Being a preceptor blows

[RoyalNurse]

I'm with a nurse that's had 1 year experience in an ICU, who wasn't "making it", and had some complaints from doctors about her care. They put her with me for me to "observe" her, and write down what I see. I decided she would do everything, and I would follow her and be available for questions, and corrections. I didn't realize how hard this is! She can't figure out how to draw blood off a heparin line (should she stop the heparin or not?), she didn't tell me one of the patients only urinated 30 cc's for a 12 hour shift (I thought she should be doing her own I/O doc.), she didn't know whether to hold a scheduled beta blocker for a pt on Neo. She's just not engaged with her pstients, she just goes through the motions, but doesn't really care about them. She seems like she only cares about how she looks as a nurse.

Well, we made a few mistakes today that I wasn't ablle to catch on time, it's actually harder to have 2 nurses together than just 1 sometimes. How do I not hover over this girl, but still watch her so she doesn't harm anyone? Any ideas/suggestions welcome :).

[KateRN1]

Although my initial knee-jerk reaction is to agree with Ruby Vee, I had to stop and think about it a little more. What is the outcome that is wanted in this case? Is the desired outcome to have this nurse become a more competent provider or to document enough errors to get her removed from the unit? If the latter, then you're well on your way.

However, if the former a few things to consider first. What sort of orientation did this nurse have in the beginning? In the Level I TC where I used to work, there was a full 6 weeks of orientation that included Foundations of Intensive Care, Advanced Intensive Care, Hemodynamic Monitoring, ACLS, and a few other classes that I can't remember now. This was all classroom, lab, and unit-based with both written exams and return demonstrations. This was a basic orientation for all nurses going into any of the units, whether Surgical Intensive, Cardiac, Medical, or Peds. After the 6 weeks of classroom orientation, the new nurses then went to their assigned units where they received another 2 weeks of unit-specific orientation. After those two weeks, they were paired with a preceptor for as long as it took to deem them ready to function independently. Yes, it was a freakin' long orientation, but the nurses were ready when the time came to function independently. My point being that unit-specific skills are not taught in nursing school and if this nurse doesn't get it, maybe her orientation wasn't as thorough as it could've/should've been.

The idea of turfing her out to the floor is not a sound idea in my mind. If she can't manage in the ICU with one or two patients, how on earth is she going to manage with a team of 5-8 (or more?) patients who require multiple meds, dressing changes, frequent assessments, and the like? That would be sending her from the frying pan into the fire and a really bad idea in terms of patient care.

OP, you stated that you made the decision to stand back and let her do her tasks without hovering. Did you discuss this decision with the nurse before hand or was this a unilateral decision on your part? Have you sat down with her and assessed her knowledge level and how she feels about the unit and being a nurse in general? How does she feel she's doing? Does she feel like she needs help? Have you asked what her learning style is? Does she learn better by reading the book, watching someone else, or being talked through a procedure? Has she completed a self-assessment of her performance that you can discuss together?

Ruby made a very good point about this nurse needing to take responsibility for her own learning and orientation, perhaps that's something you can bring up with her. You can only do so much to help her, she has to invest some of her own time and effort to be a better nurse. Are there any conferences, seminars, or lectures in critical care in your area that she could attend? Do you have any favorite books that you can loan or suggest to her? Any internet resources that you can recommend for more information? Any excellent resource people in the hospital that she can utilize on her own time, like a unit educator?

While I agree with you that sometimes being a preceptor blows, if you are really feeling like you're behind the 8-ball on this, perhaps you can suggest a better preceptor for her.

Motto for life: Lift as you climb!

[JomoNurse]

i haven't had time to read the responses. but from what you said in your post, have you actually taken the time to teach her? maybe she had a $hitty preceptor and wasn't taught anything. And if you're doing the same thing and not teaching, then it's not helping her any bit. I'm not sure if someone mentioned there, but sending her to another unit so she can learn the basics and then maybe come back is pointless. Why would she be sent to another unit, learn how to do things their way and deal with patients that are suitable for them and then get transferred back? My opinion is that she needs to learn in the environment in which she wants to work. That concept is like transferring someone to a Ford dealership in preperation to work at a Ferrari dealership.... pointless! If she HAS been taught everything and isn't retaining anything repeatedly, then she needs to be terminated.

[Virgo_RN, BSN, RN]

TurnLeftSide,

I do not believe that we have the inherent right to work where we want to work simply because we *want* to. While I do agree that problems with performance should be first addressed as a training issue, aptitude does come into play at some point.

I also think you did the right thing by being honest in your appraisal of this nurse and not sugarcoating or holding back what you really think.

There is a time and a place for diplomacy, for dancing around the elephant in the room. When lives are at stake, this is not always the time. For the sake of future patients in your ICU, I thank you.

[RN1982]

TurnLeftSide,

I do not believe that we have the inherent right to work where we want to work simply because we *want* to. While I do agree that problems with performance should be first addressed as a training issue, aptitude does come into play at some point.

I also think you did the right thing by being honest in your appraisal of this nurse and not sugarcoating or holding back what you really think.

There is a time and a place for diplomacy, for dancing around the elephant in the room. When lives are at stake, this is not always the time. For the sake of future patients in your ICU, I thank you.

Thank you, Virgo. I have tried to help this co-worker as much as I can but I let my manager know it's to the point where constantly helping this co-worker is starting to interfere with my care. For example, I got a septic patient, fresh admit, at beginning of shift, I had another patient I had not even see yet and this nurse is pulling me from my patient's bedside to ask me to show him how to drain a vent tric and what the little increments mean. Let me not forget the swan incident or asking me how to transfuse blood, if NS was the only solution we hang it with, how to draw blood from a line with TPN infusing. One night, I timed him and he had questions regarding such and such every 20 minutes. I feel like I'm babysitting him or something. I can hold his hand and show him how to be a nurse. It's rather frustrating. So yes, I told my manager and I don't feel bad. Safety first as they say. So I don't know what will happen. Like I said, if nothing happens, then me opinion didn't matter and I'm not saying anything else.

[geekgolightly, BSN, RN]

I've been in the ICU for a year, and have six years other experience and still ask questions all. the. time. I would ask questions about a ventric, because I haven't had one in about five years, and certainly haven't had one at this hospital. I would ask questions about a swan because I've never had one of those as well. We recently got a hemodilution swan, but not on my patient and I harassed the nurse who had her (she works as a nurse educator for the university so she loves to educate fortunately), and begged to do the CO check myself. She showed me and then I did it. Still, I would come up to any nurse who is comfortable with the swan if I ever get one and ask to go over the procedures for the day in order to properly care for the patient.

I would NOT reject a patient just because I had never had a certain piece of equipment. I would bring out my books that I lug with me every day and ASK QUESTIONS, because that's how you learn.

If you don't know what nipride is, you look it up. Nirpride isn't used daily or even weekly in my ICU. In fact, I don't think I've given it!

In a year there are still lots and lots of questions to ask. Even if I think I know the answer, I will still ask for another opinion. If a patient is crumping, I will pull someone else to get another opinion. Maybe I am just lucky that I work in an ICU where that is EXPECTED. We all do this. Even nurses who have been in that ICU for years still pull other people and gather opinions. My preceptor pulls ME and asks questions about neuro stuff because she knows I've had years of it elsewhere.

In fact, the only thing that is just unforgivable after a year in the ICU is not understanding that 30mL urine in 12 hours is alarming. 30mL urine in TWO hours is alarming. How does someone not understand that this is not ok?

[Ruby Vee, BSN]

i've been in the icu for a year, and have six years other experience and still ask questions all. the. time. i would ask questions about a ventric, because i haven't had one in about five years, and certainly haven't had one at this hospital. i would ask questions about a swan because i've never had one of those as well. we recently got a hemodilution swan, but not on my patient and i harassed the nurse who had her (she works as a nurse educator for the university so she loves to educate fortunately), and begged to do the co check myself. she showed me and then i did it. still, i would come up to any nurse who is comfortable with the swan if i ever get one and ask to go over the procedures for the day in order to properly care for the patient.

i would not reject a patient just because i had never had a certain piece of equipment. i would bring out my books that i lug with me every day and ask questions, because that's how you learn.

if you don't know what nipride is, you look it up. nirpride isn't used daily or even weekly in my icu. in fact, i don't think i've given it!

in a year there are still lots and lots of questions to ask. even if i think i know the answer, i will still ask for another opinion. if a patient is crumping, i will pull someone else to get another opinion. maybe i am just lucky that i work in an icu where that is expected. we all do this. even nurses who have been in that icu for years still pull other people and gather opinions. my preceptor pulls me and asks questions about neuro stuff because she knows i've had years of it elsewhere.

in fact, the only thing that is just unforgivable after a year in the icu is not understanding that 30ml urine in 12 hours is alarming. 30ml urine in two hours is alarming. how does someone not understand that this is not ok?

there's a difference between asking questions/working together and needing babysitting every shift. asking questions is great -- as long as you actually listen to and learn from the answers. if, after a year, you're still asking the same questions over and over and not learning the answers, it's time to find somewhere else to work. mcdonald's maybe?

[RN1982]

I'm not trying to claim that I know everything. I don't. I've been an ICU nurse 1 year and 8 months. I still ask questions too. But we have resources available to us, protocols are at the bedside, easy to follow and I feel like I'm babysitting this nurse every time I work with him. I'm getting asked silly questions like "Can I push IVP morphine through a line with potassium?" or "the protocol says to do this, do i do it?'....instead of the person using their resources and looking it up to see if they are compatible. It's frustrating after a while and a waste of my time when that person is pulling me from my patient's bedside to ask me that kind of question. I wouldn't have taken the patient with the ventric if I didn't know how to properly use it, I would have asked someone else to take that patient, then show me how to use the device.

[geekgolightly, BSN, RN]

I'm not trying to claim that I know everything. I don't. I've been an ICU nurse 1 year and 8 months. I still ask questions too. But we have resources available to us, protocols are at the bedside, easy to follow and I feel like I'm babysitting this nurse every time I work with him. I'm getting asked silly questions like "Can I push IVP morphine through a line with potassium?" or "the protocol says to do this, do i do it?'....instead of the person using their resources and looking it up to see if they are compatible. It's frustrating after a while and a waste of my time when that person is pulling me from my patient's bedside to ask me that kind of question. I wouldn't have taken the patient with the ventric if I didn't know how to properly use it, I would have asked someone else to take that patient, then show me how to use the device.

A ventric isn't rocket science. I would definitely take it and ask for a primer. Now I wouldn't take CRRT without being familiar but a ventric? Yeah.

It's unfortunate that he doesn't know how to look up IVP compatibility issues. Is there not a program where he can type in the meds and see what is compatible? ANd if all protocols are at bedside, why can't he read them?? That's not just asking questions, that's tying to get someone to do your work for you. YUCK!

[MedSurgeMess]

I'm a new nurse and I have been trying very hard to make it and I feel as I'm not making it. I make mistakes and forget things. I'm not in ICU, but the floor I'm at is very busy. I had a preceptor who expected me to remember things right away. I'm not this kind of a person. I need incouragement and positive reinfocement. I need some one to tell me, that I have made a mistake and I will do better next time, instead of going to the managers and telling them that I'm not a safe nurse, because I misplaced a thermometer probe by throwing it on the floor,and not in the trash, or I touched a urinal and never changed my gloves, or I refused to do IV (I just didn't want to hurt my patient), or making me look unsafe on the front of the patient and yelling stop, stop, pulling things out of my hands and making me look like an idiot. I thing the main thing you have to consider, the new nurses lack the experience and they are scared and nervous, they are not used to dealing with 5 patients and million distructions. They are stressed out and vulnarable. Try to be supportive and caring and she will open up to you.

I would agree if this were a totally new grad, but this is someone that has 1 yr experience. No one expects her to act like she has 10-20 yrs experience, but she should have some tasks mastered at this time. I am kind of gathering the tone that many feel she is doing her preceptee wrong, but as a preceptor at work and a clinical instructor at a college, I know how frustrating it is to have someone not get a task or master an interpretation, despite repeated teachings. Sometimes the preceptee just needs to try another area. This is not being mean, we're all not cut out for the same area or same type of work. If it's decided that the preceptee is not ready, perhaps your manager can help her in selecting a new area based on skill assessment.

[RN1982]

A ventric isn't rocket science. I would definitely take it and ask for a primer. Now I wouldn't take CRRT without being familiar but a ventric? Yeah.

It's unfortunate that he doesn't know how to look up IVP compatibility issues. Is there not a program where he can type in the meds and see what is compatible? ANd if all protocols are at bedside, why can't he read them?? That's not just asking questions, that's tying to get someone to do your work for you. YUCK!

Yeah, we have many resources to find out drug compatibilities, he knows where they are.

[nslpriv]

I couldn't have said it better myself.

[Meriwhen, ASN, BSN, MSN, RN]

But also do her a favor. If you are one of those people who just doesn't like to be a preceptor, if you don't have the inexhaustible patients that preceptors have to have sometimes, and if you're just going to end up publicly embarrassing her by going off on a frustrated tirade in the middle of the unit about how much knowledge she lacks (or you're going to talk about her behind her back to your coworkers), go to your manager and request that she be given another preceptor. It will be exceedingly harder to teach her if she feels like you think she is stupid and doesn't know anything, because all she will be thinking about as she's doing something or listening to you tell her how to do something is, Oh man, I hope I don't screw this up. Speaking as a new grad, please be kind to her, you will make or break her future career (as we've already seen).

:yeahthat:

I remember how frustrating it was to go to clinicals and get assigned to a patient whose nurse didn't want to have a student working with her that day. Fortunately, having that happen was the exception and not the rule...but when it did happen, I'd get talked down to and/or get zero chance to do anything. Then afterwards, I'd get reamed by my CI for not doing anything since the nurse did it all, not asserting myself more, or not being able to "get along" with the nurse. The nurse was annoyed, I was miserable, my CI wasn't happy...no one wins that day.

I know not everyone wants to precept someone, especially if you were pressured or ordered into doing so. That's understandable. But if your heart isn't into precepting for whatever reason--whether you think the student/nurse is hopeless, you didn't want to do it, you know you don't have the qualities of a preceptor, etc.--if it is at all possible, please opt out of precepting and have your manager get her someone else. It's not fair to you to have to precept someone when you really don't want to...but it's also not fair the preceptee (?) to be assigned to someone she knows is unhappy about having to precept.