the stick so often. I would love to have time to just talk to my residents some days because that is often what they need the most.

Exactly. I have been in LTC for 4 months and my DON told me that I needed to work on my time management. Like you said, you have to have the time to manage it. I work nights and I'm the only nurse with 35 residents. I spend 1 1/2 to 2 hours doing charting at the end of my shift because it takes a back seat to other things they want me to get done. And they still assume that residents sleep during night shift.

Anyway, my residents were more acute since they're transitioning from hospital to home. So I have now been moved to an "easier" section of our facility and they're bringing over a more experienced nurse to make sure everything gets done. I was getting it all done. Just not as quickly as they thought I could, I presume.