Am I expecting too much? Orienting a non psych RN to inpt and losing my mind!!

[GalRN]

Hi,

I just got home after a frustrating shift that ended up requiring 2 hrs overtime so that I could complete MY charting as I had been covering a lot of the stuff that the other nurse working with me would've done in a normal situation.

I work at a 90 bed facility as the eve charge nurse on an adult unit. I started my job in Sept, was hired straight out of a travel contract at a psych unit at a large medical center. I decided to stay and make my home here, but found the morale and 50% turnover at the big hospital a huge bummer. So I got a job at this hospital as it similar to the settings I've been the most happy practicing in. I am in charge by default almost, b/c a lot of registry nurses are used. In that case the staff nurse is technically in charge.

However while I was orienting the staff were told I would be taking over charge of the unit- they never mentioned it to me. Anyway I understand that they need to hire RN's and in AZ psych positions are not being filled by staff bc registry staff often make more $, and bc they have steady hours and either don't care about benefits or get them from a spouse.

So basically the hospital announced that it had just hired about 20 RN's that had decades of experience- just none in psych. That's not really an issue, if you work with patients at all then you have some psych exp, charting is all quite similar, and I love my field, I don't mind showing someone how I do my job if they can show me things that are universal but are learned by exp.

So last week I got an orientee. They give us a week of on unit orientation bf we get a full assignment- split a 20 bed unit and have a fantastic med nurse and amazing techs that I trust and do their job above and beyond. I consider them to be in charge really as they are interacting with the patients all the time and I have to fit in 1:1 time in with all the paperwork that we have to spend time on- that's universal. We work very closely and can get an amazing amount of work done bc we all know our strengths and do what we are good at. It's not computerized and I can generate massive tornadoes of paperwork, but others are organized to the point of OCD. I assess, they put stuff where it is supposed to go, etc. Anyhoo, the RN that I got was on her last day of orientation and I was in her shoes recently- I know the challenges, esp with a hosp that isn't computerized. It took me a while to get into the groove, but I had a strong background of 10 yrs of psych under my belt. I didn't know their particular system but I have the basic psych skills.

The nurse I am working with has always worked in the OR. Probably some culture shock- just the fact that our patients are conscious must be a big deal. HOWEVER, this nurse doesn't know a damn thing about psych at all. She doesn't have a clue about the DSM criteria, what the treatments are, multiaxial dx, etc. I would be lost in the OR myself. What concerns me is her basic lack of knowledge. She has taken family members phone calls and given status updates wo checking for a release, and tells the families (even the ones with a ROI) things like "tirepitol, umm, I think it's for cholesterol, but anyway the pt is just fine." She said this to a family member who has a background in psych. She asked them to call back at time that wasn't as busy. Thank God. It was her pt, but she was making a valuable discussion into one that could have cut off communication. I needed info about a pt who had no insight, and the relative was able to give me info about what meds the pt took, what she didn't, and in this case the risky manic bx that got her there in the first place. We discussed the TRILEPTAL and she was relieved bc she felt that tegretol was worth a try and had been hoping for an antiseizure MS.

I have given the nurse a number of resources- NAMI for example- they have info for every level of understanding and it seemed like a good place to start her off.

I am becoming more alarmed by the day though. The staff was given a clinical inservice yesterday about steroid induced psychosis (it happened last week when a depressed lady became stark raving mad after a medrol dose pack). She said that she'd heard of it but didn't think that pt was a body builder. The techs and I explained that we were talking about corticosteroids not anabolic. She'd never heard of any of them and I had pulled out a drug ref and named as many as I could find- expecting she recognize one drug name. Nope. Not prenisone, cortisone or any of the different trade names. She doesn't know what an anti psychotic is or what it treats. Same with mood stabilizers. Keeps telling everyone that abilify is brand new and its for depression. Argh!!!! She got that from TV .

I damn near fell over in report today when she asked what ativan was, and then when I told her it was a benzodiazapine wanted to know what that was. She doesn't know anything that I would expect a seasoned nurse to have rudimentary knowledge of and isn't trying to learn. I let her take report on an admit but called for my own sanity bc she got nothing- not even the pts name + age on paper. I didn't call back in front of her and no one else knew- I'm not going to make her look bad. I don't think I need to.

So basically I am doing my assignment on the fly, and dealing with everything from MD orders to med ed with the pts. She is not attempting to get her feet wet.

The final last straw was when I had to save her behind from a pt that should have been screened out as too dangerous and sent to county- they released him still very sick and very dangerous. He'd almost killed his case manager last week- CAH. 18 yrs as a non compliant para schiz with a record of escalating violence. In assessment gave one word answers with major latency, stared and then glared when asked about his ability to tell staff if voices got worse. All I could get out of him before he stopped talking and just glared was that he was pretty sure someone would not die tonight. I gave her the basic safety info- be closest to the door, don't turn your back and please try not to be alone with him any amt of time. Then explained that he was quiet but a huge risk, what I picked up in his presentation and meshed with his history. Told her that ANY change in bx was a sign he was gonna blow. Later he started bouncing his knee in the day room and I cleared all the pts out pronto. She stayed and let him between her and the door. I finally told her I needed her help right away in the hall. She said "in a minute". His nostrils flared and kapow. He hit her in the face. I did everything I could do to avoid this and she sooo lucky I kicked his feet out from under him so she could get away then ran myself. His CM is still in the ICU! I feel that the issue needs to be addressed bf she comes back on the unit. It is not her fault he is violent but I warned her. She lacks judgement knowledge and honestly, a brain IMHO. It will look like I'm blaming her for being an assault victim but I can't keep her safe, and the patients and do all of her thinking for her too. I could let her sink or swim but there are 20 patients and half don't deserve crappy treatment. I can't help it, can't stand it that I know the answers and she doesn't know or care to know. Advice, please?????

[Whispera, MSN, RN]

Things you've described say to me that she isn't a good nurse, and isn't motivated to become one. Your patients' safety and that of the rest of the staff is at risk with her being a nurse.

Talk to your unit director, pronto. It sounds like some re-education is necessary, or other steps need to be taken. You can't let her keep doing as she's doing and you can't keep doing things for her. This isn't a matter of being nice or mean. It's a matter of seeing that patients get proper care!

[elkpark]

I agree that this is a situation that needs to go up the chain of command. She's dangerous and inappropriate in that setting (which is not to say that she wasn't a fine OR nurse, BUT ...) I would be sure to emphasize (with your superiors) all the problems with her knowledge base and clinical practice that you have observed, not just the one recent assault incident.

Although I've not been in a situation as bad as you describe myself (thank goodness!), I do currently work prn at a free-standing psych hospital that has an awful lot of full-time staff RNs who have spent 15 or 20 years doing something else entirely in nursing and have now recently decided that they'd like to try psych (I think, in many cases, because they were looking for an "easier" nursing job -- aaaaaarrrrggghhh!!!) The level/standards of care I see there (as a long-time, experienced psych RN and CNS) are very low, and I think that is in large part because so few members of the nursing staff (or the administration!) actually know anything about psych nursing.

IMO, these situations are just as much (if not more!) the fault of the administrators who hire people with no background and put them into clinical practice without sufficient orientation/preparation to be sure they are minimally competent as it is the individuals themselves. After all, the nurse coming into psych from another specialty area may sincerely "not know what s/he doesn't know," but the administration folks certainly should, and are ultimately responsible for the quality of care delivered in the facility.

Best wishes ...

[ArizonaMark]

Hi GalRN,

Yes, you are expecting too much too soon. If she's spent all her time in an OR, how in the world would she know about all this psych stuff. She's proven she is a good nurse, she has a license. For goodness sake, give her a chance and work with her.

If coming on to this board and reliving each and every faux pas she has committed while under your tutelage has brought you relief, so be it. I only hope you have been professional enough not to carry on as such with your fellow "experienced" nurses. As you said, if you were in an OR, you would feel like a fish out of water as well.

Look for the good, orient her, help her along. Please don't belittle her in front of others. Simply smacks of one-upmanship. And really, haven't we had enough of that already in nursing.

With all due respect,

Mark

[GalRN]

It did just occur to me that in the OR she had one patient at a time. To end up with 10 after 5 days of unit orientation must be hell. I'm gonna write down the basic schedule I go by, when we aren't getting slammed by admits. I came to this job after traveling for a while. I'm used to change and the biggest issue I had was time management. I always told the nurse orienting me that I knew the psych stuff, if they could keep me on track time wise it would be the most helpful. That and the specific expectations on the unit. Basically 1st- how are we supposed to it here, and 2nd- how do you REALLY do it here.

Mark- I haven't really said much to other nurses, being the lowest person on the totem pole everytime I started a new contract is something that I have dealt with a lot. I will not be backstabbing bully, or the one that makes her feel inferior. Or any of the other types. Ppl can be soooo vicious and I know exactly what you mean. If we have time today (she's still coming in, I called to find out who I was working with) I'm gonna make her cheat sheets for every process.

If we get slammed with admits I'll see if she wants to stay an hour later or come in early tmw so I can give her some info while we aren't running around in the chaos that tends to happen when we are working with a nurse who doesn't yet know the routine.

At a new assignment I made sure that I got a copy of every sheet cheat they used for themselves. When a new traveler came I always made copies for them- and gave a heads up on all the stuff they hadn't covered in orientation but I wish I had known.

[GalRN]

Also I forgot to mention that I have WICKED ADHD, go into overwhelm pretty quick in chaos. She does too, she asked me if I thought she did and I told here I thought she did. Said she'd been treated in the past but didn't stick with med b/c of side effects. She asked why I said yes so quickly- I told here that she understands me when I go into rapid fire talking. And she's like me with the pprwk tornado. I'm like Pigpen from Peanuts. Except instead of the cloud of dust behind me it's a cloud of paperwork!!

[ArizonaMark]

Good for you to go the extra mile. Seems like we have both seen nurses who take every opportunity to annihilate the new guy (girl)!

Kudos to you for stepping up and giving a new nurse a hand!

Kindly,

Mark

[GalRN]

Well, my helping the new nurse didn't help anything.... All it did was get me fired.

Quick back story- my supervisor had been the "I'm your buddy and I'm here to look out for my staff" person. When I started the job the facility had just failed a CMS eval and basically had one more chance to fix it before it went public and they lost reimbursement. I was told during orientation that they had hired so many nurses (40 orientees for a 90 bed hospital) because they had changed their model of care and some of the nurses had not been willing to chart correctly, so they were let go.

I had been using computerized charting almost exclusively for the past few years, but had started out on paper and was learning the very specific things that were not errors but annoyed the night staff. I was called in to my supervisors office- she told me that evening shift was getting blasted between "insert profanity's" and "insert different profanity's". She had me sign a clinical supervision form, basically it stated that I had been told the correct way to do whatever it was that had annoyed the night shift. This included not writing the dose right in the middle of the place specified on the preprinted admit order sheet, and crossing off "no pain" in the box that asked for what med, dose, etc. The problem was not the no pain- it was because I had written ativan for anxiety and the time. There was no where else on the nurse flow sheet to chart it. Stuff like that. She told me that she was standing up for her staff but if we missed charting a pain med dose she couldn't fix that and it would result in a written warning.

I never got a written warning- because I stayed until I was able to check the MAR's and BHT notes for a 2nd time to avoid any discrepancies. There was never another mention of an issue re: charting.

It took me a little while to get comfortable and physically organized (major ADD, treated) while I set up my own system that worked with the other nurses and BHT's . Simplified a few things, which staff stated was helpful. So up until today I had not been spoken to by any coworker or supervisor about charting errors or any other issues. Our unit shares a large nurses station with another and on the nights that one or both units got slammed with tons of admits we would take turns so that no got bogged down. Often it was staff's (some registry that knew the facility better than me) decision to delegate specific tasks like one person called for orders, another wrote care plans, etc. We were good, and efficient. I was happy because not only was I more organized, everyone was working together and it was so easy that way. No one stayed late because of an admit- we all pitched in equally- and did what we each were best at. For example I tend to get a chart all out of order and I take forever to put it together, so I would take out only what my techs and I needed at that moment and hand it over the very capable slightly OCD unit secretary (god bless her) and she would put it together really quick. I was so happy to see nurses (different registry every night) all pitching in equally and not minding at all- we all won.

One night we had an AWOL (she turned up in the crawl space above us). A tech and I went outside to look as she had hung herself before and almost finished the job. I realized that we had no hand held radio. Each unit was supposed to have about 4 or 5. If we had found the patient I would have called the unit on my cell phone but that was not the issue. Found out that our one radio didn't work b/c the chargers were broken. Notified maintenence, filed out the service req, and since the risk manager was right there, mentioned it to her. This had been an issue before I had started my job and was being ignored. They were getting new radios, weren't allowed to order parts of the old, blah blah. I stated that this was a huge safety issue and I would follow it up until it was somehow addressed. I followed up by calling maintenence and filling out slips every night until the supervisor said in a very annoyed voice "Just drop the radio subject, OK?" I kept quiet but still filled out the req's.

The day I wrote the original rant we had that very psychotic patient show up and I felt that he was a saftey risk and not able to sign in voluntarily to boot, and I appraoched the sup, and was just saying"heads up- we have a potentially violent" she turned around said "There all mentally ill" in a very annoyed voice and walked away. Didn't stop to hear what the safety issue was. The staff all saw it and were kind of shocked. I documented that I had made the supervisor aware of safety issue. The next night the cops showed up to f/u on a report that a patient had made about an assualt on him prior to getting to our hospital. I know firearms are not allowed and at that facility the police could not come onto the unit either. I call the sup and asked if we could put them in conference rm so he could finish the report. She yelled loud enough for all the to hear "The police are never to come into this hospital unless we call them! It's a HIPAA violation, and I don't care if the pt called them, they aren't allowed to see them b/c the police are not allowed" then slammed her phone down. Again, it got real quiet and another nurse whispered "I thought they had the right to report a crime". we went on with our business, and it was decided that if I spoke to the supervisor she would not let me finish a sentence without cutting me off, and that my requests would go through other nurses in order to get everyone's needs met.

This was the first time she had acted in anything but a helpful manner so I decided that I would bring it up with her the next day.

Yesterday the other staff grew increasingly alarmed about the new nurses lack of knowledge, inability to put dates on a care plan that I gave her (this happened several times). She also kept leaving the unit and disappearing, and was visibly shaking. Apparently this had happened on other units where she had also oriented.

She was so clearly upsetting the pts, and other ppl had noticed. I did not go to my supervisor because of the issue she had wih me- I planned on bringing it up at the end of the shift, in her office. The BHT's that work with me knew I was totally intimidated and marched their butts down and told her what was up. She asked them why I hadn't said anything. One just said that I was trying to give her one last chance to prover herself and doing double the work, basically. The other one, who I work with nightly repeated the same thing, then said that after the interactions between us she thought I was probably a bit intimidated and didn't want to bring it up during a pt care time. The sup talked to the other nurses but said nothing to me. The tech pulled me aside and said "If you want to make her stop, drop the radio thing- I will come in and hunt down maintenance for you tmw", and then said that the supervisor actually was quite annoyed with me because she was very organized and felt that the desk still was a pile of papers. It generally wasn't b/c I make it a point to got through all of my stuff and put it away frequently. My tech told me that the sup would address the issue with me the next day- today. I walked in and was told to go with the supervisor, while I walked behind her I said " How aout we make a deal? I promise not to interrupt you with anything not urgent if you are busy, and I will leave the top part of the station clear for you to put down your clipboard" She did not answer, brought me into the conference room and stated that as it was day 89 of my employment it was time to decide whether I kept my job or if we parted ways. I had not had a negative comment about my work for over a month and the night nurse and I had gotten on better terms- she said the paperwork was fine. Other nurses, one a unit manager, told me that they had let her know I was fun to work with and would like to be assigned there if reasonable.

The ADON was there and my sup told her that the other nurses had frequently complained about my lack of effort and bad performance. I had not heard about any of that. She said that I was too disorganized and maybe I couldn't handle the fast pace and that they had decided to terminate me. Then said she'd seen no improvement in my paperwork. I told her that I had heard nothing about the paperwork at all since she said that she would write us up and explained that I stayed late for a while to look at the MAR's after the med nurse was done, but about 2 weeks go had been able to leave on time b/c I had figure out a much more efficient way to get things done. She could/ would not produce any paper with an error on it. I told the ADON that I'd had positive feedback from the other nurses, and she siad that they had privately addressed the issue of my competence numerous times over that past 2 weeks. The ADON asked me if anyone had said anything at all and I stated that I had received no feedback re paperwork or disorganization. She asked me if I had asked for help with my workload since I seemed overwhelmed. I stated that it had been a bit overwhelming at first but that I'd learned who to delegate what to and that we had a very good system. Then they took my badge and keys and walked me out.

I talked to my (former) tech hen she just called me on break. Apparently a coworker had gone to management about her treatment of me and unwillingness to address valid concerns. They have developed strict anti bullying rules and must've put her on the defensive when they told her that around 9 workers had witnessed each episode. She basically told the ADON all that crap about complaints and basically incompetence. Would not produce anyone who had gone to her with a concern and had no written mistakes. Because it was day 89 of my employment they sided with her and terminated me. They kept the other nurse.

Help! I don't know what to do! I know they don't need a reason to fire me but I really liked this job and I am so screwed... I left a very abusive and dangerous husband and moved 2200miles away for my own safety, and crashed on a friends couch for 2 months saving up for an apartment. I am driving a very expensive rental bc my husband has my car and will not return it. I left everything I owned there anyway, including my cat. I signed a lease about a month ago. Rent is due this week as well as the car rental money, and the first round of all the bills. The job was my ticket to being on my own and starting to find out who I'd been before my husband started the abuse- which included felony assault, denial of $$ for food, and constant berating- including, get this "you are worthless, you'll never keep a job you are so stupid".

I am stunned. I cannot stay with my friend again- her 5 y/o kids came to live with her and there is no room. This check will pay the major bills but I will be left with just enough to buy food for the next 2 weeks. I don't know what to do, there is no one I know here except one person. I'm sleeping on my own couch now bc I decided to get that before a bed bc I could sleep on it too.

I can't believe this is happening.

[ArizonaMark]

Wow, it is tragically amazing how life can take a sudden U turn. I'm sorry for your troubles GalRN. Here are a few suggestions to keep you active, which is what you need to be doing right now.

1) Apply for unemployment insurance ASAP. Document everything that occurred with your sup. Names, dates, witnesses, etc...

2) While you are at it, apply for state assistance as well. Food stamps, rental assistance, insurance, whatever you qualify for.

3) Look on you local Craigslist for RN jobs. If you can do home health (which I loathe), there are usually lots of opportunities there. Careerbuilders.com is very resourceful as well.

4) Reach out to family, friends, clergy for moral, financial support. You need ppl around you right now who care.

5) Do what you can do. Then, rest, and leave this in the hands of God. You are an educated, articulate, and experienced nurse. You will persevere and overcome this....

God bless and keep your chin up,

Kindly,

Mark

[Whispera, MSN, RN]

Wow, you've been through more than most of us could even imagine. My heart goes out to you.

Besides what's been recommended above, I'd recommend checking in your and neighboring communities to see if there's an agency that helps abused women. You could call local ERs and churches to see what they know that might help you find.

[Simply Complicated]

As much as it sucks loosing your job, it honestly sounds like it's better that you are not working there. I just started this week in psych, coming from ICU. I get 8 weeks of orientation. I'm part time, but they have me working full time during orientation. I just can't imagine that short of an orientation period.

As far as the OR nurse. How do you not know what ativan is? Regardless of if she is OR or not, she should know common meds like that. We have to tell them when we have medicated a patient prior to surgery as it is. I can understand not knowing the psych specific stuff. I don't know it yet. But a lot of that was basic nursing knowlege.

[Kooky Korky, BSN, RN]

Well, you have learned some big lessons.

Never cross the boss. Do not complain. Get to work, accept all the conditions no matter how wrong, how unsafe. Always put yourself first. That is, your own need for a job is greater than any other need anyone else has.

That boss sounds mentally ill herself. Be glad you're out of there, however painfully and however unfairly. Be glad you have your license. Do what you have to do to survive, including begging out of your lease and wheedling another friend's couch to sleep on. Go to a shelter for battered women. I know it's terribly painful, but what can you do? Unless you snag employment right now.