Do I take too long to learn new skills?

Flatlander · Nov 10, 2014

Thank you for your honesty in this post. As another new nurse I will be very interested in hearing how others feel about on-the-job learning in a fast-paced, high-risk environment.

Off the top of my head: I wonder if there are better methods for becoming proficient with these things, rather than the typical on-floor learning methods.

I think I've read that some hospitals are requiring the use of step-by step checklists when performing procedures, for the very reason that remembering each required step in the proper order can be difficult and contribute to preventable errors. This seems self-evident, given the fact that some procedures are performed infrequently! I'd like to know what others have heard/experienced about this.

I've also heard that many nurses have difficulty with IV and catheter insertions. Why not have phlebotomy and catheter training available until the nurse can feel confident and not inflict unnecessary pain on patients? Also have options available for people with hard to locate veins and difficult to stick. (I've heard there are tools and tricks available, that not everyone might know about or have available consistently...?)

iPink, BSN, RN · Nov 10, 2014

When I was a GN, I started on a high paced, stressful, critical care floor. Like you OP, I'm a career changer, and to make it even more difficult for me, it was several months before I actually landed my job so things weren't that fresh in my mind.

There were practices I did to make sure I succeeded on the unit. One, I wrote everything down in my pocket-sized notebook that included writing step-by-step of procedures. So, if my preceptor did a procedure I just stood there and watched and helped pass her things when needed. After we left the room, I immediately took out my notebook and wrote down the steps in the nick of time before it left my brain. That is why we nurses call our nursing notes, our "brain sheet." If we don't write it down, don't ask us about it.

I also went home and reviewed YouTube videos to help give me the visual I needed to retain. I looked at NG tube placements, inserting a catheter, placing a new IV, and so on. Before doing a procedure, I would reheorifice the steps to my preceptor. The first time I was drawing blood, my preceptor chatting with the patient for distraction purposes while I nervously obtained the blood. I'm now a pro that I usually chat with the patient while getting it.

This is your license we are talking about and you are new, you should care less if anybody finds it funny that you have a cheat sheet. On my unit, many of the experienced nurses carried around binders. I asked one what was in there, and in it I found blood transfusion protocols, old nursing notes with complicated cases, common meds, many unit protocols, important phone numbers, etc. It was full of information to help them succeed.

After a few months, I didn't need my little notebook but it was available to me in my locker in case I needed to refer back to it. I have since transferred to another unit and specialty and have my own little notebook and binder full of useful information.

Hang in there. You're skills will improve over time with practice and patience.

caliotter3 · Nov 10, 2014

I used a cheat sheet when after only one year experience I obtained a job as the only nurse on the night shift. My supervisor from the old job helped me make out 3X5 cards for each "emergency" or "stressful" situation I might encounter. I only recall looking at my cards one time, it just calmed me knowing they were in my pocket. My supervisor did not make fun of me for my idea, and no one at the new job made fun of me either.

I also suggest use of a notebook. And if at all possible, try to get tasked to do each of these skills when they come up on your floor so you can get maximum practice. Make a deal where you do X for Y nurse, and Y nurse does Z for you so there is some kind of task equality. IV skills can be honed by working on the IV team for a certain length of time. Nobody can criticize you if you ask for more experience. Be sure to document when you ask and when you actually do this extra practice just in case you are pinged on your evaluation. You should be able to mention your attempts at self improvement. Good luck.

Ruby Vee, BSN · Nov 12, 2014

Background: new nurse, graduated in May, started in July. Career change after a very difficult job loss in a profession I loved (teaching). No hospital experience prior to nursing school. Spent 3 months on orientation, 1 month off then switched units so I'm on orientation again. Population of new unit is generally higher acuity and more specialized (cancer pts).
I'm a reasonably smart person I think and I *feel* like I can't be the only one who couldn't develop the fine motor skills and coordination to do some of these procedures by doing them just once... but lately on my unit that is the way I'm beginning to feel...

You don't say why you changed units one month after you got off orientation. Going to a generally higher acuity unit probably was not a smart idea so soon into your nursing career. You would have been better served staying at your original job, learned it inside and out and THEN transferred to a unit with higher acuity. Given that that particular ship has already sailed, what can you do NOW?

First, develop a thick skin and keep your ego out of it. Keep your feelings out of it. It's not about how you feel, it's about the patient, the skills and YOUR learning, not anyone else's.

Second, be prepared to study at home. It sounds as though you're already doing that, and that's great. I had a lot of difficulty with stopcocks when I was brand new, and took a couple home to play with. One of my orientees couldn't master the art of opening a crile, so I sent one home with her to practice with. Whatever you need . . . as long as you're not walking off with the entire contents of your unit's supply room.

Print off the most common procedures you use and know them backward and forward. I sent one of my clin tech students home with a central line dressing kit and the procedure, and she practiced until she got it down. If you have access to a skills lab or a sim lab, practice there.

Sometimes another preceptor can teach you the same material in a slightly different way that just makes it click for you. If someone other than your patient needs an NG tube or whatever, ask that patient's nurse if they'll let you try and walk you through the process. I'm not suggesting you ask to change preceptors entirely -- that usually blows back on the orientee in some form. But check out someone else's teaching style on something you're having particular difficulty with. Your preceptor might even suggest this herself. I have trouble teaching pacer threshold checks, for all that I'm sure I understand the topic thoroughly. Edmund teaches my orientees the pacer checks (if they can't pick it up from me) and I teach his orientees how to put a HeartMate on battery power or troubleshoot the alarms.

Be patient with yourself and give yourself time. When you changed units, they probably expected an experienced nurse, and you aren't one. Changing units reset your learning curve and you had to start all over again. Don't change units again until you've put in at least two years on this one and have become competent. Good luck.

SubSippi · Nov 12, 2014

I agree with all of the advice you've received so far!

I'd also like to remind you that while you may be having trouble with some of these skills right now, not a single one of these things is difficult enough that you won't get the hang of it if you keep practicing.

Take Ruby's suggestion of getting help from different nurses. Not only will you get to see how other people do things, you'll also get more exposure than if you were only doing these skills on your patients.

People will be more understanding of you having a hard time with IV starts and dropping NG tubes, because we all have off days from time to time, and have to ask coworkers for help. But changing a central line dressing shouldn't be an issue, make it a priority to get that right.

Good luck!

HouTx, BSN, MSN, EdD · Nov 12, 2014

Agree with PPs - skill development takes time & energy. One of the downsides of having a very experienced preceptor is that they may not have a very good recollection of what it felt like to be a new nurse, so they aren't as patient.

The examples you provided in your OP are all 'psychomotor', so you need to figure out a way to physically practice the skill in order to become more adept. Have you talked to your clinical educator? s/he may be able to hook you up with some time in a skills-lab setting so you can practice.

lorichka6 · Nov 13, 2014

Thanks for the tips everyone!

A few things: I left out details to remain somewhat anonymous. The reason I changed floors is a bit complicated. Really it was a lateral move - the unit just has a different population that makes it a little higher acuity. But it is besides the point - wasn't really by choice but had to be done for staffing reasons (and the new unit knew they were getting a recent grad).

HouTx I totally agree with you - these are muscle memory skills I'm talking about. I'm was a competitive dancer - I vividly remember having to think about every.single.step - now I don't even realize my legs are moving beneath me - they just go :) I suspect that some of the same type of learning is involved here. You just get a feel for things...

TeflonNurse · Nov 21, 2014

You are not alone in feeling this way. I too have to have hands-on experience to truly 'get' things. Oddly enough it's not the hands-on stuff holding me back and causing problems right now, it's the stupid freaking computer system we use. There are so many little ways you can get written up if you don't enter something just right. So many steps just to do one little thing.

Like others said, volunteer for doing procedures and keep doing your checklists. Eventually you probably won't need them anymore and in the meantime you can be sure that you're doing everything per protocol.

Graduatenurse14 · Nov 21, 2014

This tread has helped as I am just starting a new job on Monday and have to do skills several times without feeling like the eyes watching me aren't being too critical and forgetting what learning a new skill is like.