Residency: My First Mistake!
My preceptor has high standards. To her, I would be the perfect nurse if this was a perfect NCLEX world. For example, I can do tasks, chart accurately, and write notes in a speedy and thorough way--but only if nothing bad happens.
I am also trying to work more shifts back to back on the weekends, but this comes with consequences. Sometimes I forget that this is a job that involves many people & constant human interaction with not just patients, but also staff. They all influence me more than I thought. In fact, I started to become paranoid and thought that my preceptor was gossiping about me. I didn't have proof of that but I felt terrible for 12 hours. I kept hearing rumors and I just felt crushed from the pressure. It was awful. I have a lot to learn.
It all started with an incident. Lately, I've been trying to cram all my shifts together to get the endurance needed to become a nurse. For the past 4 weeks, my preceptor and I have been working hand in hand. It has been mostly me shadowing her closely for the first two weeks. But after that, she began to gain confidence in me and gave me one, then two patients.
She wanted to try me with three patients today, but then something happened. My first two patients were much older & extremely high fall risks because they were AxOx1 and had active UTIs. I suspected that we couldn't have 1:1s on them because we were short staffed (again). One wanted to beat her husband with her cane and it was sad to see his little limp body crying in the hallway. Apparently, she's convinced that he cheated on her. It turns out that it was true! ...60 years ago. But you can't blame her for perseverating on it for almost a century. (NEVER CHEAT ON YOUR SPOUSE is the lesson here). The other one also had severe dementia, but she could still furiously press the nurses' call button and yell "help, HELP" every 3 minutes. Oh and they both had an ostomy for me to clean q2h & neuro checks. Since I was a 'primary' (my preceptor didn't want a Corpsman to help me because she wants me to do it all on my own), I would drop everything and run if either one of them would try to leave the bed.
One of them did leave the bed. How did I know? Because whoever was messing around with the alarm while trying to help her to the bathroom while I was on break forgot to reset the alarm. When I went to do my hourly checks on the homicidal lady, all I saw was an empty bed. Then the Flagyl I had up was still running (it wasn't supposed to be done for 2 hours), but no patient! I followed the line and saw that the catheter was on the floor, dripping. I announced that I was coming into the bathroom and when I went in, I saw my lady tugging at her tele leads, diaper on the ground, ileostomy open (leaking red bile now, btw), pee all over the floor and what looked like gallons and gallons of blood on the toilet (I had given her heparin earlier that morning)! Luckily, she hadn't fallen. So I snatched her up, put the gown over her, placed my gloved hand on the bleeding site, and walked her back to her room and placed a new IV (after 3 tries) while she was wiggling around.
My third patient was in airborne isolation to r/o TB. I didn't have an N95 so I had to use a helmet and a papper (machine that blows air down into my helmet) to be able to enter the room. I had him running intermittently on Zosyn q8 and Vanc q12. My preceptor would watch me prime and hookup the bags, program the pump, and flush the PIV through the room window to make sure I prepared it right. Then she'd mask up, walk in, & administer the ATBs. I also had to get three sputum samples by the end of the day, a urine sample, and draw stats lab for his trough levels (his creatinine was up to 2 today). He was a hard stick so I would use his feet. He had continuous meds, like usual, but was also very nauseous and wanted only ice cream to eat so I had to get him new ice chips (because they were stale) and heat his soup. He started to fail to thrive so it got to the point where I went down to Subway to give him something he'd like to eat. Then I'd push Zofran, make sure his SCDs were on, make sure he'd do his spirometer, his oral care (because my assessment note indicated that he needs more of that), and ambulate him around the room while hooked up to the meds. He wasn't really a fall risk but because he said he had syncopal episodes at home we kept him in bed in SCDs and a bed alarm, which he kept telling me that he didn't like.
Then something else happened. One of my other disoriented ladies went catatonic. Then her head whipped back, she was unresponsive, and her pupils were pinpoint. Her blood pressure was extremely low and she was barely breathing. My preceptor called a CODE Stroke. Then I rushed to stabilize her. At this point, I was still in the TB room but I started to see the commotion. My guy's Zosyn was done so I d/c'd it but kept him on the NS flush. I was programming it to run continuously, so I put it on rate 999, and was just about to input the VTBI when the stroke happened. I couldn't see with my helmet on so I pressed the start button and ran out of there to help. After quickly stabilizing the patient, the Rapid Response Team arrived and I tried to gather my thoughts. Then it hit me.
I had programmed my IV as a bolus.
I ran back into the isolation room and suited up as fast as I can and turned off the pump. I assessed my patient (he was perfectly fine) but the damage had been done. I had pushed around 250 mL of sodium chloride without a doctor's order. I had to tell my preceptor and then I had to tell the doctor. No interventions were necessary but it was very embarrassing. It could have been worse. But it is still a grave mistake in my eyes.
My preceptor said that it wasn't a big mistake, but it was still a mistake. However, she didn't demote me to two patients because of that! It was because my charting wasn't exactly the way she wanted it. Charting for her is very confusing to me because there are some invasive devices that I have to chart on, such as PIVs, Foleys, but some that I can't, but are still there such as ports. She also doesn't chart by exception so I can't miss anything. And even if I charted everything, I still had to do it in the right order.
All the progress I made during these past few weeks felt like it was all for naught. Was my preceptor giving up on me because of the pump mistake? Was she just parading me around to taunt her power to the rest of the staff? One of the Corpsmen asked me to help her transport a patient so I did. While we were walking down the hall she said, "why do you let [the preceptor] talk down to you? You can just ignore her." I told her that I couldn't. No matter how my preceptor acts towards me, she is still teaching me. And for that, I'm grateful.
Don't get me wrong, I'm very thankful for my preceptor because she is guiding me to be a stellar nurse. But an occasional compliment or reassurance that I'm making progress wouldn't be such a bad thing. It sucks when I'm only being talked to when I make a mistake. It seems that my charting is always "nearly at [her] standards," but not quite. It's demotivating. I'm only human. One time, I saw her talking to her Corpsman on the screen and every time I walked by, they would hush. Were they talking about me? I thought I was improving...I felt crushed.
This was the last straw. Now I felt like I wasn't being taught--that I was being bullied. I decided to call the Professor on break and ask her if I could talk to my preceptor about how I was feeling. I also wanted to ask Professor if, on the chance that my preceptor and I couldn't see eye-to-eye, that she let me reschedule my shifts so that I can try with another preceptor. Any other nurse would have been much nicer.
Professor listened to my complaints and my proposal. She encouraged me to talk to my preceptor about what I was feeling and had me practice it to her over the phone (I didn't do too well). Then she told me that changing preceptors wasn't really an option unless my preceptor insisted on it. I had to work it out with my preceptor.
Dejected, I went back to finish the rest of my shift. I couldn't look anyone in the face. People were wondering because I wasn't my usual smiley, jokey, flashy self. When my preceptor saw me, she demanded to know if I was 'really' doing my q2hour ostomy checks on my ladies. I said "yes, of course. Up until 1300 before I went on break." And she said, "well, I don't know, because while you were away my Corpsman saw that the bag was red and her stoma was swollen and extra beefy and now her H/H fell 4 points so..."
How can this day get any worse? I felt like a spotlight was on me. I practically begged my preceptor to take one of my patients back, but she said no. She would help out more with the ladies but she would still entrust the patients to me. She didn't say why, and then she left. Then one of the other nurses called out, "Hey, bed __ needs some help. His leads are off and he needs a bunch of other stuff." Without hesitating, I jumped up and said, "Oh, he's mine! I'll take care of him." It was nice to know that even as bad as I felt, that I would still take care of my patients. Inside I felt like I was the WORST NURSE IN THE WORLD, but I still wouldn't let my patients see that. I can still be a professional. I can always drink my sorrows away later. But for now, I still had two more hours left at my shift and I'll be DAMNED if I turnover a neglected patient to the oncoming shift.
Without prompting, my preceptor came back into the room and said that my charting "only had 1 or 2 mistakes on it, but I changed them online so it's ok now," then flew away again. That was the best compliment I could hope for. My patient looked at me and said, "that nurse preceptor of yours only has one speed, doesn't she? Even after ten hours I only see her as a blur." We both laughed. I really needed it. I came up to my preceptor before handoff report and asked her if we could talk about...things.
"Well, I just want to discuss...my performance today. We can talk about it together or you can also call my professor."
"Which is it? Talk to you or to your professor?"
"Well, we can talk first, if that's ok."
"Ok. Let's talk. Come with me to the nursing station."
Before I could ask her to go to a private room, she began our conversation. "Is this about the stat lab? Because when I tell you to draw blood or get a specimen I want you to do it now."
"But didn't you teach me that the flowsheet charting was more important than anything?"
"Yes, but this is more MORE important. I feel like you want me to give you a black & white answer, but that's how nursing is. Everyone is different. Charting is different for different people. That's just the way it is. That's why I don't want you to copy your notes forward, I want you to start your assessments from the very beginning without looking back at yesterday's notes."
"Okay, but it's hard for me to know how to improve if you don't set a precedent. I can't prioritize if our priorities always change! I'm not trying to shortcut on charting but based on other nurses' charting your notes have way more content. You don't like charting by exception."
"I never leave anything to chance. And you should be the same way. But if it makes you feel better, my standards are very high. Not everyone can achieve them. And you seem to be intimidated by me sometimes."
"Yeah, I am. Because your opinion is important to me. You are teaching me."
"Then keep at it. I think you're making progress. You just have to do things over and over. I've already been a nurse for a year. You still have a long way to go."
"Then how do I know if I'm improving."
"You are. I just don't have the time to tell you. I have four other patients and I'm watching you while you take care of your two. When you can show me that your charting is not just excellent, but that it is perfect, then I will move you up to three patients again. It's better to be perfect with two patients before you move up. I know you can handle three patients but it's just not up to my standards quite yet. But you'll get there."
"Are you sure I'm not getting in your way?"
"Of course not! We just need to communicate more. It's easier for me to catch & fix your mistakes if you tell me what you're going to do. Now, when am I going to see you next?"
"Good. I'll see you in a few days."
Dec 27, '17I've been a nurse for almost 28 years. At no time has my charting been "perfect," and at no time has my care been "perfect." And I highly doubt that your preceptor, even with her whopping one year of being a nurse, is perfect either. Nursing isn't about perfection. It's about doing the best you can with what you've got. You can say "I leave nothing to chance." I'm here to tell you that it is humanly impossible to prepare for every possible contingency, no matter how much you try. I commend you for hanging in there and being open to learning from her. You can be a respectful, humble learner, but you needn't feel intimidated. I recommend you write down what's happening and in 6 months look at it again, with fresh eyes. I'll bet you will realize you weren't a horrible nurse after all!Dec 27, '17Quote from maxthecatWell said. I hope your preceptor isn't setting unrealistic standards. You will get the hang of it. Oh and heaven help you those patients that are not all with it and get on the call bell every 2 seconds without any specific complaints or requests can be very frustrating and draining. I had a patient that wouldn't even get on the call bell he would just yell loudly "nurse..nurse..nurse" so of course the other patients on the floor were complaining about him too. He kept at it for 12 hours. Very frustrating.I've been a nurse for almost 28 years. At no time has my charting been "perfect," and at no time has my care been "perfect." And I highly doubt that your preceptor, even with her whopping one year of being a nurse, is perfect either. Nursing isn't about perfection. It's about doing the best you can with what you've got. You can say "I leave nothing to chance." I'm here to tell you that it is humanly impossible to prepare for every possible contingency, no matter how much you try. I commend you for hanging in there and being open to learning from her. You can be a respectful, humble learner, but you needn't feel intimidated. I recommend you write down what's happening and in 6 months look at it again, with fresh eyes. I'll bet you will realize you weren't a horrible nurse after all!
As for charting you will develop your own style and technique when it comes to it. What to document, what to leave out etc..soon enough it will be second nature to you. Not for nothing but your preceptor has only been a nurse for a year..definitely not a long time by any means. She is probably just finding her footing herself. I know my confidence was in the toilet for a while after I moved out of "new grad" status.Dec 29, '17Your preceptor needs to calm down. Seriously. I don't care how long one has been a nurse whether it be 1 year or 50, there is NO way for any of us to be perfect.Dec 29, '17Quote from Irish_MistAgreed. I would tell your preceptor...Your preceptor needs to calm down. Seriously. I don't care how long one has been a nurse whether it be 1 year or 50, there is NO way for any of us to be perfect.
"Girl you need to tone it down a notch. You need to relax."
For real though. Nursing is stressful enough. I understand striving for excellent patient care but some people seriously overdo it.
The truth of the matter is that nursing is imperfect because we deal with imperfect beings and situations.
Just roll with the punches, like take it as it comes. Man some days suck so much, you can't do anything about the circumstances.
My best advice to you is this:
Practice within your scope
Document these two things:
Interventions & dialogue with doctors and patients.
Take a DEEP BREATH.
Seriously you're too early in the game to burn out and feeling like you gotta be perfect is gonna crisp you up!Dec 29, '17As far as I'm concerned, a nurse who has only been a nurse for a year, has NO BUSINESS being a preceptor, It's untenable.
Upon reading about your "day", you should be commended for all that you accomplished!
Please, please, do NOT turn to the bottle when you are off duty! Not a good plan. Also, you may want to reconsider working back to back shifts and take care of YOU.Dec 29, '17Sounds like a horrible day! I would have made sooo many more mistakes and omissions than 1 silly little .25 liter NS bolus. Take a breath, that assignment was a challenging one for ANYBODY. Many experienced nurses would have drowned.
That said, one thing jumped out at me - you went to Subway for a patient? Um, no. Not only did you not have time, but...just no.Dec 30, '17What a nightmare. Perfection doesn't happen, don't put that pressure on yourself. Everyone alive at the end of the day is sometimes a crapshoot. That assignment was physically impossible. you can't monitor two crazy wanderers while you're in an isolation room. Just one yelling "Nurse! Nurse!" would put my stress level over the edge. It sounds like you are doing well to me. Prioritize patient care (lifethreatening, treatments, then comfort needs) than scut work, like phone calls, coordinating care, then paperwork, and your preceptor can decide whet paperwork she wants done first. Keep your chin up.Dec 31, '17Hey don't feel bad. Have been a nurse for over 30 plus years. Started a position where my preceptor with two years experience is "a rising star," meaning, I guess she is on the presidential track in management. Working night shift, patient assessment completed (if it was even started that is) in a dark room (hello, there is an invention called electricity) took less than 5 minutes, out of the room charting like crazy. So I ask, "what are you charting?" Wow, if looks could kill. After three weeks nurse manager says I don't seem a fit for the unit, I guess I spend too much time with my patients and perhaps I made their electric bill go up.
I will hand it to her, she was sure fast with copy and paste notes and duplicate charting. This nurse will go far.Dec 31, '17Let me just say this - I graduated 24 years ago, and perfection is a highly sought yet unattainable lofty goal. You hit the nail on the head: we are only human.
Patient care is busy, unpredictable business and often times we fly by the seat of our pants most shifts.
Learn what this nursing goddess has to teach you, but also remember that we can only do as well as the circumstances we find ourselves in. Period.
We all want to function at the highest level possible, but that isn't always achievable. Continue to do your best. Be proud of yourself.
We graduate with the bare minimum from nursing school - it is only on the job we begin to learn the skills we need to do bedside care with the highest proficiency. Everyone always wishes it was the other way around, but that just cannot be so.
When you begin to rack up on the job hours your skills will improve accordingly. Truly, you are functioning at exceeds expectations levels. Cut yourself some slack my friend. I would be proud to have you care for me or mine if inpatient. You will be stellar.Jan 2Is this an old story? I see you have 15 years experience. Was that as an LPN only and now you are with an RN and work in a military hospital. It is confusing to me. Many LPNs have trouble with adding some of the tasks on to what they have already done as well as added responsibility. You tell this like you are a brand spanking new grad. If you are out of school, why is she talking to the professor. You say residency, but is this an internship for last semester of school...but you are BSN LPN? The preceptor is a little big for her panties with a year's experience! I think there is some back story missing that I do not understand. The preceptor is there to mentor and support, not to punish. Maybe she needs to collect Quality data or work on the schedule for her clinical ladder points. Leave the precepting to the kind, patient,and competent!Last edit by Knotanoonurse on Jan 2
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