Recent grad, orientation issues - advice request

[murphyle, BSN, RN]

Hello, everyone! I am a recently graduated RN (BSN) working in emergency and orienting to my first employed unit. I am struggling with a bit of difficulty in my orientation, and would appreciate any advice you might be able to give me.

The unit I'm in is outstanding, in a word; my hospital just opened its brand-new Emergency Center about a year ago, and it's probably the most beautiful and functional emergency facility I've ever been in. We have a paperless EMR/CPOE system, and we are plentifully stocked with Workstations on Wheels (WoWs) so we can chart in patient rooms as needed. Likewise the staff; 99.44% of the nurses, techs and unit employees and volunteers I've worked with have been exceptionally helpful, considerate and have gone out of their way to make sure that I'm becoming comfortable in the department and getting the experience I need, and our staff MDs will always stop to explain a point of care or listen to a nurse's concerns about a patient. This is reflected in our patient safety and patient satisfaction measures, which compared against other local emergency departments, present a fairly significant bragging point.

The difficulty is with my preceptor. I feel that P.'s style of practice is detrimental to patient safety; for example, on medications, P. actively discourages taking a print-off MAR in the room and outright refuses a WoW. On my very first day in the unit, P. was involved in one documented medication variance (admittedly a system failure; the staff MD failed to activate protocol orders for a particular therapy, and then the specialist MD blew out the door before writing orders, repeatedly failed to answer his pager, and then yelled at us for not reading his mind) and two near-misses r/t medication allergy and medication dosing. P. also appears to set very inconsistent priorities on nursing tasks. P. is happy to pull you off administering a slow IV push because the patient in room so-and-so is complaining of cold and needs a warm blanket RIGHT NOW THIS VERY SECOND, but we'll get a new admit to our team and P. won't go assess the patient or even look through the curtain for two or even three hours. This individual is also, quite honestly, the single most negative person I've ever met in my life. I have witnessed P. repeatedly being verbally inappropriate to department and hospital administration staff, and routinely snapping at fellow nurses, to say nothing of techs and other staff. P. will happily complain about anything from the weather to politics to the condition of the cafeteria line, and never has a good word for anyone. Even on the rare occasions when P. is laughing, it's sarcastic laughter, always at someone else's expense.

I recently worked with a different preceptor r/t scheduling changes, and the difference was night and day. We talked at length about the orientation process while we were at break, and I was very careful to qualify my statements and emphasize that I don't want to be seen as the prima donna or the know-it-all new grad. However, my primary preceptor's style is so at variance with the way I was taught to practice nursing, and the way our hospital expects patient care to be delivered, that I don't even know where to find common ground. I am also aware of the need to practice "cover your rear" nursing in the modern era, and frankly I don't want to be associated with this person when the inevitable serious error occurs. My secondary preceptor agreed, and told me to go up to Administration and have the situation documented immediately. However, I am not absolutely certain that I have enough experience in the unit or confirmation of events to "pull the trigger" on an action of that magnitude, and the absolute last thing I want is to start the discipline process on a fellow nurse and then find out that the situation isn't what it seems. In short, I am torn between being proactive and being precipitous.

I have a routine meeting scheduled with our unit's nurse educator first thing next week, as part of the general orientation monitoring process. The conversation will be documented. Should I say anything about my preceptor, and if so, how should I frame that discussion?

Thank you all in advance for your advice! :)

[expltcrn]

It sounds like by this time you've already had your meeting. I hope all went well. If there is still time to give you some advise, this is what I would say - having personally experienced the horrors you've had with not so good outcomes after speaking with the supervisor (I ended up resigning soon after, as I did not want to jeopardize my license, but I had more options because during that period of my transition, I already had about 14 years of nursing experience):

Focus on patient outcomes, and it sounds like you are with your reasoning. So, in essence, approach the issue from a patient safety standpoint. By all means, speak up about your concerns, but include the fact that you want nothing more than to put the patient's safety first. Explain that you personally feel that your own skills would be best honed, and that the outcome and success of your orientation program would be greatly impacted if you were given the opportunity to shadow someone who is a consistently safe practitioner (nurse). Perhaps even post it as a question to your supervisor/educator. Orientation programs are supposed to be dynamic and interactive, not dictated and one-dimensional, especially the on-the-job part. Perhaps take it to the next level by saying, "Put yourself in my shoes, what would you suggest?" and emphasize how much you love the unit, the job, the hospital, etc., and how much you want to succeed as a team member.

So, lots of luck to you. Regardless of the practice of "covering your rear", the other 2 thing to remember

1) "The only one who can protect your license (which you have worked long and hard to obtain) is you!"

2) For anything that you are a part of, will you be bullet-proof in the witness stand?

Food for thought. Congratulations on landing a job in the ER being a new grad (not the norm!).

[Lunah, MSN, RN]

There is nothing wrong in saying that your style of learning differs from your preceptor's style of teaching, and leaving it at that. They'll get it. I'm surprised that they let this person precept -- maybe they thought it would be some kind of good "therapy" for P., or they're giving P. enough rope to hang? Dunno, but you should request a different preceptor ASAP. Good luck!!

[sasha1224]

I would agree with LunahRN and state to the educator that your had a better connection(rapport) with the alternate preceptor. This may be enough to get to work with the preceptor who you click with better without enraging the first preceptor. If you have to work with this person, you might claim a schedule change was the reason. You don't necessarily have to disclose the reason you asked for a different preceptor. In the end, you have to advocate what will work best for you.

[murphyle, BSN, RN]

Thank you all for your advice! I will be asking the educator about switching preceptors. I still have to work out how I'm going to phrase it (as satisfying as it might be in fantasy, I can't just waltz in there and say "I think P. is a danger to patients, not to mention a jackass and borderline laterally violent, and I want away from this person before a patient gets killed" - ) but I think a change of preceptor will be the most beneficial step to take in this situation.

expltcrn: No, you got your advice in ahead of the meeting, and good advice too! :) My overriding concern here is patient safety, and if I were a little more secure in the position I'd go right to that point, but given how new I am to the department and the profession, I'm hesitant to come out swinging the patient-safety bat without a little more confirmation that this really is P.'s routine style of practice. (I get the impression from the rest of the department that P. is kind of a maverick on good days, but I'm also aware that as my preceptor P. can very easily get me fired. See also: new graduate, rarity of hire into ED.) I don't want to get into that kind of adversarial situation unless I absolutely have to. Yes, if it comes down to it my practice will stand in court and P.'s won't, but I'd basically forfeit my job, and I like where I work too much to see that happen.

Lunah: We have a total of six preceptors in the department; of those, three work on days, one afternoons and two midnights. (Out of the twelve-week orientation, I'm on days for my first six weeks, and then I transition to midnights for my remaining six, which will be my permanent assignment.) The day preceptors, P., Q. and R., go in straight rotation when assigning new orientees to preceptors, except R. has been out on medical leave for the past several weeks. Q. had the last orientee, so I was assigned to P. Just luck of the draw, I guess. If I ask to change, Q. will be my alternate preceptor until I make the shift switch, at which point I'll pick up either T. or U.

Sasha and Lunah: I thought about going that route too, but I was concerned it'd come off like I was whining or excessively thin-skinned. (See also: new graduate, cannibalism of.) The educator seems to be a pretty perceptive individual, though, so I might use "personality conflict" as the subtle approach, and bring up "prefer to work with a safer practitioner" if asked. Again, I just have to be very careful about how I say it - I perceive that there's a very fine line between "put your big-girl pants on and do what's best for the patient and yourself" and "make a fool of yourself and possibly poison the opportunity for anyone who might follow."

You guys have provided some great advice, and I thank you all. :yeah:I'll let you know how it goes next week.

[murphyle, BSN, RN]

Quick update: The educator allowed me to switch preceptors, and was actually the first to bring it up - she said to me "We believe in a self-motivated orientation process, so if you feel that there's an experience that you aren't getting or need more work on, or if there's something impeding you from succeeding here, all you ever have to do is let one of us know." I told her that while I respected P.'s tenure as a ED nurse, I felt that there was some personality and practice conflict between us and that I had much better rapport with Q., and she said "Say no more; I'll switch you to Q. right now, and we'll go to the admin office at break and get your shifts re-scheduled." She also indicated, in a somewhat roundabout fashion, that it wasn't the first time they'd had issues with P. precepting, and that they were working to correct the situation.

So far I'm two weeks into working with Q., and it's been an exponential improvement. We practice in a much safer manner, we time-manage much more effectively, and we have a constant ongoing dialogue about practice issues, orientation needs and learning the culture of the department. And if people were decent to me before, they're practically my best friends now. The only issue, predictably, is with P., and even that's not much: P. just doesn't speak to me. Small price to pay!

Again, thank you all for your advice and encouragement! :yeah::up:

[Lunah, MSN, RN]

Great! Glad you got that resolved -- I'll bet it was a huge relief! Thanks for updating us.