Any advice or words of wisdom for precepting new grad ER nurses?

1fastRN · Mar 13, 2014

I think that is the problem my orientee has. She has been on orientation for several weeks now and sounds like she has had several different preceptors... and she seemed confused on the way to do things because different preceptors have told her different things.
There was one thing that really bothered me, though. I had a critically ill patient come in by EMS... we ended up having to incubate and do a lot of other things. My orientee was nowhere to be found. At the very least I would have expected her to observe in the corner. When I was new I wanted to watch everything and was always thinking what could be wrong with the patient, what would we do to fix the problem, etc. Even today I'm the same way... if I'm not assigned to trauma and we get a trauma or critically ill patient through our door you better believe that I am in the room ready for action.

Nerves maybe? Try to encourage them to jump in there. I literally had preceptors push me in. Total deer in the headlights but now I too jump in to help out on other codes. My favorite preceptor literally said, "you are pushing the meds for this intubation." Walk them through it. Have them do different things, tell them to "write" during the code and document the sequence of events (RN transcriber). Maybe they're shy so push them!!

I had 12 preceptors within my first couple months due to scheduling. Sucked because every preceptor has a different style and it was like starting all over again. It's good because you learn different styles of doing things so you can find what you like best, but also bad because you need to have a consistent teacher to adequately evaluate your progress.

Now's your time to build your own little ER nurse. They'll be your co worker soon so give them the exposure and guidance they need! :)

zmansc, ASN, RN · Mar 13, 2014

I agree with 1fastRN, alot of people get intimidated by the mass of moving parts whirling around the patient in what appears at first to be complete chaos, yet is somehow a synchronized team doing an intricate dance. It can be very intimidating the first time someone sees it. I know several who have been intimidated by just the flow into a room of a chest pain patient, with the ekg, ivs being started, several people asking questions at the same time, meds being hung/given, monitors connected, registration, etc.

When I have someone who is overwhelmed by those situations, I try to take them into a code or even a chest pain and have them do tasks for me, keep them by my side, but busy. Or sometimes I'll just take them into a room when a code is in progress and talk them through what is going on for a few minutes, settle their nerves, then they can often either observe or be a general helper for that code.

Often on things like a conscious sedation I'll talk them through what is going to happen and have them transcribe the first time. Then after the pt is coming around, I can have them do the q5 checks and that documentation while I check in on them every so often. In each case it's first getting them some exposure that is non-threatening to them, and then they feel much more comfortable taking the next step.

emtb2rn, BSN, RN, EMT-B · Mar 13, 2014

...I had a critically ill patient come in by EMS... we ended up having to incubate and do a lot of other things...

Therapeutic hyperthermia? :^) sorry, couldn't resist.

turnforthenurse, MSN, NP · Mar 13, 2014

Nerves maybe? Try to encourage them to jump in there. I literally had preceptors push me in. Total deer in the headlights but now I too jump in to help out on other codes. My favorite preceptor literally said, "you are pushing the meds for this intubation." Walk them through it. Have them do different things, tell them to "write" during the code and document the sequence of events (RN transcriber). Maybe they're shy so push them!!

Perhaps... she has been on orientation for awhile now, though. I know I was nervous when I first started but I still wanted to see EVERYTHING, even if it was just to observe. If I heard something critical was coming, believe me, I'm THERE. I wasn't going to just throw her in the middle of everything, I really just wanted her to observe. Maybe I actually have to be like, "hey, come in this room" - maybe she was waiting for me to ask. She did come into the room and very briefly asked what happened after everything was done, but then left the room, almost like she wasn't interested in what was going on. Or maybe she was scared, I don't know.

When I have someone who is overwhelmed by those situations, I try to take them into a code or even a chest pain and have them do tasks for me, keep them by my side, but busy. Or sometimes I'll just take them into a room when a code is in progress and talk them through what is going on for a few minutes, settle their nerves, then they can often either observe or be a general helper for that code.
Often on things like a conscious sedation I'll talk them through what is going to happen and have them transcribe the first time. Then after the pt is coming around, I can have them do the q5 checks and that documentation while I check in on them every so often. In each case it's first getting them some exposure that is non-threatening to them, and then they feel much more comfortable taking the next step.

Good suggestions. She doesn't have ACLS (didn't even know what it was) so during a code situation there's not really much she can do other than chest compressions. I guess I will just have to throw her into situations as we go along. I need to learn how to light a fire under her butt. I guess that's the way to do it?

turnforthenurse, MSN, NP · Mar 13, 2014

Therapeutic hyperthermia? :^) sorry, couldn't resist.

:laugh: I just now realized that.... my computer keeps autocorrecting intubate, lol

1fastRN · Mar 14, 2014

Perhaps... she has been on orientation for awhile now, though. I know I was nervous when I first started but I still wanted to see EVERYTHING, even if it was just to observe. If I heard something critical was coming, believe me, I'm THERE. I wasn't going to just throw her in the middle of everything, I really just wanted her to observe. Maybe I actually have to be like, "hey, come in this room" - maybe she was waiting for me to ask. She did come into the room and very briefly asked what happened after everything was done, but then left the room, almost like she wasn't interested in what was going on. Or maybe she was scared, I don't know.
Good suggestions. She doesn't have ACLS (didn't even know what it was) so during a code situation there's not really much she can do other than chest compressions. I guess I will just have to throw her into situations as we go along. I need to learn how to light a fire under her butt. I guess that's the way to do it?

Hopefully she'll come out of her shell once she gets her confidence up. I used to hesitate to go into a code situation. 1) I was afraid I would look stupid 2) I was afraid I'd somehow mess something up and hurt the patient in some way 3) Many people were assisting and I felt like I'd be in the way. I thought I'd just be fumbling with things and embarrassing myself... and I really thought the other nurses would chew me out or think i was a bad nurse or incompetent.

I was wrong, all of the fellow RNs were very helpful and would explain things to me... I didn't even ask.

A preceptor I had for a brief time wrote on my initial evaluation that I looked "unsure of myself" and "hesitant" during an intibation. This was during my 6th week as a nurse. Of course I was unsure, I didn't know *** I was doing! Fun to look back and laugh.

DavidRNNV · Mar 19, 2014

Thanks for your post 1fastRN! Just had my first week in the ER (previous 3 years M/S) and was feeling frustrated and stupid, because we had very high acuity patients each shift. But after reading your post I feel much better and feel like I learned a lot in just one week. Still feel stupid, but, frankly, I'm suppose to feel stupid and it is motivating me to read up on new tasks/situations that I'm running into. Thanks for the post, got me in the right perspective!

1fastRN · Mar 19, 2014

Thanks for your post 1fastRN! Just had my first week in the ER (previous 3 years M/S) and was feeling frustrated and stupid, because we had very high acuity patients each shift. But after reading your post I feel much better and feel like I learned a lot in just one week. Still feel stupid, but, frankly, I'm suppose to feel stupid and it is motivating me to read up on new tasks/situations that I'm running into. Thanks for the post, got me in the right perspective!

I STILL feel stupid at times, even one year later. Feeling stupid and questioning yourself is better than a dangerous sense of arrogance. You're going to learn so much. Trust me, it's gets better...you'll look back and laugh!

krazievi3t6url · Mar 21, 2014

Gosh, I wish you all were my preceptors when I started off in the ED as a new grad! Sadly, I left after 3 months! I had a terrible experience so here's my 2 cents!

1.) Be nice.

2.) Sit down and talk prior to starting shift. What are your goals as preceptee/preceptor? Another discussion at the end of shift. What could have been done differently, what went well, etc. Doesn't have to be long, a few mins!

3.) Let your fellow coworkers know prior to start of shift if there's anything interesting going on in their rooms to have preceptee participate or observe.

4.) Don't make them look stupid in front of patients, intentionally!

I'm still a little bitter about my experience! I just wish it could have been different. Still hoping to return to the ED some day. =)

1fastRN · Mar 21, 2014

4.) Don't make them look stupid in front of patients, intentionally!

Or make them feel stupid in front of other nurses!

I had a preceptor for a day when my regular preceptor called out. I don't even think she was interested in precepting and I got the feeling she was annoyed when the charge nurse asked her to precept me for the day. I wish she had just refused because it was the next 12 hours were incredibly awkward and embarrassing. She basically ignored me and went on as if it was a regular day. I would keep asking her questions and trying to get involved and she would sort of blow me off and let me do things here and there. I think she thought I was incompetent. I wanted to cry. I had never been treated like that, not even as a nursing student!

To make matters worse, I was charting something and I overheard her and a couple other nurses (2 of which were med-surg floats and not even ER nurses) talking about how new grads shouldn't start in the ER. They went on and on and I was sitting right next to them. If I could have teleported myself I would have. Thank god for a tough skin, looking back on it, it seems 10x ruder now. What would make you think you can treat another human being like that!? Her passive aggressiveness was uncalled for but now that I think about it I don't think she even works on the unit anymore. Good riddance.

zmansc, ASN, RN · Mar 21, 2014

Yes, sadly there are far too many of those sad stories where people do not treat others with respect or dignity. I have always found that a little respect and communication goes a long way. Alot of the time we need to remember to put ourselves in the shoes of those we are interacting with, be it patients or other staff. The patients are in pain, feeling sick enough to come to the ER, in a foreign place being left alone for long periods of time with no clue what is going on... Even if you tell them what is going to happen next, they worry, they have concerns, so when we talk to them, we need to take into account where they are at. New nurses, are afraid they won't cut it, don't know the details of how things work, where particular items can be found, and often have never or rarely done a procedure some provider just ordered them to do. They need to be brought up one step at a time, helped with basics like procedures before we expect them to prioritize multiple patients at the same time. I still remember when I was a new nurse and I felt like I could handle two patients, but three was just an overload and way too much, how could anyone do that???!!! So, if I can apply that though to where my newbie is, then I can probably help them get over that hump.

turnforthenurse, MSN, NP · Mar 22, 2014

I didn't have the greatest orientation when I started out on the floor - I think I had maybe 6-8 weeks? They did start me off slow, first sort of shadowing and then I had 1 patient, then my preceptors gradually increased the number of patients I had until I was pretty much on my own. But that's the thing, I was basically on my own from the start. My preceptor was more so just someone to be there for me to ask questions and to help me with the charting system. I also had multiple preceptors, and I feel like an orientee should be with just one person who is competent and has experience. Maybe have another competent, experienced preceptor as a backup in case the primary gets sick or whatever, because you know, life happens.

When you have multiple preceptors, you don't really develop a system with your orientee because they see so many different ways of doing things, some of those ways aren't correct. For example, someone taught my orientee that you should only auscultate if the patient's CC revolves around something cardiac, respiratory or GI-related. I said you should be listening to EVERYONE REGARDLESS of their CC as a bare minimum. Just things like that.

I felt like I had no guidance when I was a new grad, so I am trying to give my orientee a good experience, something I didn't have. Luckily I turned out okay despite my orientation experience but having a good orientation and good preceptor is so critical for a new grad's success. I just want my orientee to grow and be a great ER nurse that she strives to be. If not, then I feel like I have failed as her preceptor.