Discouraging orientation

[Sunbird21]

Hi,

I recently moved out of state and started a new nursing job in a pediatric ER. I have app. 5 yrs nursing experience prior to this job-2 1/2 as an adult med/surg LPN,1 as a PICU RN, and 15 mos as a pediatric floor RN.

I am currently three months into my orientation(they claim it takes 4-6 mos) and I am starting to have a really rough time. The first two months,I seemed to be doing ok,my primary preceptor(we'll call her Annie) was very thourough at explaining how the ER worked,was encouraging,gave positive feedback,etc. My secondary preceptor(lets call her Bonnie) was a bit more stressful-she moves at a fast pace and is all about getting everything done five minutes ago. I wasn't with Bonnie as much,but it came to a head at the beginning of February,when I approached my educator and asked for advice on how to approach her about the difference in our paces.

From this point on,my orientation has gone DOWNHILL. The educator,whom I'll call Sally, gave me good advice at the time,but a week later in our regular meeting with Annie,stated that i was having a lot of trouble and needed not to work with Bonnie anymore.That was fine with me,but then Sally kept making vague remarks about how I needed to "take a step back," and go back to handling 2 patients with more efficiency. After the meeting,i asked sally for specifics-I had thought I was doing at least all right,I had never received any severely negative feedback. Sally kept saying "well,how do YOU think you are doing?" and "we've hit a setback,but we'll keep moving forward." I was puzzled,and asked Annie,who just said that Sally was just making general comments.

Then I spent a day working with Sally to "evaluate" me,and at the end of the day,I asked for feedback,and she shugged,threw the question back at me,and said "well,speed definately needs to come up." I was starting to get a little frustrated,but still not sure how all of the sudden I was doing so badly.

I spent a large chunk of Feb in required classes,my schedule was all over the place,but I thought I was improving on what time I managed to get on the floor.I went back up to three patients,and still got mostly positive feedback from Annie. Then,last week,everything fell completely apart.

I had a patient come in with asthma via EMS. As one of the many,MANY mixed messages I've received in this orientation,I was told that we had to do the computer triage form for EMS patients "right away." I looked at the girl,put her on the monitor,and she was on O2.I started the form,and Annie came in asking me what she sounded like.i said I hadn't done the full assessment yet(again,I was told to to an "eyeball" assessment first,then triage,then come back for full).She hurried me off the computer,had me listen to the patient,then start on this standing protocol that they have. Later Annie told me that with respiratory kids,it was better to assess them first,get them the treatment,then do the form.

OK,so I flubbed that one,I get it,but we talked and I figured it was resolved. But in the meeting a few days later with Sally,Annie(who had otherwise given me several positive remarks,and had been helpful in chaotic times) went on and on about the above patient,as well as mentioning that I "got flustered" when there were several orders on multiple patients at once. She admitted that I knew which one was the priority,but kept recalling how I was "stressed" and she had to tell me "one thing at a time."

Sally kept shaking her head,saying that she wished the respiratory assessment piece had "clicked already" and that I had had several resp. patients,I should be better by now. The whole meeting was very discouraging,and left me feeling very down on myself,my nursing abilities,and my orientation. As the meeting was 30 minutes into our 12 hr shift,I spent the rest of the evening flustered,making stupid little mistakes and then the big one.

I had a resp. kid at the end of the night,I could tell that she had some retractions but she was playful,squirming around,and was difficult to auscultate sounds and really assess her work of breathing. I thought she wasn't too bad off,told Annie so,and of course,when Annie went in,she was calmer and you could see that she was retracting heavily.I felt completely stupid,and even more so when Annie came out of the room,chewed me out,calling me "scary" and saying that she didnt know what to do with me anymore,and that she was told that I had experience,but it didnt seem like it.

Needless to say,i ended the nigth in tears,although two other nurses talked to me afterwards trying to make me feel better. I spoke to my manager the next day,who suggested switching preceptors and starting fresh,and working extra to increase my resp. skills.I was agreeable.

Then i spent the last two days with my new preceptor,Cindy.At first,she was nice,telling me that it was ok to start fresh,she had no preconceived notions,etc. The first day started out ok,but I know I made some small errors(wording in charting,not moving fast enough,having a little trouble with task prioritizing) and she seemed a little annoyed with me at the end of day one. Day two,I tried to do better,and I think i did,but we had a difference in pulse measurement,I used a different cath kit then i had been,thus messing up my sterile technique,and finally,one pt I assessed as not appearing as dehydrated as she thought(we had differing views on how dry his lips were,and how active he was-he was austistic and it was 11pm). I ended the day again feeling like a total screw up,going home in tears.

I have another meeting Wedsnesday with my mgr,Sally,and Cindy.I'm scared that they are going to get rid of me because they think I am incompetent. I know that i have experience,but in my past jobs I wasn't diagnosing and mentally planning the treatments for each kid. I know that my resp. skills need work,as I am used to simply noticing a kid with difficulty breathing/wheezing,and calling RT or the MD and following through with treatment.

I am not making excuses-I know that I need work. But after several weeks of so many mixed messages(take time with patients,but move faster;charting can wait,but hurry up and finish it;you can ask questions,but dont ask me,tell me what you want to do;etc etc etc) I dont know what to do. My boyfriend tells me that my lack of confidence is killing me but I dont know how to feel better when I'm being torn down so much. And after initially getting decent feedback to all of the sudden being ripped apart every day,I feel like I want to just crawl under a rock.

I apologize for rambling,but if anyone has any advice as to what to say in the meeting,how to improve and get better,or if I'm in danger and should just run,please tell me.

Thanks.

[NeoPediRN]

I can understand why you're having trouble transitioning. Especially coming from a PICU, you've been in a controlled environment. You're expecting kids to have respiratory issues, to retract, sats in the 80s probably don't even phase you. You can CPT, suction, turn up the FiO2, bag, turn up the sedation, ask for a neb. The PICU resident can tube a kid in 2.5 seconds, and you can run a controlled code. In the ED, it's the battlefield. It's where it happens before the kids get sent to the unit. It's not normal for them to have respiratory distress, and sats in the 80s will often buy them that tube.

As you well know, kids will compensate and compensate until they don't. An otherwise healthy kid with severe retractions is probably pretty close to the end of their reserve. It doesn't matter what they teach you in the ED, you're going to hear 10 ways to do everything "the right way". ALWAYS ASSESS FIRST. Paperwork is last when you have a kid in trouble. You won't get blamed for taking a listen to lung sounds, but you will get blamed if that kid crashes in front of you while you're entering their triage info BECAUSE you didn't listen to their lungs first.

The most challenging thing coming from PICU to peds ED is the triage piece. Who's actually in trouble? Who do you need to keep a close eye on? In the PICU, the answer is all of them. They're almost all critical. It's a given...but in the ED, you get parents who call an ambulance for a sore throat, and other parents that walk in with a pale listless child and tell you he always looks like that but you know you've got 5 minutes to get access or that child is in deep you-know-what. It's separating the routine stomachaches from the appendectomies. It's eventually being able to take a look at a child and know what priority they fall under without even lifting your stethoscope...and it's not easy.

Maybe this isn't the place for you right now. It doesn't sound like you're enjoying the hectic pace of the ED, and that pace is a given on any shift. You need to be able to feel confident and valued in any job you're going to have. This particular ED just may not be the right fit for you. Take a step back. What have you enjoyed most so far in your career? Do you love peds? What about these jobs has been your favorite piece? Is it the critical aspect? The hands-on? The technology? The assessment? Maybe working in a pediatric urgent care might be a good place to start if you're truly serious about a career in a peds ED. It takes a long time to become very comptent in any ED setting, and it's ten times as difficult if you don't have a consistent orientation with a supportive preceptor. Only you can decide if this is all worth it. Good luck to you.

[Sunbird21]

Thanks for your reply.

I am actually most recently from the peds med/surg unit,and i liked that,but I had been searching for a job in this particular state for more than 4 months(my boyfriend relocated) and I had to cast my net pretty wide after a while. I most enjoy the pediatric part of it,interacting with the kids and parents,and Im ok at most of the skills(meds,cath,NG,suctioning,etc).I eventually received two offers,one for this ED and another for a NICU(which I havent yet done) 45 minutes away. I didnt especially enjoy PICU,so i thought that the ED was a better choice for me.

I understand what you say about the assessment piece,and I agree.As I said before,I have recieved so many mixed messages as to what to do first,not just the triage vs assess piece,but also the "dont waste too much time on vomiting/diarrhea kids" vs "make sure you really assess them for dehydration".

I dont know what to do.As I said,I have a weekly meeting with my manager,educator and new preceptor tomorrow,and my stomach is churning thinking about it. I cant just quit,as I dont have anything else lined up,not sure how it would look,but Im afraid that theyll make the decision for me. How do you know when its not a good fit vs. just needing more time?

[NeoPediRN]

I wouldn't necessarily take to heart the advice that different nurses give to you when it comes to what NOT to worry about. It's your license, not theirs. You have enough experience that you should be able to eyeball a kid and know if he/she needs to be seen NOW or if it's a typical diarrhea/vomiting case. You have to trust your instincts. What does the child look like? If it's a baby is their fontanel sunken? Does the child have glassy eyes? What's their color? Is there petechiae or broken capillaries? How's their turgor? Cap refill? Altered respiratory effort from dehydration? Significant tachycardia? Dry lips are dry lips. Unless they have dehydrated mucous membranes as well, you're not going to get a heck of a lot of information. All these things should be running through your mind as you're giving your patient a once over. You have to be able to prioritize and reprioritize. You're going to fall behind on paperwork when it's busy, but as long as you get the critical things done ASAP, you can catch up on the rest during the short lulls that come in between waiting for the doctor, labs, testing, etc...and as far as feeling flustered, don't let anyone tell you it's not normal. You're going from the frying pan to the fire, and even the best nurses have a hard time keeping their cool at times in the ED. The difference is you have to be able to push through it, regroup, and be effective with carrying out the doc's orders and keeping track of where your kids are.

I think if you've given it your absolute all, but still find yourself dreading going into work, you may have your answer. I don't get the feeling from what you posted that you really love the ED. I think you like working with kids, but may not enjoy the head spinning and constant change in an emergency setting. Is there any way you can talk to the nurse manager for the inpatient peds unit? Sometimes there are openings internally that aren't posted online. Don't feel defeated. The ED can be a tough place to find your footing, and it takes a lot of support for a successful orientation and transition. When there isn't success, it's usually a system failure and not the result of the individual alone.