Capstone/preceptor woes

[RookieRoo]

Wondering if anyone has any advice for me. My ER capstone is not going as smoothly as I had hoped and I am not sure what to do to turn it around.

I have been 6 out of 16 times now and I feel moderately comfortable now in the environment I'm in. I'm understanding pulling meds, learning all sorts of little ER-specific tricks and tips, learning charting (when my preceptor allows me on the computer- many times, he just does it himself). I'm learning new skills but I get the impression that I am not learning as fast as my preceptor would like. I also think we don't communicate well and I'm not honestly sure whose fault that is... but I guess "fault" doesn't matter, I just want to do better, communicate well, and learn!

One thing I feel my preceptor still looks down on me for: I still cannot reliably get an IV in in stable patients (though, ironically, the two times I have done it perfectly and by myself were in trauma situations without my preceptor guiding me). He has told me that his goal is to be able to send me into the room of a pt who needs an IV and get it done while he does other things, but that hasn't happened yet except the one time. But, I feel like I get nervous or self-conscious around my preceptor because I feel like they expect me to fail, and so I fail (plus other, technique-related reasons... but I mainly think it's a mental block I have). Does that make sense? How do I talk myself out of that? I have done IVs before with other nurses during previous clinicals and not had problems. I had one amazing mentor who was able to talk me through exactly what to do and after that I got every line I stuck that day and from there on out... until now. I just don't get it.

I make plenty of other little mistakes as well, which I know are expected because I am a student, but again I get the impression that my preceptor is just not impressed with me and I want to do better! An example- I was placing a triaged patient into a room to wait and asked the patient a question about their symptoms. When I returned to my preceptor I discussed what I had found out with her, and she told me I shouldn't have asked the patient anything because that was not my role at the time. My mistake, I didn't know. Haven't done it again. A bigger mistake was a time when there were two traumas going on at once and my preceptor and I were helping out with both. We were going to put a catheter in one patient but the pt wasn't ready and meanwhile, they needed help in the next room. So we walked over to the other room and I was mainly trying to stay out of the way while my preceptor tried to place a line, when the nurse we'd been helping from the previous room came and got me and told me I could come place the catheter then. So I went and placed the catheter with that nurse but later my preceptor told me I should have told him first... and he's completely right, I should have. I didn't think about it at the time, I just went and did it. He told me he didn't have a problem with me doing it (all the ER RN's know when there's a student and they will frequently come get me for cool opportunities), he just wanted me to tell him first. Totally makes sense and I felt like a dunce for not having done so. So that was another mistake I made.

I guess I just feel like I can't do anything right. I normally do really well in clinicals, have gotten stellar evals from all my other nurses and instructors... but this one just started off on the wrong foot and I can't seem to turn it around. I'm trying to do well- I constantly stay busy, I help out restocking and other stuff when we aren't busy, I try to anticipate needs and what's going to happen next with patient care... but I feel like these mistakes are bogging me down. Anyone have any perspective for me, or advice on communicating better with my preceptor? Anyone know how I can pep talk myself into doing better? I wish I could start over but I can't, so I need to make the most of the second half of this and try to finish strong.

[jadelpn, LPN, EMT-B]

So, your preceptor has a difficult personality. Try really hard not to personalize this into "I can't do anything right". Because that would be false.

The ER is a "specialty" therefore, it will take you time to adjust to how to do things. Because you are a student on a limited time basis, you will need to learn what you can, and move on.

There are nurses who have a sense of urgency when things are happening in the ER. Your sense should not be of urgency, but of focus on task at hand.

BTW, I am sure that if you interrupted your preceptor when he was attempting to get a line in a fresh trauma to "tell him" that you were doing the foley in the other trauma room, you would have been "spoken to" about that as well.

You need to ask for clarification if you need to. Sometimes with nurses who are in a constant state of urgency, that is not always possible, however, to even say to the nurse who came and got you for the foley "I need to wait for my preceptor" sounds kind of lame, but if that is the boundaries in which your preceptor wants you to work, then it is what it is.

Sometimes, patients go on and on about important things that they seem to leave out of triage. I this happens again, I would say to patient "I am going to interrupt you for a moment and ask that you discuss this with the provider. It is important information that he/she should hear from you".

One of the things you can start getting involved in is patient education at discharge. It is important. It is something that you can learn a lot from, and will get you communicating with patients in a way that will make a difference.

Now onto the IV thing. On a "stable" patient (no sense of urgency) Gather all your supplies. Identify yourself, Identify your patient, explain procedure. I like to say "I am just going to look first, but I will let you know before I do anything". And start at the ac and work your way down if you have to. You should have on the smallest pair of gloves that you can. And learn to feel for those veins. Who cares if you can see them, feel for them. Make sure the area (especially the AC) is positioned well. Meaning that elbow can not be bent, or you will go through the vein. Agitate the skin with the wipe. Move the arm if you need to. Dangle it if you have to. Focus. Do not let performance anxiety get the best of you. Now if it is a "get a line in now" thing, again, learn to feel for the vein. Agitate the heck out of the skin. If someone is up by the ac, look on the wrist. Even the hand (the hand can be trickier veins though).

You got this. And interesting capstone paper topic would be "anxiety in the ER, a student perspective".......

Best wishes!

[NurseGirl525, ASN, RN]

First of all, don't ever let them see you sweat. I think your lack of confidence is showing to your preceptor. Don't do that. Yes, you are a student and you are going to make mistakes. That's a given. But don't ever project anything but confidence. If you screw up, own it and move on. That is honestly all you can do.

If you are having problems communicating, talk to your preceptor about it. I know in clinical I always introduce myself, thank them for taking me on as a student, and start asking what needs to be done. Also, let them know what you would like to learn and see. Just be yourself, be energetic, and let them know they are appreciated. I honestly think if you start better communication, you will find that you will do so much better.

[RookieRoo]

Thank you both. I think you both hit the nail on the head when you touched upon the confidence issues; my confidence, previously high, has really taken a nosedive with this clinical. However, no matter how I feel inside, I need to project confidence outside and I will work on that.

Jadelpn, thank you for the advice about the patient symptoms and the IV line. Ironically the two I've done well so far were under pressure, one on a hand and on in the AC! I think my personal issues with working "under pressure" are solely when my preceptor is in the room... and I will work on that, yes. The other tips (especially the arm dangling, key for patients who like to clench up!) I will also use!

Thank you also for your perspective on the foley issue- I had not thought of that before but you are probably right, had I interrupted him, I probably would have been spoken too as well and as such I was in a catch 22.

Heathermaizey- I will definitely try to communicate more with him and project more confidence and see where that leads me! Thank you!