Does anyone else feel as if they are barely treading water? - page 2
Whew, graduated in May...started on a busy med-surg floor end of June. I knew the first 6 months to a year would be hard...but I feel like I am about to go under at any moment. I run around like a... Read More
Aug 22, '06Quote from Lisky90:yeahthat:My preceptor has taught me a ton...but as I run around like a lunatic...she runs around behind me saying "did you do this???" "did you do that???" and telling me that I really can't get behind...and that once I'm on my own that I'll have 5 or 6 pts...and that I really need to chart as I go.
I can't tell you how comforting it is to know that it's not just ME that's getting this kind of vibe - not that all this newbie nurse stuff is comforting, but I don't feel so alone in the world now.
Don't you wish we could fastforward through the first year and already KNOW where all the supplies are, how the paperwork is supposed to be done, the basic skills are down and have some type of routine figured out.
I've always had a pretty decent self-esteem and done ok - but more often than not, I've come home feeling rotten about myself and my abilities. What was I thinking?!?!
I just have to keep reading all the posts reflecting at the end of the first year and know that it does get better eventually. 8 months from now we'll all look back...blah blah blah.
Aug 22, '06Quote from Lisky90that's insane! more than 4 trached pts in an acute care facility??MEEEEE!!! Chicken with my head cut off is the perfect description. I spend the day trying to remember sooooooo much...that half the time I don't even hear people talking to me...or that if what they are saying is not more important than what is already up in my brain, it just doesn't register. I am up to 4 pts...all on vents...one with funky cardiac rhythms, one with no urine output, a BS of 49, whose tubefeed I held due to 110cc of residual and no BMX2 days, the third had a fever and was pulling on his trach...and the fourth with neuro issues and is unresponsive. My preceptor has taught me a ton...but as I run around like a lunatic...she runs around behind me saying "did you do this???" "did you do that???" and telling me that I really can't get behind...and that once I'm on my own that I'll have 5 or 6 pts...and that I really need to chart as I go. While I completely agree with her on the charting, and I really appreciate her keeping such close tabs on me, I also feel like this assignment is unrealistic. I have been an RN for 5 weeks!!! There are experienced nurses that float to this unit and sink...swearing for 12 hours straight about how ridiculous a 4pt assignment is with pts at these acuity levels. I feel like it is crazy to have assignments such as this...but that is the norm in this unit. Just when I think "Wow...I can't believe I'm handling this" for the maybe 5 seconds that that occurs throughout the day...my preceptor is telling me what I forgot. And then after working for 12, 13, 14 hours a day...I spend my days off obsessing over what I should've/could've done different. I CAN'T WAIT to have my nursing legs under me!!!
call joint commission honey. to be frank, that's un acceptable.
ask your nm if taking more than 4 trachs is the norm. if she replies yes, tell her you may have to reconsider your future there.
NEW NURSES: IT'S LIKE THE OLD SAYING
"JUST SAY NO!"
if you continue to put up with these kind of assignments ,they will continue to give them to you and all the nurses who follow in your footsteps for years to come.
Aug 26, '06Thanks for all of your responses. I feel better knowing I am not alone. I appreciate the advice about using different timeline sheets to organize my day. However, with report done at 7:15 and patients needing insulin and meds by 7:30-8:00, I hit the floor running. There is no time to sit down and fill out such a sheet! We can not even have anything to drink at the nurses station, we have to go to the breakroom...which is on the opposite side. So, I also feel dehydrated when I get home. Plus, I just found out I am expecting.......I start nights next week.......hopefully things will calm a bit!
Aug 26, '06Quote from TXNurseBSNFirst off, Congrats on your pregnancy!Thanks for all of your responses. I feel better knowing I am not alone. I appreciate the advice about using different timeline sheets to organize my day. However, with report done at 7:15 and patients needing insulin and meds by 7:30-8:00, I hit the floor running. There is no time to sit down and fill out such a sheet! We can not even have anything to drink at the nurses station, we have to go to the breakroom...which is on the opposite side. So, I also feel dehydrated when I get home. Plus, I just found out I am expecting.......I start nights next week.......hopefully things will calm a bit!
Work on and print off your sheet at home. Then you fill it in during report. I even have squares on the back of my sheet for each hour, with the things I normally do already printed in them.
Aug 26, '06http://allnurses.com/forums/f224/one-year-175053.html
Aug 26, '06I've posted this before:
Quote from ZASHAGALKALook at the 'first year in nursing' forum. I think this is, indeed, a common sentiment. It's a reality check, eh? But, it's also a gut check.
Some environments are better than others, but there WILL be a push for you to time manage 5-6 pts instead of just 2. And that IS a learning curve, for all new grads.
Don't freak because you aren't 'in your comfort zone'. You're not supposed to stay within the 'comfort zone' you learned in school. The way to expand that zone is by learning to push and exceed your own limits. Worry more about being in a 'danger' zone. Work on knowing your limitations and balancing against working to expand your comfort zones without being dangerous.
If you feel you're being dangerous, set limits with those pushing you along. But, don't presume that you can set those limits to the same comfort zones you learned in school.
I'm fond of saying that arms you with the skills and tools to learn to be a nurse. OJT is what actually teaches you how to BE a nurse.
This is some advice I've given in the past for new nurses (long):
Until you know your way around practical pharmaceuticals, never give more than two of ANYTHING: vials, pills, etc. without double checking w/ a more experienced nurse.
Some of the biggest med errors in new nurses that I have encountered had something to do with "I didn't know 3 of them were too many". And let's face it, doctor's aren't known for clear handwriting and intent with their orders. . .
(There used to be a chemo med that required 10 pills per dose. After the FDA approved it, the off-label use required a much higher dose. There are times when 4 or 5 or 10 pills IS the right dose. But, you're better off being able to say, "I checked the dose with the charge nurse.")
At the end of a shift, decompress the shift before you leave. Spend 10 minutes going over everything you did and didn't do. Critique how you 'time managed' with the goal of learning from what you did right - and what you did wrong.
Then, give a follow-up report if needed (so you don't have to call back) and THEN, let it go.
Nursing can be so stressful you HAVE TO LEARN when to leave work at work.
More than anything else you learn, learn to chart as you go along. Consider having to 'stay and chart' to be a time management failure that you have to work on improving.
Too many times, you have 10 things to do at any given time, and that will completely take over your shift. Charting must be a higher priority item in that list.
Besides, I find that, by taking 'time outs' to chart, I can get a better handle on the chaos. Humans work better when they can take a few minutes and decompress and reanalyze their situations. A few minutes here and there charting does JUST THAT FOR YOU.
If you want to learn to 'work smarter, not harder', then learn to chart as you go. DECIDE that 10 minutes of every hour is 'charting' time and ONLY pain meds and emergencies can invade in that sacred time slot.
Remember: you don't HAVE to chart EVERY assessment in one sitting. Break it out, take it one bite at a time.
Find an older nurse or two you trust and enlist them to be a 'mentor'. Not a 'preceptor', but someone you can turn to to help you analyze a situation. Someone you trust there is no 'stupid' question you can't ask.
Respect your contribution. You can only work so hard. Work diligently and learn and be proud of what you are doing.
All of us have situations that overwhelm us. Just don't let those situations overwhelm the value YOU place on your efforts.
Don't get so caught up in your own routine that you can't find the way to observe the 'learning' stuff that happens on your unit. Get in to see the codes, the central line placements, etc. Watch not just in awe, but with an eye as to the nursing roles you see going on about you.
Start every IV you can. Make sure everybody knows that YOU will try their IV first. My first job, I was REQUIRED to try twice on every IV on my unit before anybody else could look: no matter how busy I was.
Stressful to be sure, but 500 IVs my first year as a nurse, and hey, I'm fairly good at it.
Ask nurses from other job types (OB, ER, OR, med/surg, etc.) about their jobs. Learn not only what they do, but get to know THEM. Network. It'll make you a better known nurse around the hospital, and it will give you insights about where you might like to end up.
Grab all the certs (ACLS, PALS, TNCC) and CEUs you can. Your hospital will probably even pay for most of them.
Volunteer for committees, especially P&P (policy and procedure) committees. Being a voice there will not only help you make a real difference in YOUR job, it'll give you insight into WHY things are the way they are. Besides, your manager is always looking for such volunteers: the brownie points are just a bonus.
Smile and never seem hurried in front of pts. I won't go so far as the goofy "how can I help you, I have the time" campaigns, but nursing is as much acting as it is caring.
Spend 2 minutes 'acting' the calm unhurried part (even though you're frazzled and falling apart) and the reassurance you give your pts is worth hours of your time.
I can't tell you how many times I hear in report, "so and so was on the call bell ALL DAY". When I get out of report, sure enough, call bell. I'm johnny on the spot. Five minutes later, call bell - johnny on the spot again. Now, once that pt knows I'll materialize when called, they don't feel the need to hit the button NOW JUST IN CASE they need something in twenty minutes.
It never ceases to amaze me how the pts that are 'always on the call bell' never bother me again after that 2nd or 3rd call that I promptly answer.
Nursing as acting: never admit you don't know something to a pt. Their confidence in YOU is based on your competence. Always front that competence. If a pt asks me a question I don't know, I'll say something like "give me a sec to take care of xxxxx, and I'll come back and explain it to you." Then, I go look it up.
ON the same topic: never give a med if you don't know what it does. Always look it up again until you learn it. Nothing is more deflating than a pt asking you what x pill does and then getting a blank stare from you.
After all, if YOU don't know what it does, why are you giving it to ME?!
When I first started out, on a medical unit with 10 pts, I organized myself into 3 first rounds. The first time through, I just introduced myself and stated I would be back soon.
That way, I could make sure that everyone was where they're supposed to be (not on the floor) and nobody was in acute distress (my first priority on everyone).
Then, 2nd rounds: I'd go back through and do my assessments (and vitals if that is your job).
3rd rounds, med pass and taking care of 'creature comforts'.
I found that those 3 'first' rounds organized my shift better, highlighted the priorities more soundly, and gave me time to 'impress' my pts. Nursing is at least part an acting gig. You can't 'take the time' with x pt when you don't know anything yet about 'y patient'.
I never stopped until my 'first rounds' were complete. But, at that point, my shift was well organized.
When a new med comes out, ask the pharmacist to send you a package insert and read up on it. You can learn all kinds of things that way.
For example, did you know the molecular wt of Viagra is 666. Don't believe me? Look it up!
Also, I used to drive my co-workers crazy by sing-songing about the drug, integrillin, "eptifibitide, the cyclic heptapeptide!"
When you are doing assessments and giving report think in the following terms in the following order:
1. Overall appearance: Stand back and take in the scene - in distress? talking on the tele? Annoyed (means a little emotional massaging from you)? etc.
2. Neuro - most important specific assessment, yes? Whether chronic or not, a pt 'not with it' is in a high order of distress. Act on that.
3. Cardiac - even if not 'on tele', you can make quick assessments about circulation, cap refill, pulse, etc. Look at the skin color of extremities as a CARDIAC assessment. A mottled pt should either be on 'comfort measures' or, your highest priority. (or have a severe and long hx of uncontrolled DM or Raynaud's DX - NCLEX hint: look it up.)
3. Pulmonary - look at 'work of breathing' not just 'lung sounds'. Working hard at breathing will tip you off to all kinds of problems, not just pulmonary ones. When YOU'RE STRESSED, what happens to your breathing? (I'll tell you: your metabolism kicks into overdrive, dramatically raising your lactic acid production which has to be blown off by the lungs in order to maintain metabolic balance. Breathing hard is a tip off to a pt that is stressed or in distress, whether the root cause is pulmonary - or not.)
4. GI - bowel sounds, dietary intake, mental note of NPO status/restrictions, etc.
5. GU. Eyeball the foley bag NOW so later you can compare to see how much is 'flowing'. Start thinking in these terms: the kidneys are often the first hint YOU can observe to impending general organ failure. If the kidneys aren't working, your thoughts should be: what ELSE isn't working? (But don't call a doc to tell them that their anuric dialysis pt isn't peeing. Please. I've seen that happen before. It's never a pretty sight to behold.)
6. Integumentary - skin, et. al.
7. IVs and 'lines'. - patency, fluid, rate. Your first few times w/ things like chest tubes - ASK. Those are not 'stupid' questions and you'd be surprised at the discomfort level even EXPERIENCED nurses have with uncommon 'accessories'.
This not only organizes your assessments by priority, but your reports.
2. dx (why are they HERE)
5. general info (nursing home pt, PIA, etc.)
6. Assessment in the above priority. (this will include things like diet, IVs and O2 status)
7. Upcoming tx and procedures next shift needs to know about
8. A summary of what happened on your shift.
Quick and to the point. Leave out trivia and cut to the chase. Each pt should take less than 2 minutes. If not, work on honing in on what's important. I consider 'reading the doc orders' to be a useless report. I CAN DO THAT.
Start to think like this. If you build a 'mental template' of what you are doing and in what order, it is a foundation to build upon.
Never apologize for or diss co-workers EVEN IF YOU AGREE WITH THE PT'S ASSESSMENT OF THEM. 1. Nothing will cause you more interpersonal co-worker grief. 2. Some pts just love to manipulate and play off the 'changing of the guard'. It's pretty flattering to hear 'what a great nurse you are', but if that is in the context of 'as compared to the last nurse', then, however true that might be, you're being played.
The pts and families that most loudly complain "I'm going to report you", are, in my opinion the least to worry about - at least as far as being reported. The ones that report YOU for your honest efforts, have already reported 4 more for real concerns and yet again, another 3 that worked as hard as you did. That lends to discredit them.
Answer their concerns, but don't be put off by, "I'm going to report you". I always respond, "My name is Tim and I'm the only Tim that works on this unit. My manager will know to whom you are referring to." And then I smile and say, "But, I'd be happy to do whatever is WITHIN MY POWER to resolve your concerns, NOW." Key phrase: within my power. That does not mean I'll kiss your booty, but that I will deal with you professionally and courteously.
Trust your gut and be assertive about it. If 'something is wrong', then 99% of the time, SOMETHING IS WRONG. Every experienced nurse out there can tell you about the 'steep' learning curve of not 'trusting your gut instincts". You KNOW more than you think you know, and lots more than you consciously know. Otherwise, you wouldn't have gotten this far. ACT ON THAT.
Aug 29, '06I am up to 4 pts...all on vents...one with funky cardiac rhythms, one with no urine output, a BS of 49, whose tubefeed I held due to 110cc of residual and no BMX2 days, the third had a fever and was pulling on his trach...and the fourth with neuro issues and is unresponsive....
.....and that once I'm on my own that I'll have 5 or 6 pts...and that I really need to chart as I go
I also feel like this assignment is unrealistic. I have been an RN for 5 weeks!!! There are experienced nurses that float to this unit and sink...swearing for 12 hours straight about how ridiculous a 4pt assignment is with pts at these acuity levels. I feel like it is crazy to have assignments such as this...but that is the norm in this unit.
Perhaps I know not of what I speak BUT... This seems like a ridiculously UNSAFE situation. For anyone. Anywhere.
The pts you describe sound like they should be ICU pts where the ratio is 2:1 (at the MOST).
I dunno. I am new - graduated in May, working Med/surg (primarily surgical). I thought we had pretty high acuity on our unit (usual ratio is 5:1 or 4:1) but it is NOTHING like what you are describing. At least no vents.
I don't think any nurse (under reasonable circumstances) should be expected to take on that assignment.
Just my 2 cents, I realize that sometimes it can't be helped but I want you to know that you are managing a VERY VERY hard task.
Aug 30, '06I too find it a relief to know that I'm not the only one feeling like I can't keep up. I can start out a shift on top of things and keep up with charting, but then something unexpected happens, and then it just snow balls. I feel like I'm constantly putting out fires. I have gotten better at keeping up with charting, but it's hard when you're patients needs come first. It will be an hour before the end of my shift, and everything will suddenly go to sour, and I end up having to stay late to chart the events of the last hour. I dread going to work, and constantly stress that I won't get out on time. I will give up every break, just so that I can make sure I get everything done by the end of my shift. If I have to stay 15 or 30 min late to finish charting, I worry that I'm going to get in trouble or fired because I'm too slow (and costing too much overtime). While advice from more experienced RN's is helpful, it can't make up for the inexperience. I just hate it.
Sep 2, '06A running chicken sums up my days as well--on any floor and esp. at teaching hospitals. It is scary to think that we are responsible for lives and need to be thorough and accurate while at the same time being incredibly fast. Where is healthcare going in this country? The shortage is apparant in, seemingly, all of our hospitals. I hope it gets better in the future. But, with nurses eating their young and scaring people out of nursing and acuities getting higher and the availability of preceptors and clinicals getting smaller, I wonder. God bless us all!!
Sep 2, '06That's why there is a shortage of nurses, but mostly a shortage of floor nurses. Goodare hard to find.
Sep 2, '06Janfn and Tim responded to similar posts that I have written. Thanks for sticking up for the new grads!
I'm just so sorry to hear that new grads are feeling the same way that I do. Yes, 4 vented patients that are so sick was an inappropriate assignment but, honestly, what can we do as new grads? Say no? Can't say no. You have a preceptor there to back you up---sort of. I had complained in one of my posts about the constant buzzing in my ear "did you do this? I asked you to do this, and you didn't. You forgot that. You're going to have 6 of these, you know!" We are doing the best we can with assignments that make 20 year veterans almost cry and we get criticized for not being more "organized", etc. and we are afraid of being fired!
Is all hospital nursing like this?
How did we go from excited, passionate, nursing students to headless chickens?
Sep 2, '06Somebody HAS to start saying NO! Unsafe assignments are unsafe assignments, whether you've been nursing for five minutes or five lifetimes. You know what you can handle and what is reasonable for you to be expected to provide. You also have a lot to lose if you just accept the status quo. I get so frustrated when people just accept a ridiculous patient load on the excuse that they don't like to complain, or rock the boat. This is me , rockin' the heck out of the boat!!! Maybe it doesn't make me popular with my manager, but I care more about the safety of my patients and my coworkers than the admiration of my boss. I don't always get the assignment changed, but I always make my point. While I've been off on sick leave, I've heard that my unit is finally following our own staffing and assignment rules again. Hallelujah! But the proof is in the pudding. I'll see when I go back next week if it's true or not. If it isn't, a lot of people are gonna get wet.