Dear preceptor

[Ivanna_Nurse]

Dear preceptor.. I came to you smiling, full of energy and ready to tackle the last leg of my orientation journey, with your guidance of course. I haven't really gotten any inclination on where that guidance is at. You tell me what patients to take, and I take them. Then when I am at the bedside, communicating with the family (you know that rapport thing?), you decide that it is a great time to tell me *not to touch the patient*, or the machines for that matter unless you are there. What? I did not fall off of the nursing school wagon yesterday. I am new to your facility, but not a new grad. I did get a smug sense of satisfaction when the family told you it was fine and I was handling things.

I see that you do not have any intention of assessing my skill level or evaluating areas in which I need assistance. In your eyes, I have no skill level or even brain stem function because every action on my part is met by you with some sort of resistance or interrogation. You cant wait for me to come out of the bathroom before you call the doc... making me look like some sort of fool that cant call the doctor. Lo and behold the toilet flushes and I am greeted with 75 orders, all of which you *write* but make me *do*. Although I am a critical care nurse, and am comfortable with bedside procedures, it is *imperative * on your part to ensure that I am educated on sterile fields and how to open packages. That makes me feel so great, especially with the doc at the bedside.

Precepting with you has given me a great opportunity to practice dealing with "the cold shoulder, being aloof and unapproachable." I *know* that you aren't any of those things, just preparing me for when I run into someone who is. Thanks! I am now well versed in forced conversation, fake enthusiasm, and being lonely but not alone.

I have been practicing my mental, telepathic and psychic abilities... seeing as how there isn't any verbal interaction between us, its time to take it up a notch. *places fingertips to temples* Can you hear me now?

Here is an interesting thought. You breeze in, tell me how the lights have to be like this, and these lines need to be like this and so on. I am respectful of those requests. I like things a certain way too.. try to be mindful of that. The road goes both ways here. The same goes for documentation. Maybe you could ask me why I wrote a certain thing before you scratch it out and write error... although all the extra embellishments make my flow sheet look freakin fantastic, right?

When I ask you about something, especially when its a policy and the rationale for not following it... I just love when you get mean and flash those *knowing* looks to all your friends at the desk.

Precepting with you has been quite the experience, and as life goes, all things must come to an end. Now that our journey is finished, know that I will *never* forget you.

Love, your preceptee

[Keepstanding, ASN, RN]

like they say "what doesn't kill you, makes you stronger" !! you are quite strong now, so go out there a "knock them out" with you talents ! good luck to you

praiser :heartbeat

[classicaldreams]

Dear Ivana,

I'm just another nurse who can raise her hand to your temporary plight. You are obviously articulate. I hope you can use that ability to identify the problem (the preceptor) and move forward. It does get better.

My first preceptor saw the opportunity as a time to spend socializing while I took care of our patients. Honestly, I can't remember anything she purportedly taught me. But the second preceptor was terrific and she taught me a lot. Thank god those days are over, and as someone else commented, you'll discover who is really good and use them to learn and grow.

Could it be that some of these preceptors lack the knowledge and understanding that is necessary, and rather than ask questions with the fear of looking dumb (after all, they sit on a pedestal as the preceptor), act arrogantly just to hide it? Nursing and medicine is an art AND a science. We must try to understand the science and learn to appreciate others' art.

Classicaldreams

[sasha1224]

This thread reminded me of of Jane. I have precepted many over the years and enjoyed it. Would actually volunteer to orient and at times was requested to be a preceptor. I enjoy the teaching aspect and I am completing my degree so I can teach. So along comes Jane. She had already been through 2 preceptors. The DON was at her wits end at what to do with this person. I didn't volunteer but it was known that I liked taking orientees. So I was given Jane. She was a second career person who had already been let go from another RN position. I generally have the patience of Job, but this poor nurse just didn't get it. I tried everything I could think of, she even changed preceptors towards the end for a different perspective. But in the end, she was let go. I had generally had success before this, and felt bad that she just didn't get it. At this same place, my "preceptor" had been a nurse less than a year. She had been given no training on how to orient. After one day of hell, I told her what I needed, got it, and I was able to function. Did she hold this against me? I think so, because her "friends" made my life difficult. Go figure.

[classicaldreams]

. . .

But there are also "okay" preceptors too, and I'm tired of reading in these threads "if they don't want to precept they should get out". It's not that easy. When you have to teach and precept no matter what, even if you say you don't want to, there really is no choice if you want to keep your job. And it's a lot different teaching families and patients, than it is teaching new nurses.

I wish there was a way for it to be ALL "great" preceptors, but there aren't enough of them to go around.

Please take this as a vent also, from someone burned out from doing this too much; and a recent really bad precepting experience that took a lot out of me and made me reconsider ever doing it again. . . .

Seems to be like you are taking an individual's vent and turning it into your own vent.

Ivana's post did not describe an "average" preceptor. I think most of us don't hold grudges against those who must precept and are not great at it.

I don't hold grudges against all of the burned out nurses I have worked with. I recognize their need to move on, however, sometimes they must stay in their jobs for a while before new opportunities arise. But the majority of them do move on eventually and it is nice to see them in their new positions.

I suffered from burnout in another field before nursing. How stupid I feel now. I was burned out because I couldn't, wouldn't (take your pick) muster up the energy and courage to move on.

Classicaldreams

[classicaldreams]

. . .

I gather the OP is working in critical care. I haven't worked critical care as a nurse, but I floated there a few times in my prior position. You do realize, don't you, that you people are control freaks? I mean, sure, we all are, but you folks are obsessed. Almost as bad as L&D. (A male orderly in L&D stocks paper towels and toilet paper. Preferably when the patient is out of the room.). . .

Nursemike,

Your L&D orderly comment made me laugh. I work Critical Care and, yes, there are a lot of control freaks. I see alot (not all) of control over trivial things. . . fold the sheet my way, lay out the IV lines my way, let me show you how I really fluff that pillow.

We assign the sickest patients to our preceptors and orientees, rather than give our orientees a mix of patients with time to learn both task-oriented skills and thinking skills. Instead the poor orientees are bogged down with tasks for 12 hours. I wish they would ease them into to the sickest patients, allow them time to stop and think about what they are doing and why. Talk about the patient's history, allow them time to see the problems develop.

Classicaldreams

[SheaTab]

And so it goes in the world of nursing that we eat our young and also each other. This is known as lateral violence and until the world of nursing stands up and says, "No More!," we will be challenged to put this abuse of each other to rest. I am so saddened by your story because I know it happens all too often. I hope that your organization offers the option to give feedback on your orientation experience and process.

The problem is so convoluted that there is not one simple solution. This lateral violence that is prevalent in all nursing practice areas is a symptom of what I believe is a much bigger problem. Burnout. Nursing is under attack, now more than ever, and we are constantly challenged to perform at a higher level, take care of increasingly complex patients, and fill out an enormous amount of paperwork to meet the demands imposed upon us by our facilities. Many of the "unfunded mandates" are passed on to us as a result of health insurance companies requiring herculean efforts by hospitals to attain maximum reimbursement. In order to sustain a profit, healthcare organizations must jump through an amazing number of hoops and pinch every penny. Unfortunately, this doesn't translate into effective and safe levels of nurse staffing. Many organizations haven't embraced the concept that in order to have lofty goals, they also must be willing to devote the necessary resources to achieve those goals. They have turned to manufacturing process improvement methodologies in the effort to remove all possible waste, and this has had the unfortunate result, in many cases, of leaning us to death.

Most of us, with a few exceptions, graduate from nursing school with the overwhelming desire to take expert nursing care of our patients only to find that we will never have enough time in a given shift to do all that we'd like. We are haggard! Many of us have felt that we have been set up to fail in a system that should have safe and quality healthcare as the principle driver to all decisions made in the organization. I have worked in a number of organizations and also teach nursing students. I have seen some horrific nursing care given in all the areas I've worked. I do not blame the nurses; however, I blame the system. My mother spent 11 days on an oncology floor this month and only one time did a nurse assess her lungs and bowel sounds! This translates into falsifying shift assessment documentation on at least 21 occasions. I refuse to believe that she just happened to get a few bad nurses. This is a system problem. We are burned out to the point that our patients are suffering and the only safe place to vent our frustrations with the system is by taking it out on each other. Read up on "failure to rescue" if you want some sobering statistics on the state of our healthcare system. The patients are suffering tremendously as a result of hospital acquired infection and because we are failing to recognize their subtle signs of decompensation before they ultimately succumb to cardiac and/or respiratory arrest.

Burnout starts as idealistic new nurses first hit the floor. We have incorporated teaching about "reality shock" in many nursing programs because we know that the "real world" of nursing is nothing like what we learned in school and we hope that preparing students will slow the inevitable course of disillusionment. When we hit the floors, we realize we can barely tread water much less give the care we were all taught was so important. Some of the more feisty among us fight the system with the hopes that we can change it; however, fighting can be career suicide (i.e. you will get fired)! Others realize that the system is not changing and is in fact, getting worse. Some of those nurses choose to leave nursing altogether. Those who choose to stay will eventually become resentful of their employer. This resentment comes out sideways at each other and also our patients. The end result is varying levels of apathy which further erode our ability to provide safe and quality patient care. This apathy is a function of self-preservation! It is prevalent in all areas of healthcare and has not been lost on doctors. If you don't become apathetic to a certain degree, you will eventually become exhausted and our reflexive primal instinct is to avoid exhaustion at all costs in an effort to survive. Check out the statistics. Nurses have higher rates of depression, suicide, and substance abuse than the general population. This is true of physicians and many other helping professions as well. The research also supports that burnout is contagious. In other words, we pass this legacy on to new nurses as soon as they hit the floor. We teach them that this is the appropriate way to behave.

I am one nurse in America who is looking for answers and would love to generate a thoughtful discussion to that end. There are pockets of us who are willing to stand up and fight; however, many are just too tired which is completely understandable. While working in an emergency department last night, I had an elderly patient with a significantly elevated potassium. I was discussing her care with another nurse who suggested that I wait until she was about to go to the floor to give her dose of Kaexalate. I know what this nurse was thinking. We are terribly busy in the ED and the last thing we have time to do is to manage a patient with limited mobility and severe diarrhea. However, what happened to this nurse that he/she would suggest that I put this patient at risk of developing a fatal cardiac arrhythmia to avoid inconveniencing myself? At the start of my horribly busy shift, I tried to call report to a floor nurse who asked about the patient's IV access. I looked at my paperwork and realized that the patient (who had been in the ED for 8 hours) did not have a line. Her hostile response to me was, "I am going to have to call the house supervisor and ask why you think it is okay to send me a patient without an IV line." Here's the deal, I placed the line and sent the patient up, but I was actually really hurt by the interaction. We are all busting our proverbial orifices, why can't we at least be kind to each other. There are enough folks standing in line ready to take a jab at us; why must we also do it to each other? What happened to the professionalism of nursing practice? My students wonder aloud all the time why they are required to thoroughly assess their patients when it is rare to see anyone else doing it, doctors included. How many times do you see docs fly through the unit placing their stethoscope on the front of a patient's chest when they know full well that early pulmonary edema can usually only be heard on the posterior chest? Are they waiting for it to become severe enough that the patient requires intubation and significant diuresis? Shouldn't we all be focused on prevention, early identification and treatment? Come on, what has happened to us? I believe we have all run of time and also of the energy required to do the right thing every time for our patients. We are so busy making sure that all of our paperwork is filled out so that we meet our hospitals documentation requirements that we have lost sight of the most important thing a nurse does and that is, assessment. How in the world can we justify any intervention when we haven't adequately performed the one thing that our interventions are supposed to be based upon?

Nurses of America, what are your thoughts? Does anyone else feel a similar sense of urgency to reclaim the ability to safely care for our patients?

I am so sorry you have had this experience with your preceptor, but I am afraid that it happens across our country more often than it should.

Warmest Regards,

Tabitha

[ethelbsnrn]

I am a preceptor myself...my advice is to have a heart-to-heart talk with your preceptor, when both of you are not stressed-out.

These preceptors have taken coaching classes and were not designated to be preceptors w/o any reason. I bet, she was tired, you were tired, nobody talked, thus...this post.

You said this was the end of your journey (last day with her?). Was she like this before or only this time?

[SheaTab]

Sasha, is this "our" Jane? Are you my "Sasha?" Tabitha

[perfectbluebuildings, BSN, RN]

I want to apologize... now i've slept, i realize my post was inappropriate to this thread and does not belong. I don't want to be a coward and delete the whole thing, b/c I did say it & have to stand behind the fact that I did. but I'm sorry because this was the wrong thread for that post, however well-intentioned and relevant it felt this morning. Ivanna, I wish you all the best with coping with this preceptor for however much longer you have to, working with her as well as being precepted by her; and I'm sorry for temporarily hijacking your thread. Take care all...

[nursemike, ASN, RN]

I want to apologize... now i've slept, i realize my post was inappropriate to this thread and does not belong. I don't want to be a coward and delete the whole thing, b/c I did say it & have to stand behind the fact that I did. but I'm sorry because this was the wrong thread for that post, however well-intentioned and relevant it felt this morning. Ivanna, I wish you all the best with coping with this preceptor for however much longer you have to, working with her as well as being precepted by her; and I'm sorry for temporarily hijacking your thread. Take care all...

You know, I don't think it's inappropriate at all to point out the other side in response to a vent. Frankly, if a thread is limited to: "This is awful," and a chorus of, "Yeah, you're right," it's about as useful as the sports scores.

I don't doubt the OP's word that her situation was bad, and she deserves credit for getting through it. And she deserves the chance to blow off some steam. Fine. But it isn't a new problem, is it? Others have had it as bad, or worse. I think it's very worthwhile to look at why it happens and what can be done about it. I think your post makes a start at something Tabitha made very eloquent: very few enter nursing as ogres. Who among us went to our pinnings thinking, "Before long, I'll be able to eat my young."? Something made Ivanna's preceptor the way she was, and if this was the only instance, I could maybe buy lack of character, an abusive husband, whatever. But her story is far from unique.

I've been a nurse for a bit more than four years. I pushed beds and wheelchairs for seven years before that. I thought I knew what I was getting into. I didn't. I thought I was going to be the kind of nurse I think a nurse should be. I'm still working on that, but I notice I'm a little crustier than I used to be. I still think my major advantages as a nurse are my strong back and soft heart, but that thicker skin I've had to grow isn't as sensitive as it used to be. Some of that thicker skin would be necessary no matter what. The patient who always meets you with a smile and a joke when you enter his room sometimes dies. You can't bleed every time. Some patients are rude and demanding, some are needy, and some are just nuts. There may be ways to improve some of that, but it's always going to be part of the territory. So you have to get used to it. But there's a lot of stress that doesn't have to be that way, and unfortunately, sometimes we do it to each other. To some extent, we're in the same position as an abusive husband who gets chewed out at work and feels powerless, so he goes home and beats his wife. Clearly, that's no excuse, and just as there are lots of husbands who cherish their wives, many nurses understand that our best allies are our fellow nurses. But few, if any, of us are saints, and it would be a real good deal if we could figure out ways to have less need to be saintly.

[perfectbluebuildings, BSN, RN]

Thanks nursemike. made me feel better this morning after a long night @ work :-) I've been a nurse probably around the same amount of time as you, and I know exactly what you mean about the thicker skin, and all that comes with it... heck, your whole last paragraph. haha. Wish I could be more expressive/explanatory this morning but I can't, just know I appreciate that you understand!!!

[husker_rn, RN]

I am so sorry you have had a bad experience. Some of us do enjoy teaching/learning with new grads. You are our colleagues and I wish you could all be treated as such.