Preceptor Problems... HELP!

NICU_Nurse, BSN, RN · Oct 4, 2003

Okay. Let's see. First of all, I believe you were correct in your assm't of that baby. The first thing I thought before I'd even gotten 2/3 through your post was withdrawal (from the morphine). The uncontrollable crying, jitteriness, arching, tachy, these are all signs of withdrawal, and she probably should have had a PRN Ativan/Versed order that would be slowly weaned over the course of a few days/a week (or whatever worked best for that baby). One of the things that works with some of these withdrawing babies is containment- likely the reason that being held was so comforting to her. I swaddle my drug babies TIGHT so that they almost look like little mummies- it calms them down, which is precisely what was happening. You picked her up, she felt contained by your arms and chest, and she stopped crying.

I will never tire of saying this and it is one of the most frustrating things in the world to me, and people WILL disagree with me on this (it's happened more than I believe it should have at work), but I firmly believe that:

IT IS IMPOSSIBLE TO SPOIL A BABY THAT YOUNG!!!!!!!!!!!!

Grrrrrrrrrrrrrrr!!!

Babies that small NEED TO BE SOOTHED when they are crying- they are usually too young to have an understanding of manipulation. They have an emotional or physical NEED and it must be met! There is a REASON that they are crying, and even if the SOLE REASON is because they need attention, well, DAMN IT, it has been PROVEN that babies need attention and affection, so freaking give it to them already! When we're talking about a six month old crying because he/she knows that you'll come pick it up, that might be a different story. Neonates and infants have no other way to communicate! They cry, we try to figure out why. Think of Erickson's stages of development- Trust vs. Mistrust- and imagine what you (not YOU) are doing to these babies who are crying to have a need met and largely being ignored.

I'm not yelling at *you* here. You are new. You have excellent instincts, IMO. Next time, chart YOUR assessment of this baby's pain. If it's 8, then darn it, chart an 8. Of course, you as a new trainee are having to defer to your more experienced nurses, and it's impossible for you at this point to know if your instincts are correct. It's a shame that you were paired with this nurse, because I feel that she needs some re-education on infant pain management.

Did you know that mother nature designed babies to develp a certain way for a reason? I read a theory that the reason infants of all species are so "cute" (ie, large eyes, big head) is so that, considering how defenseless they are, the mothers will bond more easily with them and thus ensure their survival. They've done studies and found that images of children and adults who retain some of these characteristics are considered preferable to to other people when polled and presented with slide-screen images. This is one of the reasons that many of the young starlets in Hollywood resemble each other- petite with large eyes (think Winona Ryder)- and why the public prefers certain stars over others. It's subconscious, but it's been studied scientifically and that theory makes a hell of a lot of sense to me.

Even if a baby is crying ONLY to be held, why would we deprive that infant of that? As you said, on a vent for 3 or more weeks, this baby has missed out on the oportunity to bond with ANYONE, and likely the only touch he/she is used to receiving is painful, traumatic, invasive touch. It is OUR responsibility to do what we can to nurture these babies and teach them that touch can be wonderful and calming and soothing; that they can depend on adults to love and care for them and not to hurt them. This is necessary and follows the widely accepted theory of development by Erickson that we all learned in nursing school.

Next time, in a discreet way, I say go right to the NNP.

Phrase it in a non-accusatory manner:

"I am new, and I just needed some reassurance, so forgive me if I'm totally off-base here, but I was speaking with another nurse who felt that this infant may be experiencing withdrawal symptoms. She's tachy, arching, screaming, irritable, jittery, diaphoretic (whatever- inconsolable, just list the presenting symptoms). She's been rec'ing ATC Morphine and now has nothing ordered. I really feel that this baby is extremely uncomfortable, and has a pain score of 5+ (the ACTUAL score according to the chart, not what you compromised on). Is there ANYTHING we can do? Perhaps a PRN order of Ativan to be weaned over the course of 3 days? ANYTHING to make her more comfortable? I understand that you're the NNP and you would certainly know better than I, but I feel very strongly about this and was hoping you could help me."

Don't accuse the other nurse (out loud!) of not caring or not doing what needs to be done; do it in a way that is neutral (no need to offend people right off the bat) but also present the symptoms and basically build your case for this baby. You're the advocate (and that other nurse should be, as well!). If the NNP says no, there's little you can do, but at least you tried. If that fails, get your cuddler ASAP, whether the other nurse likes it or not. However, ultimately, this other nurse is not the final word- that's why you have an NNP or resident or MD present on or nearby the unit.

Though the KUB was okay, I'd also be looking at how recent the resection was- this baby COULD very well be in pain. Surgery is painful. An adult would never stand for inadequate pain management and it irks me that babies often HAVE to. They are not vocal- that's why WE'RE there.

Forget your age- this shouldn't be an issue for you (though I understand how you might feel about it). Very soon, you're going to be a 22 year old nurse on your own making your own decisions (ie, without a preceptor coupling your assignment and taking partial responsibility). While you will still have people to answer your questions, the final decision will reside with you. There's no need to be rude, simply present your case when the time comes and pray that, if you're correct, someone is there and willing to listen.

When I was brand new, it was not uncommon for me to ask THREE people the same question until I heard enough to either be satisfied or to come to my own conclusion by combining other people's opinions. I always worried that I'd offend someone (What? MY OPINION isn't ENOUGH for her?) but I eventually realized that no, it's NOT enough for me. I have no idea if what you say is correct. I need reassurance. No offense, end of story. Which, btw, is why this board became my second home- the nurses here are FANTASTIC and have done more for me than any of my preceptors or mentors have done, precisely because this forum is anonymous and allows me to make a total fool of myself if I'm incorrect without jeapordizing my professional reputation.

((((((((((((((((((((((((((((hugging you))))))))))))))))))))))))))))

Tomorrow is a new day. Take advantage of it. Just because you're young doesn't mean you're wrong.

NICU_Nurse, BSN, RN · Oct 4, 2003

Holy crap, that was longer than yours! Sorry. I'm an empassioned woman.

Brownms46 · Oct 4, 2003

CallaRn not much to add on here, as NICU_Nurse has done an excellent job in her posts. But I feel compelled to say to you, be very careful in how you approach, and talk with this other nurse you were unfortunately paired with.

Please don't talk about her or the situation, with others in an accusatory way. In fact talk about this situation with your preceptor, and your CNS, but keep to min those who don't need to be involved.

I would be very careful as to who I voiced my frustratons with. You sound like a very knowledgeable and caring professional. I guess I'm just an old traveler who has seen too much, and just wanted to give a little cautionary advice. Good Luck!

NicuGal, MSN, RN · Oct 5, 2003

Wow....that was certainly a sucky day! I have to agree...be very careful in how you approach this subject with anyone....you probably should just tell your preceptor the facts( and make sure they aren't good friends, if they are go to the CNS or unit manager) and not make any judgemental calls (ie she is lazy, she is mean, etc ).

You are, unfortunately, going to run into this sort of thing for the rest of your nursing career. And believe me, if this is your first job, you don't want to start off with the rep as being "the narc" or " the know-it-all" I have seen a lot of things in my 17 years and those that are labeled like that usually end up quitting because life becomes pretty miserable.

I think that you are going to make a wonderful nurse, and like Brown said, keep it professional, and don't be talking about it to too many others....things tend to get back to people. Good Luck!

Brownms46 · Oct 5, 2003

Ditto on everythng NicuGal said! Just one other thing I thought of. Do not alienate this nurse. Be warm, and polite everytime you speak to her. This may not be the case in this unit, but I have worked where there were family members in the same unit. I have worked with an mother and a daughter, and aunt and niece, and so on. And the mother and daughter looked nothing alike!