Advice from experienced nurses please

[ADN_Is_Complete]

Good morning everyone. I'm back again to vent lol. So, I've been a nurse for 5 months now going on 6. I currently work on a Heart & Vascular floor in the hospital, where our ratio is 5-6 patients. I'm on the night shift.

Anyway, I just thought I'd feel a little bit better approaching the 6th month mark but I don't. I feel worse. I don't feel like I'm performing as I should. I've talked to my director and she stated I was doing great. She also said she isn't hearing from other nurses that I'm leaving work for them, even though I feel I am.

The other day I had to call a critical WBC count @645 am, it was an expected value anyway since the patient has cancer and is on radiation and chemo. When I called, I didn't realize the BMP was back as well and I should have also told the physician about that to see if he'd order replacement for a 3.0 potassium level. The day shift nurse ended up replacing it once the doctors rounded that morning and put in orders.

So, when I met with my director, we talked about working on my time management. I just didn't realize how busy charting, assisting with toileting, meds, and other tasks can get. I get frustrated when I have 4 patients and an empty room, because I already know I have to get a patient. Which I don't mind, it just throws me off a lot. I feel so busy most times that I'm overlooking things.

Ex. 1. Friday, I received a patient from another floor around 2am in with encephalopathy, and narcotic dependency. She had a fentanyl patch on.

I remember to put her on telemetry since there was an order for it. She didn't have any meds due. Normally, the MAR system gives a message about continuous pulse ox for fentanyl patches. It didn't this time and I forgot to put her on pulse ox. Her vitals were good and she was on 3 L NC and was sating high 90s.

The day shift nurse asked me later in report did I put her on pulse ox and I felt so embarrassed. I told her I'd do it once I gave her report. She beat me to it.

Ex 2. I've had 2 mislabeled blood specimens in the past month and a half, which were both caught by lab promptly.

I've been using the 2 person system, but I think that person was just signing instead of verifying it was the correct patient.

I'm just very afraid to be considered an unsafe nurse and it worries me.

On my days off, I still think about how I could have been better during a shift and what I didn't do.

Anyway, I just feel like I'm barely making it each shift. I have support from other nurses if I need it but I hate nagging them. I know they have their own load. Now, the CNAs are another story. Some will flat out refuse requests or either forget. How convenient, right?

Ex. "I'm not going to the cafeteria to get the patient a snack box. He should have eaten his dinner".

Seeing as dinner is served between 4-6, and its now 11pm. I'd think he'd want a snack.

Ex.2 " I forgot to retake the BP you asked me to retake because you gave PRN hydralizine.

Even though I'm just sitting at the desk on my phone, I still managed to forget.

I have one cna who thinks I just like to find work to do. No, we're supposed to reposition patients and recheck vitals, sugars, etc., when they are high or low.

I had another one tell me since she had 4 3am labs that morning, we needed to split them. Normally, they have more than that seeing as they can have between 8-10 patients. I normally help with labs anyway. But that morning I was swamped, I had to in and out 2 patients, finish charting, and get ready to pass 6 am meds.

I really don't think some of the aids understand how busy we can get. And I'm not one to overly delegate. Most of the time, I do things myself if I can. But I'm learning I can't do everything. Especially when I'm leaving work after 8 or sometimes 9 and the cnas are leaving before 730 am. I really want to switch floors soon. But I'm not sure if Id get the same support elsewhere.

Sorry for the long post, I just really wanted to give the full picture. Thanks for reading.

[mtmkjr, BSN]

4 hours ago, Ruby Vee said:

As far as working with aides -- you don't say where you're from, but what you describe sounds like an east coast (of the US) thing. You have to learn how to work with aides. They are part of the health care team as well. It doesn't seem fair that you have to cajole them to do their jobs, or spend time talking with them to get them to want to work with you, but sometimes that's what it takes. Aides are people too, and if they think you like them and care about them, they'll work much harder than if they think you don't like them and don't care about them. Take the time to get to know them as people, and you'll probably find you'll have less trouble getting them to do their jobs.

First thing.. what?? I'm confused. What happens in the rest of the country that's different than on the East coast??

Next... I agree with the second part I highlighted. Respect and genuine interest. Some aides have an "us vs. them" attitude and it's partly based on a wrong belief that they are not valued in the same way as nurses, that their job is harder and they do the dirty work that we don't want to do. I try to erase that way of thinking. Aides that work with me know that I respect them on the same level as I do anyone else. and I'm genuinely interested in them as a person. I will do what I can to help them, no job is beneath me, and they know it, They know that I notice when they get overwhelmed and help out if I can. They also notice more when I'm busy and are more willing to do what is needed to be done. Someone suggested asking, "I need..." instead of "could you..." Sometimes it might even be better to say, "(pt's name) needs..." Aides aren't there to meet my needs, but to meet the patient's needs.

One more thing... some of the aides will be testing you to see what they can get away with. If they learn that if they refuse then you will just do it, you can count on that happening regularly. Be firm. Don't be intimidated. Along with showing respect and having a team approach you will learn how to get what you need accomplished with the least amount of negativity.

All that said, I have to say I work with just one who is really difficult... all my attempts to create a good working relationship are nearly futile, but thankfully it is really just one small fly in my ointment.

[TriciaJ, RN]

I agree with the others for the mostpart. I agree with being friendly with the aides and taking an interest in them as people. Thanking them when they do something well.

What I don't agree with is cajoling them to do their jobs. "Do you have time to..." is for someone you can rely on. For the others it's "I need you to......please." If the thing doesn't get done, then you make firm eye contact and unapologetically reiterate that it needed to be done. If they legitimately weren't able to, then it's on them to communicate that back to you so you can problem-solve around it. To just not do the thing or refuse for flippant reasons, then it's a write-up.

I get that write-ups don't always help, but contributing to the paper trail is all you can do. Letting it slide makes you part of the problem.

As far as feeling you're not doing enough, that's a nurse thing. Your managers and coworkers don't expect perfect; they'll cut you slack if they see you're trying to be conscientious. Try to let things go when you get off duty. They're not paying you to worry about stuff on your own time. Hang in there.

[ADN_Is_Complete, ADN]

17 hours ago, brownbook said:

You're right on track..... minimum one year to start feeling comfortable.

I worked with one CNA who was infamous for valid sounding reasons to not do things.

Advice I got here on Allnursus was to say "I need" not "could you" for recalcitrant CNA's. (I use this in my grandson also.)

I have to add almost all CNA's I've worked with have been amazing and saved my hiney numerous times

Thanks Brown Book. There are a handful that work really well and I know that if their names are on the schedule, we're going to provide excellent care. Its the other ones that worry me. I'm learning how to appropriately delegate. I've definitely learned that this isn't a one man show. Lol and I'm learning to put that urgency in my tone along with the please and thank you.

[ADN_Is_Complete, ADN]

11 hours ago, TriciaJ said:

I agree with the others for the mostpart. I agree with being friendly with the aides and taking an interest in them as people. Thanking them when they do something well.

What I don't agree with is cajoling them to do their jobs. "Do you have time to..." is for someone you can rely on. For the others it's "I need you to......please." If the thing doesn't get done, then you make firm eye contact and unapologetically reiterate that it needed to be done. If they legitimately weren't able to, then it's on them to communicate that back to you so you can problem-solve around it. To just not do the thing or refuse for flippant reasons, then it's a write-up.

I get that write-ups don't always help, but contributing to the paper trail is all you can do. Letting it slide makes you part of the problem.

As far as feeling you're not doing enough, that's a nurse thing. Your managers and coworkers don't expect perfect; they'll cut you slack if they see you're trying to be conscientious. Try to let things go when you get off duty. They're not paying you to worry about stuff on your own time. Hang in there.

Thank you Tricia J for your response. I love talking with my aids and getting to know them. I have the uttmost repsect for them as well as other staff. There is still a job to be done regardless of how we feel that day or about the task. And you're right. I still haven't gotten the hang of leaving work at work. I know that's one of my issues. I just over think everything. Haha.

[ADN_Is_Complete, ADN]

12 hours ago, mtmkjr said:

First thing.. what?? I'm confused. What happens in the rest of the country that's different than on the East coast??

Next... I agree with the second part I highlighted. Respect and genuine interest. Some aides have an "us vs. them" attitude and it's partly based on a wrong belief that they are not valued in the same way as nurses, that their job is harder and they do the dirty work that we don't want to do. I try to erase that way of thinking. Aides that work with me know that I respect them on the same level as I do anyone else. and I'm genuinely interested in them as a person. I will do what I can to help them, no job is beneath me, and they know it, They know that I notice when they get overwhelmed and help out if I can. They also notice more when I'm busy and are more willing to do what is needed to be done. Someone suggested asking, "I need..." instead of "could you..." Sometimes it might even be better to say, "(pt's name) needs..." Aides aren't there to meet my needs, but to meet the patient's needs.

One more thing... some of the aides will be testing you to see what they can get away with. If they learn that if they refuse then you will just do it, you can count on that happening regularly. Be firm. Don't be intimidated. Along with showing respect and having a team approach you will learn how to get what you need accomplished with the least amount of negativity.

All that said, I have to say I work with just one who is really difficult... all my attempts to create a good working relationship are nearly futile, but thankfully it is really just one small fly in my ointment.

Thanks for mtmkjr. I always try to help to the best of my abilities. I don't mind helping with a bedpan or toileting or any ADLs. I pitch in for the 3am labs. I'll do whatever needs to be done for the patient. I know they realize that but some still feel that they don't have to be bothered when they don't want to. Not sure what gave them that impression.

[ADN_Is_Complete, ADN]

19 hours ago, Ddestiny said:

I think you're right on schedule with where you "should be" for your level of experience. None of the mistakes you've described are terrible. They don't show any glaring lack of critical thinking. They're just little mistakes that people will make, especially when they're busy, trying to rush, and maybe a bit distracted. No patients were harmed. ? You're doing better than you realize.

I wasn't a new grad when I entered the hospital (3 years primary care) but I still felt like I was drowning. My expectations of myself were not realistic and I beat myself up for every little mistake, no matter how insignificant. I went to my boss crying and she was surprised because she'd been hearing good things about me. I just expected that I should be doing better.... more time efficient, more knowledgeable, etc. Unfortunately the only way to get rid of that feeling of drowning.....is to continue to allow yourself to drown. I had to take deep breaths, remind myself that other people went through this same process and that's how they got to be the people that I looked up to and admired. None of them started out that way. I worked on that floor for 2 years before I moved to the ICU and I became someone that new hires and nursing students looked up to because I made a point of letting them know that it's okay to feel overwhelmed and to make mistakes, as long as you learn from them.

Writing everything down helped me a lot. If I have to rely on my own memory by the end of the shift, that information is going to be gone. lol I updated my little nurse brain sheets to have a "things to do this shift" section where I could write down things that needed to be done as I was getting report or along the way, and a "things we did this shift" section so I could give updates in a prompt way during hand-off rather than trying to look back over the shift in my head.

Take note of that voice in your head that says you're not good enough. If you pay attention, you might be able to decide whose voice that is.

You'll figure out your way, in your own time. Self-flagellation will not make you a better nurse or a happier human being. Be patient and kind with yourself. Remind yourself at frequent intervals, that a lot of people that have been where you are right now and lived to tell about it, all say you're doing a good job.

Great points Ddestiny. My director told me when I met with her that she thinks I'm too hard on myself. I'm not a perfectionist and I'm not sure why I've set these unrealistic goals. But you're right, I just need to ride the wave and wait for the storm to pass. Being new at anything is difficult and I need to be more kind/patient with myself. I CAN do this. And you're right about the negative voice. I need to focus on all the postives things I have done. I'll try to get myself more organized and write down all tasks I need to have completed and check them off as I complete them.

[ADN_Is_Complete, ADN]

19 hours ago, UrbanHealthRN said:

I don't have any other advice to add, but I just wanted to say that based on your OP, ADN_Is_Complete, you sound like a very conscientious nurse who has the initiative to reflect on your work regularly and think about areas where you can improve. Kudos to you for that!

If your nursing coworkers and director are being supportive of you, and you're getting good reviews from them, I'd encourage you to hang in there and try to stick at this position a little longer. Having that support can really make the difference with a hospital job. As for the CNAs, I agree- the issue needs to be addressed, but at least it sounds systemic and not like anyone is targeting you specifically to give a hard time to.

Good luck to you!

Thanks UrbanHealthRN for your kind words. I think I'll hang in there. And my director says she is working on the CNA issue. So hopefully something will be done. There are many that are a pleasure to work with but some. Smh. I don't know what to say about the others. Why choose such a wonderful field and not care?

[Katillac, RN]

1 minute ago, ADN_Is_Complete said:

. . . And my director says she is working on the CNA issue. So hopefully something will be done. There are many that are a pleasure to work with but some. Smh. I don't know what to say about the others. Why choose such a wonderful field and not care? 

It might help to think of it from the perspective that not all enter the field for the same reasons, and not all have the same perspective. Some CNAs see the work as a valuable team effort, others see their day as a series of tasks they must perform and prefer the list be short. Some are experiencing compassion fatigue or burnout. Like nurses, some see it as a paycheck, some see it as a calling and most are somewhere in between. As supervisors, nurses need to balance supporting other team members to the extent possible while ensuring the work gets done regardless of their take on it.

[ADN_Is_Complete, ADN]

17 hours ago, Ruby Vee said:

The way I read this is that you're a new grad only six months in to your first job. Is this correct?

At six months, you're not only still learning the job, your co-workers, time management, the drugs, the labs, how to talk to physicians, etc. you are only now beginning to realize how very much you DON'T know. This is more or less what we old timers used to call "reality shock." You THINK you know what you need to know to do your job, and you are only just beginning to understand the sheer magnitude of things you DON'T know. It's pretty overwhelming.

It takes about a year for a new grad to start to feel comfortable in the job, and about two years to become confident. Changing jobs not only looks bad on your resume, but it slows the process as well. So please, do not even think about changing jobs at this point. The time to change jobs is when you're competent at this one.

This is a normal part of being a beginning nurse. Unfortunately, the only way to GET through it is to GO through it. We have all been there -- at least those of us with enough healthy fear not to be dangerous. We got through it and you will too.

As far as working with aides -- you don't say where you're from, but what you describe sounds like an east coast (of the US) thing. You have to learn how to work with aides. They are part of the health care team as well. It doesn't seem fair that you have to cajole them to do their jobs, or spend time talking with them to get them to want to work with you, but sometimes that's what it takes. Aides are people too, and if they think you like them and care about them, they'll work much harder than if they think you don't like them and don't care about them. Take the time to get to know them as people, and you'll probably find you'll have less trouble getting them to do their jobs.

I hope this helps. Stay in touch with us and let us know how things go.

Thanks so much for commenting RubyVee. I've seen your advice on other posts and it is always spot on. Yes ma'am. I'm a new grad, 6 months in. And I thought the honeymoon and excitement phase lasted a little bit longer. It only took a few weeks for that to wear off for me. But you're right. I'm discovering the magnitude of everything I don't know and it's stressful. I still hate having to page doctors and relay information. But its a must. I'll get through the new grad experience somehow just like everyone else. I think my worst fear is being a dangerous and unsafe nurse. I just want to do right by all of my patients and keep them safe. I'm from South Carolina. And even when I try to be chummy with some of them, theyll stilI do what they feel is warranted. I think the attitude is because they feel they dont get paid enough for this. Plus, many are probably burned out from chronic short staffing. I definitely will continue to post updates.

[ADN_Is_Complete, ADN]

3 minutes ago, Katillac said:

It might help to think of it from the perspective that not all enter the field for the same reasons, and not all have the same perspective. Some CNAs see the work as a valuable team effort, others see their day as a series of tasks they must perform and prefer the list be short. Some are experiencing compassion fatigue or burnout. Like nurses, some see it as a paycheck, some see it as a calling and most are somewhere in between. As supervisors, nurses need to balance supporting other team members to the extent possible while ensuring the work gets done regardless of their take on it.

I agree 100%!

[ADN_Is_Complete, ADN]

I see many of you on other posts and you guys always give good advice. I truly appreciated everyone who commented. Thanks for the support. I feel much better being able to vent my frustrations with all of you because you've all been there. "

Thanks

[JKL33]

37 minutes ago, ADN_Is_Complete said:

I still hate having to page doctors and relay information. But its a must.

There is a mindset and an approach to this, as well. Communicating with other members of the care team, including physicians and other providers, should not be viewed as a necessary evil any more than we would want them to consider communicating with us to be a necessary evil. We are merely conveying something on a patient's behalf/in a patient's best interest. We can only take responsibility for how we approach others; we allow others to take responsibility for how they approach us and respond to us.

When I have communicated in an informed, straight-forward manner, the number of times I have been treated poorly is less than a handful. Those poor responders were outliers and I viewed them as such rather than basing my entire self-worth on their poor reaction.

On an occasion or two I received terse responses as a result of someone (appropriately) wishing that I had handled something a little differently - - I simply accepted the response and let it inform my future practice.

As a new grad, I had the (hard copy/paper) chart open and would even make a list of basic facts I wanted to convey, because I was well aware that I was still learning how to synthesize information and present an overall issue succinctly. Sometimes I either prefaced or ended my information/report with the fact that I haven't made too many of these calls and so if I don't/didn't present all the information they need, they are invited to let me know. Some people don't agree with this approach and find it self-deprecating - I personally never felt that way, and in every instance that I chose that approach, it put me on the fast track to a rapport and a very normal conversation ensued.

58 minutes ago, ADN_Is_Complete said:

I'm discovering the magnitude of everything I don't know and it's stressful.

58 minutes ago, ADN_Is_Complete said:

I think my worst fear is being a dangerous and unsafe nurse. I just want to do right by all of my patients and keep them safe.

These are the kinds of concerns that are going to drive your development into a great nurse.