Long post from new orientee with questions

Nurses New Nurse

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I've worked three 12-hour shifts on Orientation! So far so good!! But...

I have some concerns about med passes here (it's a large teaching hospital affiliated with universities in other cities in the state.)

I did all of my clinicals and worked as a nursing assistant in another hospital- a large teaching hospital system affiliated with a big university in the city. This hospital system was a Top 10 of US News and World Report, international sites, big research going on, etc. Most of their facilities are Magnet, patient-outcomes are better, the amount of RN's who have a BSN/MSN/DNP is very large, and the amount of RN's who publish is large. Essentially, where I worked as a nursing assistant and did my clinicals is a superior healthcare system to the one I am employed so I am apt to go by their practices which I will compare and contrast below.

As good as they are clinically and well-respected internationally, is also as shabbily as they treat their employees so that's why I didn't want to work for them again this time as an RN.

My basic question is this: Since none of them are policy-related and mostly preference, I want to do what learned as a student at clinicals and saw working as a nursing assistant as I saw tons of students nurses/preceptees/orientees while working get taught, reminded and drilled about some of the things that I'm concerned with.

1.) My Preceptor said I don't have to swab the vials as they are sterile. On clinicals, I've seen the dirt on the swab myself and found on here a 2010 position paper from the Association for Professionals in Infection Control and Epidemiology, saying to swab (scrub) the top of the vials and the CDC in 2011 says to scrub the top of the vials.

http://www.apic.org/Resource_/TinyMceFileManager/Position_Statements/AJIC_Safe_Injection0310.pdf

http://www.cdc.gov/injectionsafety/providers/provider_faqs_med-prep.html

Question: I want to scrub my vials. How do I do this without offending my Preceptor in her clinical practice? Do I print the article and website? Or do I just say, "I'm more comfortable scrubbing." I really do not want to make a big deal out of this but I think it's important. I really need some guidance on this one!

2.) The next ones so scare me and is so unsafe that I'm actually more comfortable not doing it how she does (and everyone else too) and explaining why.

-I'm used to using on clinicals/seeing while working, the COWs with individual patient drawers stocked by pharmacy. Pyxis used for opioids and such.

-The EMAR was brought up on your COW so it's up to date to the second as you pull your meds out of the patient's drawers. Cerner was used where I did clinicals and worked and it asked for pain rating, location of injection, blood pressure, apical pulse, etc. right at the bedside and I used VeriScan with Sunrise while precepting at a third independent hospital. At both places the Patient ID band and meds were scanned at the bedside. Of course, all of this info seamlessly went into their chart.

-At the hospital I've only been at 3 days, all of the meds are kept in the Pyxis and taken out per patient med pass, there is no bedside scanning of meds/ID bracelets, very few use a COW at the bedside though they are available and all RN's write down all of their patient's meds/times on a piece of blank paper at the start of shift even though they could print each patient's med list and times which seems very inefficient at best and unsafe at worst if not checking new orders or the EMAR before med pass.

- The inefficiency of everything stored in the Pyxis drives me crazy but I can't do anything about that. It was drilled into me at clinicals and I saw it drilled into tons of students nurses/preceptees/orientees while working as a nursing assistant to not to go by the printed med list you printed off at 6:30 am or if you wrote them down by hand, since it could literally change in seconds if the MD changed/discontinued a med and to refresh and check your EMAR before administering anything!!

-Since there is no scanning of anything you have to go back into the EMAR and "sign off" your meds that you gave and the time and apparently, it's not required to be done immediately following the med pass. For example, we gave a patient a PRN opioid and didn't sign it off for hours. Yes, they all write down when everything is given but if you forget to sign something off or lose your paper or it's been super crazy and you literally can't remember when an opioid was given and didn't write it down, that's so dangerous for the patient and your license!! I am so freaked out!

-I want to take a COW and chart as I go, print each patient's med list rather than write them all out, check the EMAR prior to pulling them from the Pyxis then again at the bedside, give my meds then immediately sign them off at the bedside. They have a computer by each Pyxis but not at very good viewing angles so it will be cumbersome and there is usually a few people waiting. Maybe that's why I haven't seen anyone else do it but go off their handwritten med list.

I'm a second-career RN on my first job in a new-to-me hospital and don't want to seem like I know it all but in these situations, I feel confident that what I was taught on clinicals and saw taught to so many other SN's/RN's is truly "best practice" as opposed to what I've seen where I now work.

Thoughts?? Advice?? I'm looking for normal, healthy, constructive feedback regarding safe nursing practice not people automatically assuming that I'm just another unteachable new nurse who already clearly knows everything since I am willing to try safer nursing practice.

I think you are in a tough spot because I can definitely see where your preceptor could possibly have an issue with you not doing things her way. Personally when I preceptor I knew everyone did things differently and as long as it wasn't wrong it was fine with me. I actually liked to encourage people to watch other nurses and try out different things so they could figure out what things worked for them and what didn't.

Chalk the first one up to habit maybe? With the second I would tell her as a new grad right now you feel most comfortable charting as you go so you can keep things straight, that's the truth and I would hope she would respect that. Do you think she wouldn't? Your plan of printing things out and verifying it before you pull meds sounds smart and I agree not charting for long periods of time after is a bad idea.

Pediatric Critical Care Columnist

NotReady4PrimeTime, RN

5 Articles; 7,358 Posts

Specializes in NICU, PICU, PCVICU and peds oncology.

I agree with NightCrow to a point. But I feel I should point out that the environment you describe for your clinicals and previous workplaces is actually quite a luxury. Many facilities cannot afford to have all the bells and whistles such as individual patient med drawers on your COW, EMARs, bar-code scanning and so on. There are still places where there isn't CPOE, places where charting is still done on paper (yes, even in high-prestige teaching hospitals), places where nurses prepare ALL of their own infusions and meds.

There's no way you can make your workplace fit your ideals, so you're going to have to do the adapting. Personally, I don't think I'd want to be carting around 5 pages of electronic med sheets for each of my patients everywhere I go, or printing and reprinting all the time in case something has changed... but that's just me. I'd rather make myself a list of what meds are due for whom and when, then check the EMAR just before I prepare to give them. Charting as you go is a good habit to develop and now is the time to do it. Use that explanation for your preceptor and I doubt you'd have any blow back. "I want to develop good habits, so if it's all the same to you, I'd like to chart as I go. I'm less likely to forget things that way." And leave it at that.

There is always more than one correct and safe way to do things. In my experience as a preceptor, as long as the orientee followed the principles of whatever s/he was doing and the patient was safe, it was fine. If I offered to show them a quicker or easier way to do the same thing while following the principle of that task, it wasn't to make them look stupid or to make myself look like a super-nurse, it was to help them streamline their work flow. Each of us has to try things a few different ways before we find the one we're most comfortable with, and even then, we may refine that process over time. If PATIENT SAFETY is the main goal, then it's all good.

SWAB those vials! When the cap is popped off you have no way of knowing whether you touched the rubber seal or not. Better safe than sorry. I even swab the necks on ampules. If you suggest to your preceptor that she's doing anything wrong all you're going to do is get on her $#+ list... even if you're absolutely right. You're only responsible for your own practice. "Good habits from the beginning" is the correct response to just about everything.

Before I forget, keep in mind that it's not always going to be possible to do everything exactly as you were taught in school. Everybody knows hand hygiene is required before patient contact, and everybody knows not to touch any body fluid without gloves, but if you walk past a room and see a patient vomiting blood while flat on their back, odds are you're going to run into the room and turn the patient to one side, hit the call bell and THEN wash and glove. Same thing if you saw a toddler going over the side rail. And there will be times when it's impossible to chart as you go and to sign for your meds immediately after giving them. Good habits. Not always realistic.

Graduatenurse14

630 Posts

Thank you, NightCrow!!! No, I don't think that she would mind my way of charting and med passing to help to keep things straight as a new grad, however, she did make a comment about the COW slowing us down.

She's not used to traveling with one on the unit with one so I can see why she said that but interestingly it was when when were in a patient's room and were asked something that she needed to look up and I asked if she wanted me to get my COW and then said no, it slows us down. We had to walk back to a computer at the nurses' station which was all the way down the hall to find the information and walk back to tell the patient. Pretty inefficient if you ask me.

Maybe when I'm with her, I won't scrub the vial but when on my own I'll scrub. I'm very conflicted as I have anecdotal (I saw the dirt) and research-based evidence that scrubbing the vial is correct (at this time anyway.)

Graduatenurse14

630 Posts

Thank you, NotReady4PrimeTime! I was answering NightCrow before I saw your post!

The other facility certainly has a lot of bells and whistles that's for sure! Not so big on how they treat their employees, though!

Personally, I don't think I'd want to be carting around 5 pages of electronic med sheets for each of my patients everywhere I go, or printing and reprinting all the time in case something has changed

I would only print at the beginning of the shift as a baseline and check for new orders and the EMAR throughout the shift especially before pulling/administering. I'm sorry that I wasn't more clear about that part! I feel like printing them out is much faster than writing them all down so I can get into see my patients earlier.

places where nurses prepare ALL of their own infusions and meds.

You mean there isn't a fully-functioning pharmacy on site? I remember a few experienced nurses telling me about having to prepare IV meds when they first started out. I didn't know that still happened! Very interesting!

I know I have to do most of the adapting in this situation and I will in time. I really want to do right by my patients and not (regularly) get out an hour or more later than I was supposed to so I want to be as efficient as I can.

How do I tell her that I want to swab every vial? Her belief, which has to be supported by this hospital too, is there is no need to swab. I don't want to question her clinical practice but that's really what I'm doing. Should I print those articles I posted? After she said that I didn't have to swab, I didn't for the rest of the day as I was very surprised and didn't know what to say and I also knew that there's a been a debate for awhile so I wanted to research it for myself.

And there will be times when it's impossible to chart as you go and to sign for your meds immediately after giving them. Good habits. Not always realistic.

I agree. I really need to find out what the policy is for signing meds off especially for opioids and other controlled meds before I work again.

wheeliesurfer

147 Posts

Is there a nurse educator on your unit that you can ask about specific P&P for scrubbing/not scrubbing the stopper on the vials? I would come armed with EBP showing that 'best practice' is to scrub to sterilize stopper and decrease the risk of BSI. I know that personally (I have a port), I scrub ALL stoppers prior to spiking because as soon as you take off the protective cover, the vial is no longer sterile. Who knows if you accidentally contaminated the top of the vial when you took the cover off. Also, there are documented cases of diversion with people using super small needles and going UNDER the protective cover, withdrawing the medication and replacing with sterile saline.

My basic rule of thumb is that unless I just opened a sterile package using sterile technique (ex sterile saline flushes that are okay to go on a sterile surgical field), things are going to get scrubbed with CHG or alcohol wipes to prevent the possibility of BSI to the best of my ability. It only takes a few seconds and can save a patient from getting septic. I've had CLABSI's myself with previous PICC lines, and I wouldn't wish that on my worst enemy!

Pediatric Critical Care Columnist

NotReady4PrimeTime, RN

5 Articles; 7,358 Posts

Specializes in NICU, PICU, PCVICU and peds oncology.

I think you'd be fine to simply tell your preceptor that you're still getting the hang of being a nurse and you really can't be sure you didn't touch the top of the vial when you flipped the cap off, so you're just going to scrub and be safe. That way you're not taking on the whole unit.

I work ICU in a university hospital. A BIG university hospital. We only get a handful of antibiotics prepared by pharmacy. Everything else we do ourselves. We reconstitute antibiotics that aren't stable at least 24 hours once mixed (like meropenem) as well as other drugs; we mix almost all of our infusions, unless they come prepackaged by the manufacturer. Our pharmacy is closed from 2230 until 0700 every day. If we need something that isn't in our Pyxis we have a global locator function on it that will tell us what other units might have it; otherwise we get it from the night cupboard, and if that fails, the on-call pharmacist comes in. It's far from ideal.

annie.rn

546 Posts

Hi there! Congrats on finishing nursing school and getting that first job :-)

It's tough being new and synching the way you want/have been taught to do things w/ the way they are done in the real world. We've all been there.

To address your concerns: as far as swabbing the caps goes, do it. Do it nonchalantly w/o saying anything about it. She may not notice but if she does you can say something like, "I know you guys don't do it but it became such a habit for me during school that it's hard for me to stop." Or, "I know you don't do it but I'm such a germ-a-phobe I feel compelled to swab! I blame it on my microbiology professor." Make a little joke if it and move on. If she still pushes the issue, you can pull out the research. I would not pull out the research sooner than that or you risk alienating her and getting a reputation as a know-it-all before you even start.

As far as the med pass goes, pulling everything from the Pyxis seems to be the wave of the future. We just started doing it where I work and it takes some getting used to. You might find that printing the EMAR is too big a time commitment. I did. We write the meds down and then we pull the meds and place them in a separate baggie for each patient. I agree that it does not seem proper to not check the meds against the EMAR just prior to administration. Even when we did paper charting, we brought the paper MAR into the pt.'s room at the time of administration, checked them against the patient information and signed meds off as we gave them. I am surprised that they don't do this on your floor. I don't see how a nurse can perform all of the med "rights" w/o the EMAR/MAR at the bedside. I'm surprised that this is accepted. Do you work nights? Sometimes night shift will do some things that day shift cannot get away with when the big wigs are around. (BTW, I work nights so not bashing night shift)

Bring the COW to the bedside and sign off as you go. It really would be LESS work in the end b/c you don't have to chart things twice (once on your papers and then in the EMAR) If your preceptor pushes the issue you could reply, "I'm so new and there's so much to process that I really would feel better if I charted things right away so I don't forget." Or, "I'm not as confident with the med pass as you experienced nurses are so until I get as comfortable as you I'd like to have the COW to double check meds just before I give them".

You're in a tough place but try to stick to your proper way of doing things. It's human nature to want to avoid conflict. Hopefully you can try by passing things off w/ a little humor sprinkled w/ a light dusting of self-deprecation.

.

Graduatenurse14

630 Posts

@wheeliesurfer, Thanks for responding! Yes, there is a nurse educator for my unit who is also a big part of the hospital's RN Orientation Program so I've gotten to know her these last few weeks and I think that she would be open to hearing about my concern. She's worked there a long time and if hospital policy is to not swab or even just leave it up to the RN's discretion, she too may believe it's not necessary. That's where the APIC and CDC articles may need to be referred to.

Graduatenurse14

630 Posts

@NotReady4PrimeTime, I definitely don't want to take on the unit so I think I will say something about not being sure about touching the top of vial. I can't even imagine having to mix meds! Your unit's orientation must be wicked hard!

Graduatenurse14

630 Posts

@ annie.rn, Thanks!! It was a rough road but things are falling into place! I wonder why everything stored in Pyxis is the wave of the future. Probably cheaper and faster for pharmacy to load it than individual med drawers in COWS and saves money on not having to buy COWS with med drawers for each RN. It's just more time away from the patient while waiting in a long line in a fairly small med room where a lot of other essential supplies are stored in addition to where we prepare all of our syringes (it's not done at the bedside even if you don't have to waste) so it's chaotic and takes up a lot of time. I asked about pulling all of my patient's meds at one time and was told that we really shouldn't but I'm not sure what the official policy is. I need to find that out too. If I can then I'm going to pull them all at once put them in baggies and make sure I get one of the COWS that does have 6 or 8 drawers that lock since the unit does have a few and they aren't really used. I'm going to definitely bring the COW to the bedside and have the EMAR up during med administration and try to sign them off right there.

annie.rn

546 Posts

I was told the reason we have to pull from the Pyxis now is b/c there is some kind of robot that pulled the meds before, bubble packed them and collated them into the pt. envelopes. They had to get rid of the robot. Budget, I'm sure.

Since we scan our meds, we each have our own locked COW each shift w/ a large drawer for baggies so we pull all the meds for the day at the beginning of the shift.

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