Advice for RNs who are still wet behind the ears

nambour51 · Jul 22, 2006

Be willing to learn from anyone with more experience, but be wary of anyone who big notes themself or infers that they 'know' it all. Some people have a very good knowledge in a limited area, but just because they are experienced in one area doesn't mean they know 'everything'. Be prepared to check on things that others tell you - to verify and also consolidate what they tell you. We learn much through experience and if we are wise we will learn through the experience of others.

weetziebat · Jul 22, 2006

I'd be very leary of anyone who claims to know so much more than others. Generally, in my experience, that is a big tip-off that they know much less than they think they do, but have a enlarged ego.

ZASHAGALKA, RN · Jul 22, 2006

Until you know your way around practical pharmaceuticals, never give more than two of ANYTHING: vials, pills, etc. without double checking w/ a more experienced nurse.

Some of the biggest med errors in new nurses that I have encountered had something to do with "I didn't know 3 of them were too many". And let's face it, doctor's aren't known for clear handwriting and intent with their orders. . .

(There used to be a chemo med that required 10 pills per dose. After the FDA approved it, the off-label use required a much higher dose. There are times when 4 or 5 or 10 pills IS the right dose. But, you're better off being able to say, "I checked the dose with the charge nurse.")

~~~

At the end of a shift, decompress the shift before you leave. Spend 10 minutes going over everything you did and didn't do. Critique how you 'time managed' with the goal of learning from what you did right - and what you did wrong.

Then, give a follow-up report if needed (so you don't have to call back) and THEN, let it go.

Nursing can be so stressful you HAVE TO LEARN when to leave work at work.

~~~

More than anything else you learn, learn to chart as you go along. Consider having to 'stay and chart' to be a time management failure that you have to work on improving.

Too many times, you have 10 things to do at any given time, and that will completely take over your shift. Charting must be a higher priority item in that list.

Besides, I find that, by taking 'time outs' to chart, I can get a better handle on the chaos. Humans work better when they can take a few minutes and decompress and reanalyze their situations. A few minutes here and there charting does JUST THAT FOR YOU.

If you want to learn to 'work smarter, not harder', then learn to chart as you go. DECIDE that 10 minutes of every hour is 'charting' time and ONLY pain meds and emergencies can invade in that sacred time slot.

Remember: you don't HAVE to chart EVERY assessment in one sitting. Break it out, take it one bite at a time.

~~~

Find an older nurse or two you trust and enlist them to be a 'mentor'. Not a 'preceptor', but someone you can turn to to help you analyze a situation. Someone you trust there is no 'stupid' question you can't ask.

~~~

Respect your contribution. You can only work so hard. Work diligently and learn and be proud of what you are doing.

All of us have situations that overwhelm us. Just don't let those situations overwhelm the value YOU place on your efforts.

~~~

Don't get so caught up in your own routine that you can't find the way to observe the 'learning' stuff that happens on your unit. Get in to see the codes, the central line placements, etc. Watch not just in awe, but with an eye as to the nursing roles you see going on about you.

~~~

Start every IV you can. Make sure everybody knows that YOU will try their IV first. My first job, I was REQUIRED to try twice on every IV on my unit before anybody else could look: no matter how busy I was.

Stressful to be sure, but 500 IVs my first year as a nurse, and hey, I'm fairly good at it.

~~~

Ask nurses from other job types (OB, ER, OR, med/surg, etc.) about their jobs. Learn not only what they do, but get to know THEM. Network. It'll make you a better known nurse around the hospital, and it will give you insights about where you might like to end up.

~~~

Grab all the certs (ACLS, PALS, TNCC) and CEUs you can. Your hospital will probably even pay for most of them.

~~~

Volunteer for committees, especially P&P (policy and procedure) committees. Being a voice there will not only help you make a real difference in YOUR job, it'll give you insight into WHY things are the way they are. Besides, your manager is always looking for such volunteers: the brownie points are just a bonus.

~~~

Smile and never seem hurried in front of pts. I won't go so far as the goofy "how can I help you, I have the time" campaigns, but nursing is as much acting as it is caring.

Spend 2 minutes 'acting' the calm unhurried part (even though you're frazzled and falling apart) and the reassurance you give your pts is worth hours of your time.

I can't tell you how many times I hear in report, "so and so was on the call bell ALL DAY". When I get out of report, sure enough, call bell. I'm johnny on the spot. Five minutes later, call bell - johnny on the spot again. Now, once that pt knows I'll materialize when called, they don't feel the need to hit the button NOW JUST IN CASE they need something in twenty minutes.

It never ceases to amaze me how the pts that are 'always on the call bell' never bother me again after that 2nd or 3rd call that I promptly answer.

~~~

Nursing as acting: never admit you don't know something to a pt. Their confidence in YOU is based on your competence. Always front that competence. If a pt asks me a question I don't know, I'll say something like "give me a sec to take care of xxxxx, and I'll come back and explain it to you." Then, I go look it up.

~~~

ON the same topic: never give a med if you don't know what it does. Always look it up again until you learn it. Nothing is more deflating than a pt asking you what x pill does and then getting a blank stare from you.

After all, if YOU don't know what it does, why are you giving it to ME?!

Exactly.

~~~

When I first started out, on a medical unit with 10 pts, I organized myself into 3 first rounds. The first time through, I just introduced myself and stated I would be back soon.

That way, I could make sure that everyone was where they're supposed to be (not on the floor) and nobody was in acute distress (my first priority on everyone).

Then, 2nd rounds: I'd go back through and do my assessments (and vitals if that is your job).

3rd rounds, med pass and taking care of 'creature comforts'.

I found that those 3 'first' rounds organized my shift better, highlighted the priorities more soundly, and gave me time to 'impress' my pts. Nursing is at least part an acting gig. You can't 'take the time' with x pt when you don't know anything yet about 'y patient'.

I never stopped until my 'first rounds' were complete. But, at that point, my shift was well organized.

~~~

When a new med comes out, ask the pharmacist to send you a package insert and read up on it. You can learn all kinds of things that way.

For example, did you know the molecular wt of Viagra is 666. Don't believe me? Look it up!

Also, I used to drive my co-workers crazy by sing-songing about the drug, integrillin, "eptifibitide, the cyclic heptapeptide!"

I'll think of more next week when I get back from camp.

~faith,

Timothy.

husker-nurse, LPN, LVN · Jul 22, 2006

Until you know your way around practical pharmaceuticals, never give more than two of ANYTHING: vials, pills, etc. without double checking w/ a more experienced nurse.
Some of the biggest med errors in new nurses that I have encountered had something to do with "I didn't know 3 of them were too many". And let's face it, doctor's aren't known for clear handwriting and intent with their orders. . .
(There used to be a chemo med that required 10 pills per dose. After the FDA approved it, the off-label use required a much higher dose. There are times when 4 or 5 or 10 pills IS the right dose. But, you're better off being able to say, "I checked the dose with the charge nurse.")
~~~
At the end of a shift, decompress the shift before you leave. Spend 10 minutes going over everything you did and didn't do. Critique how you 'time managed' with the goal of learning from what you did right - and what you did wrong.
Then, give a follow-up report if needed (so you don't have to call back) and THEN, let it go.
Nursing can be so stressful you HAVE TO LEARN when to leave work at work.
~~~
More than anything else you learn, learn to chart as you go along. Consider having to 'stay and chart' to be a time management failure that you have to work on improving.
Too many times, you have 10 things to do at any given time, and that will completely take over your shift. Charting must be a higher priority item in that list.
Besides, I find that, by taking 'time outs' to chart, I can get a better handle on the chaos. Humans work better when they can take a few minutes and decompress and reanalyze their situations. A few minutes here and there charting does JUST THAT FOR YOU.
If you want to learn to 'work smarter, not harder', then learn to chart as you go. DECIDE that 10 minutes of every hour is 'charting' time and ONLY pain meds and emergencies can invade in that sacred time slot.
~~~
Find an older nurse or two you trust and enlist them to be a 'mentor'. Not a 'preceptor', but someone you can turn to to help you analyze a situation. Someone you trust there is no 'stupid' question you can't ask.
~~~
Respect your contribution. You can only work so hard. Work diligently and learn and be proud of what you are doing.
All of us have situations that overwhelm us. Just don't let those situations overwhelm the value YOU place on your efforts.
~~~
Don't get so caught up in your own routine that you can't find the way to observe the 'learning' stuff that happens on your unit. Get in to see the codes, the central line placements, etc. Watch not just in awe, but with an eye as to the nursing roles you see going on about you.
~~~
Start every IV you can. Make sure everybody knows that YOU will try their IV first. My first job, I was REQUIRED to try twice on every IV on my unit before anybody else could look: no matter how busy I was.
Stressful to be sure, but 500 IVs my first year as a nurse, and hey, I'm fairly good at it.
~~~
Ask nurses from other job types (OB, ER, OR, med/surg, etc.) about their jobs. Learn not only what they do, but get to know THEM. Network. It'll make you a better known nurse around the hospital, and it will give you insights about where you might like to end up.
~~~
Grab all the certs (ACLS, PALS, TNCC) and CEUs you can. Your hospital will probably even pay for most of them.
~~~
Volunteer for committees, especially P&P (policy and procedure) committees. Being a voice there will not only help you make a real difference in YOUR job, it'll give you insight into WHY things are the way they are. Besides, your manager is always looking for such volunteers: the brownie points are just a bonus.
~~~
Smile and never seem hurried in front of pts. I won't go so far as the goofy "how can I help you, I have the time" campaigns, but nursing is as much acting as it is caring.
Spend 2 minutes 'acting' the calm unhurried part (even though you're frazzled and falling apart) and the reassurance you give your pts is worth hours of your time.
I can't tell you how many times I hear in report, "so and so was on the call bell ALL DAY". When I get out of report, sure enough, call bell. I'm johnny on the spot. Five minutes later, call bell - johnny on the spot again. Now, once that pt knows I'll materialize when called, they don't feel the need to hit the button NOW JUST IN CASE they need something in twenty minutes.
It never ceases to amaze me how the pts that are 'always on the call bell' never bother me again after that 2nd or 3rd call that I promptly answer.
~~~
Nursing as acting: never admit you don't know something to a pt. Their confidence in YOU is based on your competence. Always front that competence. If a pt asks me a question I don't know, I'll say something like "give me a sec to take care of xxxxx, and I'll come back and explain it to you." Then, I go look it up.
~~~
ON the same topic: never give a med if you don't know what it does. Always look it up again until you learn it. Nothing is more deflating than a pt asking you what x pill does and then getting a blank stare from you.
After all, if YOU don't know what it does, why are you giving it to ME?!
Exactly.
~~~
When I first started out, on a medical unit with 10 pts, I organized myself into 3 first rounds. The first time through, I just introduced myself and stated I would be back soon.
That way, I could make sure that everyone was where they're supposed to be (not on the floor) and nobody was in acute distress (my first priority on everyone).
Then, 2nd rounds: I'd go back through and do my assessments (and vitals if that is your job).
3rd rounds, med pass and taking care of 'creature comforts'.
I found that those 3 'first' rounds organized my shift better, highlighted the priorities more soundly, and gave me time to 'impress' my pts. Nursing is at least part an acting gig. You can't 'take the time' with x pt when you don't know anything yet about 'y patient'.
I never stopped until my 'first rounds' were complete. But, at that point, my shift was well organized.
~~~
When a new med comes out, ask the pharmacist to send you a package insert and read up on it. You can learn all kinds of things that way.
For example, did you know the molecular wt of Viagra is 666. Don't believe me, look it up!
I'll think of more next week when I get back from camp.
~faith,
Timothy.

I have to say that this is the very best advice that I've seen; the part about appearing unhurried and concerned with your patient is RIGHT ON THE MONEY; I work the same magic on my patients (for the most part). Also, I tend to tell every patient that "I always manage to get the best patients", and, the truth is, I believe it! Pay attention to Timothy's post, new nurses, it's sound advice.......

ZASHAGALKA, RN · Jul 22, 2006

When you are doing assessments and giving report think in the following terms in the following order:

1. Overall appearance: Stand back and take in the scene - in distress? talking on the tele? Annoyed (means a little emotional massaging from you)? etc.

2. Neuro - most important specific assessment, yes? Whether chronic or not, a pt 'not with it' is in a high order of distress. Act on that.

3. Cardiac - even if not 'on tele', you can make quick assessments about circulation, cap refill, pulse, etc. Look at the skin color of extremities as a CARDIAC assessment. A mottled pt should either be on 'comfort measures' or, your highest priority. (or have a severe and long hx of uncontrolled DM or Raynaud's DX - NCLEX hint: look it up.)

3. Pulmonary - look at 'work of breathing' not just 'lung sounds'. Working hard at breathing will tip you off to all kinds of problems, not just pulmonary ones. When YOU'RE STRESSED, what happens to your breathing? (I'll tell you: your metabolism kicks into overdrive, dramatically raising your lactic acid production which has to be blown off by the lungs in order to maintain metabolic balance. Breathing hard is a tip off to a pt that is stressed or in distress, whether the root cause is pulmonary - or not.)

4. GI - bowel sounds, dietary intake, mental note of NPO status/restrictions, etc.

5. GU. Eyeball the foley bag NOW so later you can compare to see how much is 'flowing'. Start thinking in these terms: the kidneys are often the first hint YOU can observe to impending general organ failure. If the kidneys aren't working, your thoughts should be: what ELSE isn't working? (But don't call a doc to tell them that their anuric dialysis pt isn't peeing. Please. I've seen that happen before. It's never a pretty sight to behold.)

6. Integumentary - skin, et. al.

7. IVs and 'lines'. - patency, fluid, rate. Your first few times w/ things like chest tubes - ASK. Those are not 'stupid' questions and you'd be surprised at the discomfort level even EXPERIENCED nurses have with uncommon 'accessories'.

This not only organizes your assessments by priority, but your reports.

During report:

1. name

2. dx (why are they HERE)

3. allegies

4. docs

5. general info (nursing home pt, PIA, etc.)

6. Assessment in the above priority. (this will include things like diet, IVs and O2 status)

7. Upcoming tx and procedures next shift needs to know about

8. A summary of what happened on your shift.

Quick and to the point. Leave out trivia and cut to the chase. Each pt should take less than 2 minutes. If not, work on honing in on what's important. I consider 'reading the doc orders' to be a useless report. I CAN DO THAT.

Start to think like this. If you build a 'mental template' of what you are doing and in what order, it is a foundation to build upon.

~~~

Never apologize for or diss co-workers EVEN IF YOU AGREE WITH THE PT'S ASSESSMENT OF THEM. 1. Nothing will cause you more interpersonal co-worker grief. 2. Some pts just love to manipulate and play off the 'changing of the guard'. It's pretty flattering to hear 'what a great nurse you are', but if that is in the context of 'as compared to the last nurse', then, however true that might be, you're being played.

~~~

The pts and families that most loudly complain "I'm going to report you", are, in my opinion the least to worry about - at least as far as being reported. The ones that report YOU for your honest efforts, have already reported 4 more for real concerns and yet again, another 3 that worked as hard as you did. That lends to discredit them.

Answer their concerns, but don't be put off by, "I'm going to report you". I always respond, "My name is Tim and I'm the only Tim that works on this unit. My manager will know to whom you are referring to." And then I smile and say, "But, I'd be happy to do whatever is WITHIN MY POWER to resolve your concerns, NOW." Key phrase: within my power. That does not mean I'll kiss your booty, but that I will deal with you professionally and courteously.

~~~

Trust your gut and be assertive about it. If 'something is wrong', then 99% of the time, SOMETHING IS WRONG. Every experienced nurse out there can tell you about the 'steep' learning curve of not 'trusting your gut instincts". You KNOW more than you think you know, and lots more than you consciously know. Otherwise, you wouldn't have gotten this far. ACT ON THAT.

~faith,

Timothy.

ZASHAGALKA, RN · Jul 22, 2006

Any mod out there: would you consider moving this to a more general forum?

~faith,

Timothy.

GoldenFire5 · Jul 22, 2006

Such good advice! Thank you so much.

sweet tooth · Jul 22, 2006

Wow! Thanks for taking the time to post Tim. I have printed your advice...too many good ideas for just one read!!!

Editorial Team / Admin · Jul 22, 2006

Thread moved to the General Nursing forum for a better response. Thanks, Tim.

gauge14iv, MSN, APRN, NP · Jul 22, 2006

Tim, you ought to write this stuff up as an article in one of the nursing magazines!

scrmblr · Jul 22, 2006

I only have one question. Why would you not admit to not knowing something in front of a pt??? I respect a nurse who can say "good question! I'm not 100% sure of the answer, but if you give me just a second I will find out" and come back to the pt after I have looked it up or asked another nurse.