Novice ER Nurse needs help please - page 4

I would really appreciate some input. This is the first time I'm posting so please forgive me if I'm doing it wrong. I'm a novice nurse, graduated last year and entered a 10 month orientation program... Read More

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    Look, cb/vr, you two are both probably wonderful nurses, and believe me, this country needs more of you. My point is getting slowed/lost here in emotional dynamics, assumptions, lost semantics and I'm trying to help/build someone. Again, this is exactly why I got out of nursing management b/c of this kind of baggage getting in the way of real work. Since you both feel insulted, I apologize, I did not mean to insult you, certainly not your performance, which sounds exemplarily.

    You cannot simplify precepting into a few concepts. I've seen tens of thousands of dollars go into a person before giving up on them and they walk out of the building, poof, gone, cha-ching. Age dynamics have to be looked at in these types of situations. Don't you find it *interesting* that she states,

    Found out today that the other novice that had been with my preceptor is going through the same thing. I'm really thinking the preceptor was on a power trip. The other novice and I are going will both be with different preceptors.
    I'm using "interesting" as a neutral word here, not a negative word, so don't flame me. I'm trying to be investigative, study, build, understand and stretch nursing science, not tear down anyone or any age/gender/race/religion/orientation/whatever group. As you can read...I actually DISSED myself in my own posting. I couldn't precept any one at 23!

    When I was a nurse manager, I actually put *careful* thought into who I placed with whom. I took into account everything to make the best possible situation (success = $$$$$). There were some employees, not matter what, that I knew, I could never trust to precept anyone and a few, I could trust to precept my dog. I would like to think you both would love my dog.

    If you both worked with this preceptor, considering what just happened, what advice would you give her now?

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    I do agree with you that age is definitely a dynamic that needs to be considered wherever precepting is concerned. This goes both ways, however. Us younger people have things to learn, while many older people often seem to feel that they couldn't possibly learn anything from someone half their it's not always a good mix. I do understand that.

    My concern was with the fact that in that one particular post, you seemed to feel that young nurses are very unlikely to have critical thinking skills at all, let alone their ability to precept. "Show me a 23 y/o with "critical thinking" skills and I'll show you an anomaly." I was just trying to say that there are indeed a lot of excellent young nurses, who do have critical thinking skills.

    As far as this particular preceptor, she may continue to stay on her "power trip" ten years from may have nothing to do with age. But obviously, if she is going to continue precepting, she needs to somehow be brought to the realization that precepting's purpose is to help a new nurse succeed.....not to show them how little they know, or how much you know.

    Just my thoughts. I understand that precepting is a very touchy issue, believe me, I know...being on my side of things is not always easy either. Being barely 27 and having seniority in our department can be very intimidating. I look young for my age...I get asked probably at least once a day "are you even old enough to work here?" New employees or employees from other departments often think I'm a tech if I don't get a chance to introduce myself or they don't get to see my badge. It's just part of life though...age is and always will be a dynamic in things that we have to deal with, and you do exactly deal with it. That's just me.
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    Lunar, let us know how you are doing. It sounds like things are back on track and I wish you the best.

    It is interesting that age has become a discussion in regard to precepting. It has sparked a discussion with our precepting group in regard to who precepts a new nurse at any given place in their orientation.

    In reviewing some of the major published discussions about critical thinking it is clear that the underlying personal characteristics of an individual in regard to their maturity greatly affect their potential critical thinking ability. Look up Rosalinda Alfaro-LeFevre, Teaching Smart/Learning Easy, for one example of these critical thinking indicators. You can download a copy for your personal review of the critical thinking indicators (CTI) if you fill out an online form and agree to her terms of use. It actually takes an individual being fairly open, honest, inquisitive, willing to be wrong, realistic and about twenty or so other personal characteristics to have a good base to be a critical thinker.

    The other pieces that get added to the maturity factor are whether you can develop adequate interpersonal relationships and communication skills along with a knowledge base, the technical skills, and experience to make the thinking process pull together. It is complex piece of work to define critical thinking and how it happens, one that could take years of study. You can find work already done at many levels to shed light on the subject. Some of it is easier to understand, some of it appears to be a major philosophical study.

    Some works show that even after a year of nursing only about 25% of nurses have competent beginning critical thinking skills, enough to be considered safe in an independent thinking area. There is then a development period of experience, knowledge, skills and critical thinking before a nurse becomes an intuitive master of their craft. Whether or not you are a proponent of it, the Performance-Based Development System (PBDS), the creation of Dorothy del Bueno, suggests that nurses may take 5-10 years to develop the intuitive critical thinking skills needed in an independent setting. Even at that, the rate of achieving this intuitive performance in 5-10 years ranges from 65-85%, depending on the nurse and the specialty they are in.

    So where does that leave all of our fabulous young nurses who are no longer beginners but have that strong solid base, fine working critical thinking skills (maybe without that total intuitive piece just yet) and sense of mastery? We have a number of these as preceptors in our ED. We have sat down as a precepting team and these nurses have offered that they see themselves best serving the new orientee in the middle of their orientation. This just so happens to coincide with these nurse's development of their nursing practice. Our orientees need someone focused on the solid basics in the early and mid stages of their orientation and our great young nurses are poised to give it to them. The intuitive nurse may not be as effective in the more concrete stages of an orientation as the younger nurses. Our plan has been to give the orientees a much more seasoned, intuitive nurse the last half or third of their orientation to specifically work on their critical thinking skills.

    It is truly a preceptor master who can empathize and work effectively with a new hire through all stages of an orientation. We hope to work through several stages of development in an orientation and more than one nurse may have a key role in doing that for an orientee.
    Last edit by Footballnut on May 23, '10
  4. 0're a good cracker, well said. I don't like the ONE preceptor approach, I see it better as a 2-3 step, graduation, starting with skills, getting thru the motions, documentation, working with the technical/fabulous nurses. Then moving on to the seasoned nurses, polishing off to stages with policies, working on problem areas and weaknesses, building on a six month plan which is guided by those RNs who have a 401k the size of the ED annual budget. Sounds simple eh?

    My concern was with the fact that in that one particular post, you seemed to feel that young nurses are very unlikely to have critical thinking skills at all, let alone their ability to precept
    ...I was speaking in "general terms" and I still stand by that statement. You my friend ARE an anomaly! And, I hope your peers and nurse manager appreciate your performance. Keep it up, you will go far.

    Here's an example that I see almost everyday in our ED. We often have other RNs float down to the department sometime during the shift from the ICUs, during those high "flux" times and so we get to see a mix of RNs from other places. I can generally tell the age range of an RN by the way they act and perform while floating in the ED, the 20-30's vs 40-50's, etc. Sometimes, it is even how long they have been a nurse <2 years vs 2-5, not age per se (!) The amount of time spent away from the ED (smoking, generally), amount of time on FaceBook (don't get me started), amount of time spent at the desk vs at the bedside, amount of time on their personal cellphone (texting), and, this one, "I can't take an assignment!" We have actually sent RNs away, choosing, as a group to just "suck it up" and forgo the pain of putting up with with this person's "help" or attitude, as the case may be. Note I typed "group" here.

    So, you see what I'm getting at. This doesn't always hold true, I've seen many folks in their early 20's that just blew me away, very altruistic, professional, awe inspiring. But in "general terms" you won't find many other professions who use early 20 somethings to orient new recruits. Nursing, however, doesn't always have much of a choice.

    Again, I'm not trying to tear anyone down here because of their age group. Everyone's experience is totally different depending upon department, area, location, type and yes, age/gender of their situation. We have to recognize, appreciate and exploit our strengths/differences to better serve ourselves and our customers. I was trying to help someone understand why and/or how their experience was not going well. Without actually "being there" it's difficult to actually understand what's going on.
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    I feel for you!!! I am in a similar situation right now. New grad who went in really excited. My first month or so was great. All I heard was that I was doing really well, and that I could speed up a bit, but that would come with time. I was having to learn everything (where thngs were, who people where, how to use the computer system, which paper work to fill out for what, where to find it, how to fill it out, where to put it, where the charts were, what to put in them, what it all meant, how to read the Dr's writing, how to get the meds, tons of passwords, etc etc etc. Its a alot at once, but I felt I was learning and doing better everyday. I did run into the situation where my preceptor would tell me to do something, and I would do it (after all this is my boss for now). Then another nurse would question why are you justing sitting there charting or cleaning a room or whatever instead of xyz. The situation is each preceptor (nurse) has there own priorities. Some are into cleaniness, and want to wipe down the entire room between patient, some thing if you do more than change the linens your wasting your time. Some want to put the zofran and morphine in the same syringe, some think you should use seperate syringes. Some nurses feel you should chart in each room, and others that you should gather info and chart at the nurses station. Some of the nurses feel that every thing that pops up on the chart should be assessed, and others that only the body system involved. The problem is that if someone see you doing it your preceptors way and its not there way they think you are doing it wrong, and when you change preceptors, and do it your old preceptors way because thats the way you were are doing it wrong. After a month or so they changed my shift to a second preceptor (young 20 something) more interested in texting, and socializing. I went from doing really well to not being able to do anything right. What did I do wrong? I don't know she couldn't tell me speciifially just never said a good word. I really don't know how she would know she wasn't really with me very often, but off talking, texting or missing in action. Anyway, I went to my boss, and was told that I was being too defensive and should listen to this preceptor. Finally I was allowed to change, but they were not happy about it. I ended up with a bad rap. I have been working with a new preceptor, and its better, but I am on a plan, and if I dont' show them I can do it by the end of the month I am in trouble. I also feel there are a lot of double messages. For example as a new grade I do not know every generic med name vs. brand. Some nurses say that comes with time, others why don't you know. I also have a ton of meds that I have never given, and have to look up. I have never seen an xyz patient, or a xyz procedure. At the same time I was expected to pass a test where I was supposed to type free hand what these symptoms mean (diagnose). What I would do, what I would anticipate the Dr would order and do, what labs to check, what meds to give, and what the outcome would be. I didn't do well!!!! Honestly I do know how to access pt., to put on monitior, O2, vitals, IV, blood draw, etc etc. I do not always know exactly what the diagnosis is, what meds I would give, or labs I would order for those symptoms (I know basic like liver panel, etc). And if I don't know the whole pic then obviously I wouldn't know the outcome. I learn more everyday, but I am not sure why I would know this as a new graduate. I was taught nuring diagnosis in school, not medical ones. I also learned nursing interventions, not medical ones. The Er is all new, and a new way to look at things. I thought it would come with time, but I am not sure I will be given the time to learn.
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    Quote from RN-Cardiac
    Lack of Critical Thinking Skills is a term thrown at new nurses everyday, but often not defined. I agree with you in that part of your Critical Thinking Skills comes from time,.from trial and error and you just can't speed that up. I have seen many a new grad become frustrated with this term, feeling that they need specific details on what to change or improve on. The problem with that is that this term really means that you need to take all the details that you've learned over the years, lump them together and see the whole picture.

    We actually have a critical thinking skills lab in our preceptor-ship. We do exercises, often not even nursing related, to encourage you to think, ask the right questions and respond with the correct interventions.

    One of my favorites is the "Help me with my car" scenario. If I called you on the phone and said "Oh my gosh Lunar, I can't get my car started. Can you help me please?" What would you do? Many of the class gives the response "I know nothing about cars, you should call someone who does!" Not bad advice,..but do you really no "nothing" about cars? Don't we all drive a car everyday. Didn't we all have to pass a test to get a license?

    Lets see if we can get this car started. We start out by coming up with all the "obvious" reasons a car might not start....out of gas, dead battery, some of the more experienced people mention things like alternators and fuel pumps. We start with what we think is an easy fix and ask, "do you have gas in the car?",.."yes, I put $47 worth of gas in it yesterday and it drove fine then",...ok,.."well is it possible that someone stole you gas?",....."well, gas tank has a lid with a lock and it doesn't appear to have been tampered with",...ok then,...well probably not out of gas,.."Is the battery dead",...."how can I tell if the battery is dead?",...hhhmmm,.."how old is the battery?",....."I put a new battery in 6 months ago",...ok,..well it shouldn't be that,..."Is the battery attached to the car?",..."I pop the hood and yes it appears to be connected properly",......this goes on for over an hour with the class coming up with all different scenarios of why this car isn't starting.

    Then finally people start asking more detailed questions,..."What happens when you try to start the car? Does it make a strange noise? Does it try to start at all?", we continue to ask questions,..we realize that the key doesn't even turn in the ignition and that lo and behold,..I've grabbed my husbands set of keys!

    Now this process usually takes two hours of class time. What turns out to be a silly mistake,.easily fixed,.took 15 college graduates 2hrs to figure out! The point here is the process. Asking the right questions. Observing. Using our deductive reasoning and finding a solution.

    This thinking process is exactly what you as a nurse uses everyday to care for pts. Is every chest pain an MI? Of course not,...but you know how to figure it out, know what to do,.....start that line, draw those labs, get the EKG,..put the pt on O2 and a monitor,....from there you can start asking all the right questions,.....where is your pain,..what were you doing when the pain started, long have you had this pain,....etc

    I try to tell all my new grads to think ahead. Learn to anticipate what you need to do to help get the answers. A great way to do this is to listen when the doc examines the pt. Listen to what questions he/she asks,..what type of physical information does he obtain,.what labs seem most important? Look at those lab results. Learn why the first three pts are sent home with pepcid and the next one is rushed to the cath lab.

    Hang in there. Tell your boss that you are going to be more aware of not only what the doc orders for your pt,..but what info he expects from you and what info will be most useful in any given situation, and that you are going to try to be better at anticipating what needs to be done to speed up this whole process.

    Becoming a great nurse takes experience. Make the most of your time so that you get the best experience that you can.

    Best of luck to you!

    (wow,..sorry this was sooooo looong.. )
    Wow RN-Cardiac, thank you for that advice. I definitely will mention it to my preceptor if she can help me hone in on my critical thinking skills by asking me questions in various case scenarios.

    BrnEyedGirl likes this.
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    Thx for your input!!
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    Sorry Lunar I did not read the whole thread, but I read the OP.

    I've been in nursing since '87, and as a new grad I went home every day for at least the first year thanking God I hadn't killed anyone. So I've got to congratulate you on taking on an ER job and making it as far as you have. I'm not one of the nurses that thinks a new grad in the ER is impossible, some people are just built with ER in their blood, or OR, or PICU. (not me though)

    My first shift floating to the ER after being a nurse for 15 years ended in tears, I swore I'd never go back. I oriented on a PICU for about 2 months, and had to stop cause my brain just refused to handle any more. I couldn't look up a drug and walk over to the bedside and administer it because I couldn't retain the information. I put my stethoscope on a baby's chest and saw him have a run of vtach from the touch.

    I thought I'd never be able to handle any critical care job, that I was stupid or defective. I also got a new appreciation for the regular med/surg people that maintained a daily routine for people that were bedbound and sick. Denture scrubbing isn't glamorous, but getting all those yucky things done makes miles of difference to someone who is helpless and wonders if anyone cares about them. Will their nurse notice if they start breathing funny- well probably, because they noticed when they needed a hairwash.

    Fast forward a few years, I've floated to ER, ICU, and OB. I'm currently working the ER and am able to take the sickest patients that come to us. Yeah, I took a break when I was overwhelmed, but with experience I was able to achieve the goal. If you choose to soldier on you have my admiration, but if you decide to fall back and get a stronger foundation that is just as valid and responsible a decision.

    My point being that just because you didn't "make" the ER team doesn't make you a bad nurse. And it doesn't mean you won't succeed in a few years and be a more knowledgeable and flexible nurse than you imagined possible.

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