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Charting and learning

Nurses   (949 Views 23 Comments)

6 Likes; 348 Visitors; 19 Posts

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I am very discouraged and seeking advice again.  Sorry that appears to be the only time I contribute....

I am in my first job out of nursing school, and have been there for a few months now.  One of the main reasons I chose this job was because they said orientation could last however long I needed it too.  I am very smart, and a quick learner, but I also want to do things right, cover my butt, and not make mistakes.  Good orientation felt like a must for a new nurse to me.

However, this place is EXTREMELY short handed (as I know a lot of places are...) and due to the need for me to cover a position by myself, my orientation lasted only a couple weeks.  The orientation I received was not very good.  The nurses I was with saw me as a way to get out early, I think.  They had me do all the work I knew how to do and could handle myself with no guidence, such as taking vital signs and retreiving supplies.  I expected to graduate to more difficult things, I thought eventually I would be doing the charting and the actual patient care while being observed by a nurse to make sure I was doing things well.  This never happened.  So basically, I went from doing CNA tasks, to winging it by myself, and learning through trial and error how to be a nurse who is not in the perfect NCLEX fantasy world.

This scares me.

I have confronted the DON about this issue, but she is new herself, and she has given me advise before, and then other nurses who work the floor have told me that her advise is bad and she doesn't know what she is doing.  I have told the DON that I need more training, and she listens and says she will make that happen, but then we are so short, there is no one to train me.  The other nurses are very helpful when I ask most of the time, but lots of time we are so short and they are so busy, that there is no one for me to ask for help.  I also don't want to come across as a bother, or like I am stupid.  I hate asking for help.

When I come to the DON with a specific question, usually she tells me she will show me how to do it tomorrow, but then someone calls in, she does a double, and does not show up tomorrow.  I am supposed to be charting daily assessments that I don't know how to chart, and she has known this for weeks and cannot show me how to do it.

I feel like I am missing out on simple things that experienced nurses may not know a new nurse struggles with.  Things like when to call the doctor, when to simply get a verbal order, how to read a urine dipstick properly, how to effectively chart without getting yourself into a heap of trouble.

I feel like I come across as really stupid, and I'm not.  I did really good in school, one of the top in my class.  I just feel like it was all crammed in my head so quickly, that a lot of it is gone now.  I try to go back over my text books, but a lot of it does not seem applicable to real life.  Also, I have trouble knowing what I don't know until I am in the middle of a situation at work and realize I didn't know it.

I don't feel like I'm making much sense.

I am looking for some advice, and maybe resources for self learning on some things like charting and nursing tasks that people assume you know.  Are there any good websites or books?  I feel particularly stupid about the urine dipstick thing, but I was not taught anything about it in school, found the jar of dipsticks in the drawer, and there were no instructions.  I had never done one in my life, never seen one, and had no one to ask.

I'm rather afraid that if I go to work somewhere else, they will expect me to have experience that I don't have, because I have been on my own winging it and not doing a good job when I didn't know it.  Does that make any sense?

I feel like I am stuck in a deep hole, and when I think I am digging myself out, I am truly digging myself deeper, and can't tell it because I have too much dirt in my eyes.  I am having a blast at this job, and am very optimistic.  That makes me worry that it is worse than I think it is.  I could be going along fine, thinking I'm doing a great job...and then find myself in court.

I am very bummed out, and this pity party is lowering my self esteem.  A cartoon would be nice, Davey 😢.

I appreciate any advice.  Thank you all so much 🙂!

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97 Likes; 4,069 Visitors; 326 Posts

It sounds like this job is setting you up for failure. I would start looking for something different. Learning to chart and perform more advanced tasks are things that are 100% essential to being successful in your role. The fact that they aren't able to provide you with the time and energy that you need to be trained successfully is unfortunate, especially if you like the place. But you're right, in court an explanation of nobody being available to train you is not going to offset any wrongdoing that should happen. 

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6 Likes; 348 Visitors; 19 Posts

Thanks Ella, I just wish I could figure out a way to learn and stay....

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138 Likes; 546 Visitors; 202 Posts

Is this a LTC facility?  Are there other licensed nurses in the building (think: Assistant DON, DON, educator, MDS nurse, nurse on another wing) in which you can consult prior to calling a Dr or doing a procedure?  2 weeks of orientation should have been enough time to cover basic every day charting.  Refer to your facility's policies and procedures.

Make yourself flash card "cheat sheets" with instructions, such as what to do when you have a fall or other change of condition. i.e. 1. physical exam 2. call MD 3. call family 4. update care plan etc. etc. etc.  After a while it will become second nature.

Even after years of experience I consulted colleagues to make sure I was covering all of my bases, and that is totally appropriate, especially when something unusual was going on.  

 

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Katillac has 18 years experience as a RN.

166 Likes; 6,936 Visitors; 321 Posts

10 minutes ago, Golden_RN said:

Is this a LTC facility?  Are there other licensed nurses in the building (think: Assistant DON, DON, educator, MDS nurse, nurse on another wing) in which you can consult prior to calling a Dr or doing a procedure?  2 weeks of orientation should have been enough time to cover basic every day charting.  Refer to your facility's policies and procedures.

Make yourself flash card "cheat sheets" with instructions, such as what to do when you have a fall or other change of condition. i.e. 1. physical exam 2. call MD 3. call family 4. update care plan etc. etc. etc.  After a while it will become second nature.

Even after years of experience I consulted colleagues to make sure I was covering all of my bases, and that is totally appropriate, especially when something unusual was going on.  

 

I think the problem is nobody actually showed her any charting, they just had her doing legwork for them. Policies and procedures don't typically cover the charting flow. Cheat sheets are awesome when you have the instructions and steps to put on them but it seems like she doesn't and has limited access to resources.

There's a difference between orienting to a new facility's systems and orienting to practicing as a nurse, and two weeks of doing CNA tasks are NOT enough to make you a safe nurse.

I'd start looking for something else as of yesterday.

ETA For the meantime, you need to work on not wanting to ask for help. You need help in order to practice safely. Think of it this way; I know you wouldn't put in a non-sterile Foley just because you didn't want to go all the way to supply to get a new one.  In the same way you need to get past your discomfort about asking for help, because it's about your patient's safety and your license.

 

Edited by Katillac

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232 Likes; 3 Followers; 95,212 Visitors; 36,400 Posts

My former supervisor was kind enough to help me make my index card 'cheat' sheet flash cards when I got a new job where I was the only licensed staff in the building on night shift.  We made these on my own time.  Worth the effort if it can't be done while on the job.  Any good supervisor should have no qualms in helping someone with this.

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Katillac has 18 years experience as a RN.

166 Likes; 6,936 Visitors; 321 Posts

And another thing. . .  LOL

If you go for another job, the way to present this experience is, "Unfortunately, the position I accepted wasn't available when I started working at Big Mistake Care Center." Which is true, you accepted a position that offered an orientation that met your needs as a brand new nurse.

But if you're in an LTC, you're going to need to take the bull by the horns and be responsible for your own learning. After day 1 of being a runner and CNA for other nurses, you need to say, "Yesterday gave me a great opportunity to meet the residents and learn the physical layout of the facility. Today may I shadow you?" Even if he or she never takes the time to stop and instruct, you'll at least learn what passes for OK practice there. And take notes. If they try to just delegate to you, take it up with the DON right away and ask for guidance.

This is going to take a shift on your part from seeing these nurses as your supervisors or like the nurses you may have worked with during clinicals to colleagues who are supporting you as you acclimate. You're not equal in terms of what you know, but you are equal in terms of deserving to be paid attention to when you state your needs. But when you're chronically stressed and pressed it's easy to lose sight of the fact that teaching somebody now is going to mean they stick around and are some day a contributing member of your team, so they may not jump at the chance to help you. If you're going to succeed, you need to make your requests count, and your attitude needs to be, "I know you're busy, but I need to ask you X. I've figured out Y and Z parts (or "I think  it goes like this") but can you tell me about X?" Then thank them. Bring them signs of your appreciation, a coffee or a muffin or whatever.

OK, I think I might really be done now.

 

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WittySarcasm has 10 years experience as a BSN and works as a Rehab Nurse.

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I agree with others saying this place is setting you up for failure. If moving to another place is possible I’d suggest it. However if it isn’t or you want to try to tough it out here’s some suggestions. I’ve worked LTC and in the hospital and this is just what I have picked up. 

1) Call the doctor for anything that makes you feel uneasy- change of condition, abnormal vitals, falls. Even if everything seems normal you can still call and be like ‘he just seems off.’ Many times elderly won’t show any symptoms for UTI except for just being ‘off’. An example- yesterday they ate everything and was active. Today they are just sleepy and barely eating. Or they were sharp as can be yesterday but now it takes repeating tasks 2-3 times before they get it. And don’t be scared to ask if you can get a UA if you suspect an UTI.

 If your facility has a communication board for the doctor this is extremely useful for non-emergent issues- the resident wants to talk to the doctor about their medications, can they get a supplement since they just aren’t eating enough. Also always listen to your CNAs if they say that the person seems different. They are the first to know and the first to see everything. 

2) Verbal and telephone orders can be taken at any time, per your facility rules. Just remember to repeat the order and the spellings of medications you don’t know or may easily be confused. Always spell out the doctor's names. For example ‘That order is 250 mg of Cipro PO twice a day for an UTI.’ This way you have verification you heard it correctly. 

3) For charting I always went basic unless something was off. And even now I still do, it helps me keep organized in my thoughts and making my notes look good. For example if you’re just charting they’re still alive and fine you can do a basic head to toe charting. ‘Resident lying in bed, watching tv (or whatever their activity currently is). Vitals WNL. Assessment done and WNL. Up to BR to void, ate meals well. (Or whatever you want to add to show their current active level). And then build on from there. If they have dressings include that into your note. ‘All dressings CDI, no signs/symptoms of infection noted. (If drainage seen chart about how much- half dollar sized drainage seen on dressing, dark brown in color- I was taught to not use words like moderate or scant because this could mean anything but to use about what size it is- dime, half a nickel, etc). If they have IVs chart that they’re in good condition, (IV site and dressing CDI. No s/s of infection. All ports flush well). If they’re on antibiotics chart that they’re tolerating that well. (Continues on Keflex for UTI. No adverse reactions noted. No s/s or complaints of urgency, burning or unable to void). Document all calls to the doctor. Even if they don’t lead to orders just so you can show you called if something happens later. If they have A/V fistulas chart that there’s a thrill/bruit. 

Also almost forgot- are they there for Medicare charting? If so that is just to include they are still getting treatments there (for example if they’re there for PT, OT then chart ‘Resident continues to receive PT and OT.’) it is it just antibiotics they’re getting chart they are still receiving them. 

New admit charting- be sure to chart any skin issues seen on new admits so your facility doesn’t get the ding for it. 

But at the same time chart any new skin issue you see and what you did for it. For example, ‘Resident’s coccyx and buttocks red. Blanchable, educated pt on turning when in bed and chair. Took resident’s brief off to allow skin to breath when in bed. Placed zinc cream (or whatever cream your facility uses for skin) on site. Note left to doctor about skin issue.’

4) If a procedure is being done you don’t know and another nurse is doing it go watch. When I first started my career I didn’t know how to change Peg tubes. I watched a couple get changed and could do it without problems. Is there a wound nurse? Follow her when she does the rounds. Is it possible for you to come in on a day off and just shadow for a shift?

I know this was insanely long, but charting is something I semi get. 

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6 Likes; 348 Visitors; 19 Posts

Thanks, you all have good advice and this has helped me a lot.

It is a prison that I work in, long term care is my background as a CNA, CMT.  This area is new to me.  Since I am a new nurse, I am not confident in my charting, and know I have done some poor charting d/t lack of knowledge and sleep.  Not asking for help is so ingrained in me that most times I don't realize I should have done it until I look back.  That is something I really need to work on.

I did not think I would enjoy this job so much.  I keep thinking about leaving, but then I talk myself out of it.  I am scheduling a meeting with management to bring up some of my concerns.  They keep telling me that providing more training won't be a problem, but then we are so short staffed that it never happens.

During my training a received copies of policies about stupid stuff, like when to take breaks and the dress code.  None about patient care scenarios, and the interpretation of these policies seems to depend on the staff member I ask.  Everyone keeps telling me the DON is wrong, is it enough to protect my license if I say "the DON told me to"?  I don't think so.

Katillac, you are correct.  They did not show me charting.  It was easier for them to do the charting while I did their leg work, then they were able to get done with their shift early.  It would have taken more time for them to do the leg work and teach me the charting, or so I believe the motivation was.  Or else, they thought like me that I would graduate on up, but then management cut it short.

I started to quit once, and decided to stay because they told me more training was doable, and they can make anything happen if only I would stay.  That has not been the case.

I feel like I am too new to make complete assessments.  Like I said, I am smart, so I believe I am making accurate assessments, but I always forget something.  Sometimes really stupid stuff, like looking at the rash :facepalm:.  I always try to go back and fix the dumb stuff I do, but know that all of it can't be caught.  I wonder sometimes if it is already done, if I should go work in a grocery store.

Did any of you feel this dumb when you started out?

Thanks for taking the time to help me!

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138 Likes; 546 Visitors; 202 Posts

I don't have a background in correctional nursing, but in acute and LTC new grads/new hires often consulted with the nurse educators when they needed more orientation or specific training.  The educator might be able to buddy you up with someone else on your shift to be your go-to person for questions, or provide some other sort of training on charting.  I think your feelings are probably normal for a new grad/new hire, but you must speak up about what you need help with.  If you change jobs but still don't speak up about what you need,  you won't be in a better position.

It just sucks that your preceptors didn't do a better job but it definitely isn't a reason to quit if you can get some more training.

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6 Likes; 348 Visitors; 19 Posts

Thank you.

Come to think of it, I am not sure if we even have an educator.  I think not, but diffinately something to find out.  I agree that changing jobs isn't the answer.  I know a lot of my problems have to do with the facility and my preceptors, but I also know that a lot of it is stuff that only I can fix.  I need to ask for help.  And I need to be more confident.

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1,094 Likes; 7 Followers; 21,235 Visitors; 2,679 Posts

6 hours ago, Trampledunderfoot said:

Did any of you feel this dumb when you started out?

Yes - having large gaps in school/book knowledge vs workplace/real life knowledge is normal when starting out and for a decent amount of time after starting.

Ineffective and truncated orientations are not uncommon but also not acceptable.

At this point you are well into territory where it's just going to become less and less likely that anyone is going to pay for you to go "back" and get more job-specific training. They'll wonder why they should spend money to do that when you have been successfully filling their holes for months (as they see it). I'd say there's a very good chance it isn't going to happen.

You say you are meeting with them again to discuss additional training. In the meantime, recall the legal and ethical principles you know and follow them the best you can while caring for patients. If you don't come out of that meeting with an acceptable plan/timeline, you will have to make a choice.

Lessons:

- Ask for a detailed orientation plan; how long it will last, what it will consist of, how it will be determined that orientation is over or that you have the appropriate knowledge and skills to be on your own

- Speak up sooner rather than later if orientation isn't happening

- If you are told that orientation is over essentially before it has begun because they need you to fill a vacancy, that is your chance to say, "I will need to continue (remain on) orientation or I will need to resign."

- When people say things that sound TGTBT (like "Your orientation can last as long as you need it to!") realize those things are lies, and you are presently having a conversation with a liar

- Remember too, that (to a good extent) we teach people how to treat us; we teach them through our action or inaction what types of treatment we will tolerate

Good luck ~

 

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