[medichall]

Help I am the clinical manager in a 13 bed ED that sees about 90 to 100 pts per day. We end up putting stretches around the nurses station and against the wall to expand to 19 beds. CHAOS!!! Here is my problem.

I usually don't take a pt assignment, I float and assist the nurses with critical pts or just the PITA pt. I have a new nurse, she has been in the ED for 8 mths, long enough to see if she would be able to pick it up. She holds pts when they already have a bed assignment. Or holds a pt discharge for hours. The rest of the team has to help her constantly with IV's, meds, ng tubes you name it. I have repeatedly talked to her about it. I stay on top of her cases but am busy helping others too so sometimes it slips through the cracks.

I don't know how else to help her. Any suggestions? I realize she is new and that it takes time, but I hate to constantly stay on her case. I've told the unit manager and she just smiles and say ***** gives pts that something special, (yeah the whole team!) She does have an excellent bedside manner and is very personable but just not cut out to be in the ED. I think she would make an EXCELLENT ICU nurse where you can have that one on one care.

Thanks
Michelle

[traumaRUs]

Then....you need to have a set of expectations (in writing for the entire unit) and go from there. With a set of standards, ie "at the end of your 12 week orientation you are expected to be comfortable caring for x number of pts with these diagnoses. At the end of six months, this is the expectation and by the time you've been here in the ER, you are expected to have the following certifications and be able to care for anything that comes thru the door.

With a standard set of expectations, there is a standard to be met, versus "she holds the pt when she has a bed assignment." HOpe this helps.

[rlgiv]

It seems like her biggest problem is time management. IVs and NGs will improve with time as will her time skills as long as she is dedicated to getting better. Throw her to the wolves. Try discharging some of her patients from underneath her and that will force her to take a new pt when that bed is open. Get he admit ready for her and call report on the pt going upstairs. That is something you will see our charge nurse doing and we are a 43 bed unit that sees about 250 people per day. We also have a written policy to get a pt upstairs within 30 minutes once a pt has a bed. That is not achieved if we have a few critical pts that come in together but at least it is in writing and can be evaluated.

For such a small ER ya'll are really busy as well.

[MichaelFloridaRN]

Could it be that this nurse is doing things they way they should be done? It seems to me that many managers expect everyone to just assume that being understaffed to the point of unsafe care is "normal" and anyone who does not cater to this thought is called slow, unfit, not a team player, etc.

This is most likely why I work in ICU and not the floor or ER, it is the only place that seems to half way allow safe patient care.

[Penguin67]

You said that she had been in your ED for 8 months, but didn't tell what her orientation period was like or how long it was. Do you have a formal orientation where a new employee is paired with a preceptor? If so, I would have expected the preceptor to work with her on developing skills you mentioned with the goal of being able to handle an asignment on her own by the end of orientation. Then again, you have to bring up the thought that no one should really be working alone in the ED, as it takes more than one nurse to get the job done.

I'd make sure that orientation gave her a variety of experiences and guidance from an experienced preceptor, and that as someone mentioned earlier, stated objectives were met before she was removed from orientation.

[squeakykitty]

It could be that more staff is needed on the floor, and she's trying to do things the right way. Is she having to work through breaks?

[KatieBell]

While there are probably things that this nurse is doing that are "The right way" holding a patient for admission, when the bed is available, is never right. ER beds are uncomfortable, and families are often waiting to see their loved one settled upstairs. Same for Discharges. People don't want to hang around forever once treatment is completed. (And people waiting dont want to wait while a DC'd patient is hanging about). These other things, IV's NG's etc will come with time. I've worked with some very good nurses who were not the best sticks ever, but they were solid nurses. Just not who you call when you cant get a vein. And I will admit while I can put in an NG tube, its about my least favorite thing to do (but I don't really need help with it).

I did work with a nurse like this, she is now an awesome flight nurse (one on one care).
and I did exactly what rlgiv suggests, move the patient out from under her. But when this is happening, find ways to help her cope, simple ones though, like bringing the new abd pt back to the room and getting the UA you know you need, and making sure the pt is in a gown so the doc isn't trying to palpate the Gall bladder through 5 sweaters.... not doing the whole assessment or anything.

How does she feel about all of this? I can not imagine she is very popular with her co-workers at this point in time. If not handled correctly it could become one of those downward spirals.... and it sounds as if she will be a great nurse, if she can get the time management down.
I wouldn't say she isn't cut out to be in the ED necessarily...but she does need to realize that time is of the essence in the ED.
Also agree with TraumaRus, very clear expectations need to be written out, thus things are in black and white.

[medichall]

This nurse did have an extensive orientation process with the other clinical manager and has taken required classes ACLS, PALS, HEMO monitoring etc.
She even did a 240 hour clinical before she was hired into the ED with this other manager for her RN program.

On a daily basis I discharge her patients and call report to the floor, I also transport them up there for her. I do try to help her and I have talked to her about time management, setting her priorties but she is still "not getting it." This is a very small VERY busy ED and she is not well liked by her coworkers because she is putting more work on them and not pulling her weight. Now having said that they also help her, they are not mean to her but they are getting very tired of it. Lots of complaints to me about her and her work. She runs our medic to death doing things for her like hanging her antibiotics, giving the pain meds, EKG's. These things are important, time is muscle with these MI pts and she is taking up too much time. We have a great team except for her. And I hope that I'm not being to hard on her because the others are doing " so well"

In the ED we don't have the excuse that we are "too busy" to take report.
When have to take that MI, CVA, resp distress or whatever comes through there regardless of what else is going on.

I'm not trying to get rid of her. I want to see her improve. I'm looking for suggestions on how to do that.

About the breaks, she gets her breaks, the whole team does because I take over their pt load while they eat, break or whatever so that is not the problem.

Thanks for the help

[MajorDomo]

Have the same type of nurse working at my place, all I can recommend is to document and document. If they are still in the probation period, then there would be enough info to get them moved to a less acute area, if not, then in their annual review same thing goes and no performance based raise for them.

[KatieBell]

[
On a daily basis I discharge her patients and call report to the floor, I also transport them up there for her. I do try to help her and I have talked to her about time management, setting her priorties but she is still "not getting it." This is a very small VERY busy ED and she is not well liked by her coworkers because she is putting more work on them and not pulling her weight. Now having said that they also help her, they are not mean to her but they are getting very tired of it. Lots of complaints to me about her and her work.

So, does she realize that people are complaining? It may help to have her realize that it really is a drag to see her name on the schedule.

The only other thing I can think of is this: follow her for a day and see where it is that she is losing time. Is she chatting extensively with the patients...or documenting every sneeze in a level 5 sniffles pt...I mean, what is she doing if the Medic is doing all those things for her? (I once oriented a nurse who continuously sat int he Docs area and flirted with the residents, so much so that the residents actually complained!!!) If you can actually pinpoint what things she is doing that are eating up her time, maybe you can help her cut them out. One of the biggest skills as an ER nurse is to meet greet treat in a short period of time, all the while using mannerisms that show you "care"...
Best Wishes!