What do you do when you can't do it all?

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Specializes in Professional Development Specialist.

My unit is 1/2 sub acute/rehab and 1/2 ltc. There were previously 2 nurses for about 24 pts, which was manageable but still a little hectic considering the acuity of the pt load. We've had a TON of admissions in the last week and I now have 16 sub acute pts and my partner has 22 ltc now mixed with subacutes. It is INSANE. Nearly every pt has a wound of some sort that needs a dressing change, some that are very complex. Every pt on the floor has at least one area of skin that must be assessed every shift. I have wound vacs, dialysis, trachs, g tubes, the entire spectrum of patients on top of the confused pts who need to be redirected 1,000 times a day. On average I send 1 pt back to the hospital for worsening of their condition (chronic uti resulting in sepsis, end stage renal or heart disease, etc.) One patient generally dies an expected death.

In the last week my pt load has increased beyond my ability to complete everything. Nurses on my shift are responsible for taking phone orders, taking off orders, calling the MD to report lab results, setting follow up appointments and arranging transportation, restocking all supplies, answering the phone (no receptionist and the phone rings CONSTANTLY but only nurses can answer :uhoh3:) giving meds, all dressing changes, treatments of every kind not to mention the charting (holy cow the charting!) Plus as an RN I am responsible for every IV and antibiotic that needs to be hung on the unit and. Wednesday I stayed until 4:30pm (I get off at 2:30) and didn't finish, but could only stay until 3pm Thurs and Fri because if I don't pick up my kids the school gets annoyed :lol2:. At the suggestion of my mentor, I spoke with my unit manager (again) today and told her straight out I was leaving a lot of things not completed. There just isn't time in the day for it all! She suggested if we get 2 more pts they may hire another nurse. I gave her many suggestions such as someone to answer the phone and take off orders, etc. and she said she'd try to get us a charge nurse. While those things may or may not happen, the admissions keep coming.

Anyway, when I flat out CANNOT do what is expected of me, what should I do? I make sure my pts get their meds, are fully assessed, and call in the more critical values to get new orders. I also make sure I take off orders that are important. But skin assessments and dressing changes are totally lost. I have a wound vac that should have been changed yesterday. I needed to be trained on it since I've never even seen a wound vac unattached but no one was able the last 2 days. I don't even want to think about picc line dressing changes, etc on the other half of the unit! I feel like I'm leaving my pts and myself at risk. Finding a new job isn't an option, I'm a new grad and have a better chance of winning the lottery than finding a new job. Do I sign and circle treatments and make a note I was unable to complete them? Do I not sign? I'm at a loss here, please help. My facility is big on making sure we don't talk about or admit we are short staffed to families or pts so I can only imagine what they'd say if I charted I didn't do something due to not having time.. I haven't charted unless it's an exception in days either. No one has charted in days, we're all too busy!

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Specializes in multispecialty ICU, SICU including CV.

I don't work in LTC (hospital nurse) but this just sounds plain old unsafe. You need to get your damn manager off her ass and into a uniform and have her help you out, for one (yeah, like she would do that, right? I'm not really suggesting that you do that. This just makes me mad.)

This is why some LTCs have terrible reputations. What you just described is a recipe for bedsores and infections. If you don't have management support, I suggest you go over her head to her boss. If that goes nowhere, I would QUIT. Actually, I would QUIT NOW. You are risking your license if 1. You can't document the care you provided and 2. The environment is such that you can't provide ordered care.

I, also, would personally report this to whatever your state board is called that supervises care in LTC facilities (in the hospital it's JCAHO. I don't know if they do nursing homes or it is another credentialing body.) It is likely that this situation should be investigated and the facility should at a minimum be cited on any or all of the points you mentioned. If this kind of care continues, the facility should probably shut down. And, don't feel guilty about it for one second. You have first hand knowledge that these patients aren't getting the minimum level of care they need. Someone needs to be held responsible for that.

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Specializes in Tele, ICU, ED, Nurse Instructor,.

You must make time to chart. If you dont document, you didnt do the work. If you already unable to finish some of the work on the patients not charting can lead to lawsuits. The first question why you didnt chart? If you did the work it is not documented. It sounds like to me you need to some nursing insurance because if something happen you need to protect yourself. The facility is going to protect themselves. I am not trying to tell you what to do it is just a thought. I agree your manager needs to help but she has a choice to help or not. You need to think long and hard about how long are you going to put up with this nightmare.

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Haha, this is only funny because I was thinking the same thing you posted after I got off of work today, "What can you do when you can't do it all?" I hear you, you are preaching to the choir. I work in the ICU and I still feel the way you do (but I only have two patients and you have many more). Today, I wish I could have been split in two. I can't be. So, while I was with one of my patients, everone else had to wait (including the doctors, patient and phone since we did not have a secretary or an aide).

I loved it when my patient's daughter called me and was on hold for 15 minutes got upset with me because I did not run to the phone when she called (because the nurses are the only ones that can update families). However, I was in the room with her mother who could not breath, was completely fluid overloaded and headed on her way to intubation. I should have known that answering her call was a priority. What was I thinking? I got out late and missed my lunch. So, I filled out an overtime slip for my missed lunch and for the time I was late in hopes that maybe they will get tired of paying overtime and give us some more help.

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Wow, well it is 1:02 in the morning and here I am in the computer, I got off after 12 midnight. I can't sleep I am still running a thousand miles per hour. I have 27 patients, anyway, I don't want to preach to the choir.

As long as money, is the main factor, the nurses will be a function of the profit and loss. So they will maximize the patient/nurse ratio, and it is ridiculous. I worked as a tech partner, (CNA),in the ICU, nurses had a two to one ratio. They were happy as can be. LTC, I don't think it will ever change. Duonebs signed off without the machines being there. New treatments, when the duoderms are days old, as you look at the wound. Inhalers not given because unlike narcotics, they are not counted.

Mother Teresa said. "In this life we cannot do great things, only small things with great love." Well that makes one a good nurse, but not a good bureaucrat.

I thought I would share your pain, because I don't have the answer. I guess prioritize, be the best nurse you can be and hope at the end of the day, you were a good advocate. A good nurse. Complaining to the state, will only add to the work load, the state has their own interest in mind. When have you seen more nurses hired after the state was there. Anyway, good luck.

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Oh, Jennifer, RUN.

That is nothing more than unsafe, for patients and for you. We are 1/3 LTC vent pts, 1/3 ortho, 1/3 hospice. Better to have your license and have to look for a new job than put what you've worked so hard for at jeopardy! I've had 10 patients and I've spoken out, because I didn't feel pts got what they needed from me. Granted, i have a great DON that advocates for her staff fiercely. Sorry you're going thru this...

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At the suggestion of my mentor, I spoke with my unit manager (again) today and told her straight out I was leaving a lot of things not completed. There just isn't time in the day for it all! She suggested if we get 2 more pts they may hire another nurse. I gave her many suggestions such as someone to answer the phone and take off orders, etc. and she said she'd try to get us a charge nurse. While those things may or may not happen, the admissions keep coming.

I agree...tell the supervisor/unit manager/DON/ADON/Administrator to put on some scrubs, roll up their sleeves and hit the floor! The unit manager can take off orders, ansewer the phones, make appts etc. The DON can do those skin asessments, change that wound vac and do those dressing changes.Administrator can handle the admits...do the entire head to toe assessment,H&P, write the orders and verify them with the doc, order labs, talkwith the pt and family and even give em a cup of coffee!!! OR...the State can waltz in and start tagging. Maybe remove the facility accredidation for Medicare. Give the State a ring anonomously. These facilitites are the reason Medicare is getting bled dry and the center of our healthcare issues. If your a new grad..it is no place for you to be. Blow the whistle nurse...you cannot be fired, or treated unfairly for whistle blowing. Protect your patients.

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Specializes in Med-Surg, Intermed, Neuro, LTC, Psych.

What you describe is exactly why I RAN AWAY from long term care.

Although I'm sure there are some good LTC facilities out there, unfortunately some of them aren't. I worked for a 110-bed nursing home/sub-acute rehab facility owned by a major national healthcare corporation. Every day was exactly what you describe... I was responsible for 24-28 residents on a mixed LTC/sub acute rehab hall; the only other staff were 2 CNAs. I had to pass all the meds, do all the treatments/dressing. There were usually around 6 PEG tubes, 3 trachs w/prn suctioning, 4 hospice residents w/prns as frequent as q 30 mins, disoriented high falls residents, etc. Plus I was the only RN on the shift for the entire building, so I had to start IVs/hang IV meds for the entire building... and I got the title of "charge nurse" which meant I had to deal with resident family issues, staff call ins & finding replacements, talking of the phone to pharmacy, etc. And I had to chart, which I usually didn't even start until an hour after my shift ended.

We operated on 8 hour shifts and they were all busy. Things got signed off in MARs/TARs that never got done... not out of neglect, but just because of lack of time. It was INSANE what they expected a nurse to do with so many residents.

Anyway, I found another job as I could, put in my notice and left after working there only 4 months. My mom worked as a floor nurse for years in LTC and she said that's just how it goes. After 7 years, she got a position in management... otherwise she said she would have left LTC to work as a cashier if she had to.

LTC FACILITIES ARE OPERATED FOR PROFIT, and as long as they can get away with operating with bare-bones staffing, they will. Get out while you still can.

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Funny, I came onto allnurses today to vent about my new LTC job and I just happened to see this on the home page. I feel pretty much exactly the same way as everyone described. I just started this past week on a rehab unit mixed with some LTC patients and it has been absolutely insane. What makes it worse is that the nurses there have said it hasn't been "that bad" compared to what they've already dealt with. As a new grad with so much less knowledge and experience than them, how am I supposed to do my med pass, deal with pt complaints/needs/extra stuff, do the treatments, document everything, check/fax orders, etc etc....It all seems like way too much for me to handle. I am giving it a little more time since I am still orienting but this just does not seem like the job for me. I feel like completely different person. When I am not at work, I'm thinking about work, crying every night when I come home and being unable to sleep. When I am at work, I feel like a chicken with its head cut off.

Someone please tell me, will this get better with time? Or am I better off looking for something else?

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Specializes in Legal, Ortho, Rehab.

As long as facilities keep taking Medicaid/Medicare (guaranteed money), they will not change anything unless the government steps out and dare I say it...shut down Medicare/Medicaid. They (LTCs) would be forced to compete with one another, and have to improve staffing and care if they are to survive.

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Specializes in Gerontology, Med surg, Home Health.

nyteshade-your idea of 'shutting down Medicare and Medicaid' is absurd. Who is going to pay for all this care? And for whoever suggested the Administrator do admissions, body checks, and take off orders....not all administrators are nurses and only nurses can do those things. You can call the state all you want but in most states there are no regulations for staffing....my state says you must have 'sufficient staffing' to meet the needs of the patient. What is sufficient depends on many factors.

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Specializes in Med-Surg, Intermed, Neuro, LTC, Psych.
Funny, I came onto allnurses today to vent about my new LTC job and I just happened to see this on the home page. I feel pretty much exactly the same way as everyone described. I just started this past week on a rehab unit mixed with some LTC patients and it has been absolutely insane. What makes it worse is that the nurses there have said it hasn't been "that bad" compared to what they've already dealt with.

This sounds familiar too... I heard the same "not that bad" stuff from some nurses. IMO, these were probably the people that documented things that had never been done, etc. It always seemed funny to me too that when the state surveyors were there, it was mandatory for almost all the staff to be working, so that things could actually get done the way they were supposed to be. But the rest of the year they have half the staff struggling to do the same jobs.

And let me say that there are many dedicated, caring, professional nurses out there that work in LTC... I'm not trying to put down the whole profession. My mother has been a LTC nurse her entire nursing career. I'm just saying that the LTC industry as a whole needs to be revamped. LTC can put it on paper all day long how concerned they are about resident care and safety, but until they actually live up to those standards, what does it matter? How can anyone think 1 nurse to 28+ residents (most with cognitive dysfunction and physical mobility issues) could ever be safe? If a nurse had 28 patients in any other setting, it would not be tolerated.

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