Worried about my future as a nurse, and afraid I'll be fired

  1. 1
    I am currently working my first job as an RN on a med-surg/neurology floor. I graduated August 2012 with a BSN. I've been off orientation for under 3 months.

    This morning after completing my night shift my nurse educator told me that my leads said I needed to work on time management and organization. I leave late after every shift because I need to catch up on charting. I can't seem to stay on top of it during the shift. I miss things, doctor's orders, due to my disorganization and changing events that occur throughout the shift.

    I start off strong: get to work early and if assignments are made, I write down all of my stuff. But then i forget to check off my checklists, and it all goes down the tubes.

    I've tried lists, circling really important tasks, setting alarms on my phone to get things done. But I seem to be easily distracted and forget things unless I do them right away.

    My educator now wants me to highlight my 'brain sheets', save them, and show them to her at the end of the week. She also 'suggested' that I sign up for a stress management course the hospital offers.

    I had to stop myself from being too honest when she asked if I liked my job (the real answer is 'not really'). I took this job as a way to learn the skills I need to do well in other areas. To get my feet wet, as it were. If I leave this job or get fired, I don't forsee an alternative area that would be a better fit.

    I will admit it: I'm ashamed of myself. Others that I graduated with seem to be cruising without effort, wheras I start to get stressed a few hours prior to leaving for work!

    I know I'm the problem but my attempts to fix my actions throughout the shift have not garnered much relief.

    Any advice or help you guys and gals can offer would be appreciated. I'm at my wit's end.

    Thank you.
    mitral likes this.
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  3. 21 Comments so far...

  4. 4
    I used to dread going to work when I worked on a telemetry floor. After 14 months I switched to women's services and it is soooo much better. Stick it out for at least 6 months to a year, and then find a different area of nursing that suits you better. Follow the advice of your educator... it takes time to get the hang of things. What is your nurse to patient ratio? Do you work days or nights?

    Start coming up with a routine that you follow each shift to help. It's impossible to get to everything... so prioritize what has to be done and get it done first if you can, delegate things that CNA's can do to help you. Every now and then throughout the shift, pause for a moment and go through your list of patients on your brain to make sure you're not missing anything, then check the charts for new Dr. orders.

    Hope that helps.
    joanna73, j_tay1981, Ir15hd4nc3r_RN, and 1 other like this.
  5. 8
    Gee OP. I'd stay put and take all the help your educator is trying to give you. Do you realize that I almost never read of a struggling nurse receiving any kind of help? Most are given a shovel to dig their own grave and then told to hop in.

    You may really hate nursing. That's OK. But for now, look at this person trying to throw you a lifeline as an extreme positive and take that lifeline!
    joanna73, j_tay1981, Ir15hd4nc3r_RN, and 5 others like this.
  6. 2
    If you really aren't getting it, ask to be on orientation again for a couple of weeks. It sounds like your educator and facility are very supportive and see if that is even an option. As another poster said, be sure you are delegating appropriately. Trying to do everything alone is setting yourself up for failure.

    ~ No One Can Make You Feel Inferior Without Your Consent -Eleanor Roosevelt ~
    PA_RN87 and j_tay1981 like this.
  7. 4
    I could have written this post myself, it so closely resembles my own story. I look around and feel like everyone else seems to be handling things just fine, when in fact, I know they are not. Not always, anyway. I am considering moving to nights, or just sticking it out a little longer, then moving somewhere else. Part of my frustration is in being worried that all nursing jobs will be this difficult for the rest of my career. I cannot work this hard for the next thirty years or so.
    mitral, j_tay1981, opossum, and 1 other like this.
  8. 4
    IMO, RN_BSN09 has probably identified OPs primary issue - prioritization.

    New grads are task oriented (this is what our nursing education system produces). They approach the shift as a list of tasks, with no or very little sense of prioritization (must do versus nice-to-do). When new tasks are introduced during the day, they try to just slot them in along with everything else without stopping to consider priorization.

    OTOH, experienced nurses approach the shift with a goal-oriented big picture (Pt A - DC to home, Pt B - teach about meds, Pt C - pulm consult, etc.) and when new tasks are added, they are prioritized in terms of how important they are to achieving the pt's goal. So in order to address the new priority (ex: critical value received), they 'bump' less important tasks to the bottom of their to-do list. This means that low priority tasks may have to be passed on to the next shift.

    These days, managers take a very dim view of new staff that request an orientation 'extension'. Labor budget pressures are more intense than ever. It is likely that an orientation extension will have to be made up by adjusting staffing levels downward to make up the difference. Not a good outcome.
    mitral, littlenurse21, j_tay1981, and 1 other like this.
  9. 0
    Thank you all for your replies!

    To answer a previous question, I work nights and I have five patients. And I should correct myself: I don't hate nursing or my job (I posted that out of frustration - mea culpa). I hate that I haven't 'gotten it yet'. I'm proud I made it this far (I was a nontraditional student). And my leads have said I'm great with building relationships with patients, and I also take great pride in that.

    You are all correct about my management being very supportive with me. My floor is often the first job of many new grads, so they may have seen some of my same issues before.

    I thought that I had been improving on delegation, but maybe I could do more...

    I really feel like my main issue is prioritization and than staying organized. When issues pop up during a shift, I tend to focus on the new stuff and back burner the older tasks. Not good.

    I want to figure out what I can do differently before I run out of chances (after I spoke to my nurse educator, I went out and bought highlighters). I will try anything at this point.
  10. 3
    Well since every department runs differently, with different patients, patient loads, acuity, routine, etc...the best way to get better would be to seek advice from a nurse on your floor who seems to manage their time better. Obviously some things come with experience. Assessments and interventions take less time once you are better at them, and you get good at them with experience.
    But if you have tried different techniques and still get frazzled, and you mention that one of your issues is that you get distracted, maybe you do just need to try a different department. Maybe this setting is just not made for you.

    Here is what I have done though. I usually will make a 'cheat sheet' for each patient, color coded. Name, room number, primary Dx, secondary Dx, allergies. Then I will add what basic stuff I need to do that shift, color coded in marker. So, VS in green, BS in blue (and if sliding scale put that too), blood work in red, IV in yellow, you get the point. So each sheet tells me what every patient needs during the shift in general.
    Then you make yourself a timesheet basically.
    7am-visual rounds of all patients
    7:10-prepare meds
    ...
    1:00pm wound care patient x

    Cross it off as you do it. That way, you get lost or confused, look at your schedule, figure out where you are, what you have done, what you need to do next. Just make sure you are honest with yourself about how long it actually takes you to get certain things done. Like, if you know patient x's wound care will take 20 minutes, don't think you can do it quicker and schedule yourself 10 minutes for it. It's a lot easier to fill in extra time you didn't schedule than to play catch up when you go over.
    gabulldogs, j_tay1981, and keli4747 like this.
  11. 1
    Quote from j_tay1981
    And my leads have said I'm great with building relationships with patients, and I also take great pride in that.
    You should. Keep in mind that management values that, too.

    I thought that I had been improving on delegation, but maybe I could do more...
    Be careful about trying to change too much at one time... it's the 'too many moving parts' syndrome. If you change a bunch of things at once, it's (a) difficult to control them all, and (b) hard to know which change created a positive result.

    Try to make incremental changes and set a couple of achievable goals each shift.

    I really feel like my main issue is prioritization and than staying organized. When issues pop up during a shift, I tend to focus on the new stuff and back burner the older tasks. Not good.
    No, really isn't good... but very easy to do.

    As each new task presents itself, consider the urgency and importance (think ABCs, Maslow, and schedule) and prioritize the things that are both urgent and important a the top of your list.

    Think about clustering care.

    Really try to finish one thing or one group of things before moving on to the next.

    Keep in mind that it's OK to tell a patient, "You'll have to hang on for a bit, I'm in the middle of something" and also to extract yourself from conversations with patients and other staff (which can suck much more time than we're sometimes aware of).

    Don't let charting hang 'til the end of the shift. This was hard for me but forcing myself to stay on top of charting really helped me early on.

    I really think the prioritization issue is a big one for you. Really work on trying to evaluate the urgency and importance of each task throughout the night and then realize that U/I > U/i > u/I > u/i but also recognizes that u/I can become U/I.

    Again, set goals for yourself each shift (small, attainable ones) and then evaluate yourself against them.

    It will get better, I promise you. As you need to spend less brainpower and energy on 'how' to do things, you'll free up bandwidth for 'what' things to do.
    j_tay1981 likes this.
  12. 0
    Thanks again for the new comments!

    The cheat sheet break down is helpful. Since my nurse educator wants me to employ highlighting, this will be a good template to follow. The bit about being distracted bothers me - I don't know if I'm distracted because so many things are coming at me at once that I can't focus, or because I'm trying to catch up with old tasks while new ones are waiting to be addressed as well...

    I have had issues with ending conversations with patients when I'm in the room. I'm used to having people respond accordingly when my responses to their non-medical questions are short and I inch towards the door with each answer! I'm slowly getting better, but I've had to interrupt a few patients so that I could move along and see others. I always feel bad about it, like I insulted them personally. I think that also still needs work.

    Do you all prefer to chart as you go, or leave the charting for large chunks after seeing people? I started off doing the larger chunks, but I got really behind and would forget aspects of my assessments. I've recently tried to implement on the fly charting. I think I need to be more diligent with that since 'Chunk Charting' hasn't been my friend.

    What I'd really like to do isn't necessarily an extension of orientation, but rather, to just come in (even on a day off) and shadow another nurse for several hours to see how he/she goes about her shift. No two shifts are alike, but it might be an eye-opener for me.

    Finally, as I stated previously, I'm concerned that any other area of nursing will likely have these specific trials and tribulations. What other areas tend to have lower patient census, or slower paces? In clinical I went to the ICU and they had three patients maximum, but of course they were higher aquity - drips, fifteen minute VS, etc. I'm not looking for an easy out, but I do want to see what some other options are out there.

    Thanks again!


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