Does anyone have advice for a new grad NICU nurse?

[Luna]

Hello everyone.

I recently got hired in the NICU, as a new graduate, so this is my first real job as an RN. I expected orientation to have a basic introduction to the unit, neonatal care in general, hospital procedures and protocols, but instead we have been thrown into 12 hour shifts with our preceptors. Considering that I just finished school, where we primarily learned about adults, I feel very overwhelmed with trying to learn about how to care for the neonatal population all at once, without any general orientation.

I had my fourth shift today, and my preceptor is always telling me I'm too slow with my touch times. I'm not a mom, and didn't grow up around babies, which isn't an excuse but it just means I'm very slow with changing diapers and doing feeds, or basic care in general. It's even hard to even navigate in the incubator for me, just through the doors and get through all the cables with these tiny babies or the concept of Servo or other incubator settings. I'm so slow to get the abdominal circumference and to change diapers and not get a new bed all dirty. I'm really insecure with my performance. IV pumps are different, the incubator in itself is new to me, documenting is completely different, UVCs and UACs are new, everything is new! I never hesitate to ask my preceptor questions but sometimes she looks at me like I'm stupid, and I feel like the unit overall is a "old eat the young" environment.

Today we had two patients, a level 2 setting, which I think would mean a good and easy day for any nurse, but I was VERY overwhelmed. ? I try my best not to show it because I don't want parents to treat me like crap, but I had some parents breathing down my neck as I did a touch time.

How do you guys go about your touch times? How was your experience as a new NICU nurse? My orientation is only three months which is another downer for me because I already feel behind.

I'm determined to do the best I can, but I feel defeated after every shift. ? In no shape or form am I willing to give up anytime soon but I could use some help. From the first day I started my shifts, I've brought a notebook and taken notes on anything I can. I edited my report sheets to my likings. I've written a checklist of ways to go a little faster with my touch times. If anyone has ANY piece of advice for me related to the NICU, I would absolutely love to hear it.

[Lunah, MSN, RN]

Were you told you would get the orientation you envisioned, or did you just kind of expect that? What level is your NICU?

I would suggest speaking with your unit educator, and you will probably have to do some study on your own time about basic neonatal care. You have entered a difficult and amazing specialty, and I would expect anyone new to the NICU to feel like they are all thumbs at first. I don't have any specific advice for you, except please always be diligent with hand hygiene, it can save lives.

Does your NICU offer any courses like NALS, NRP, or STABLE?

[Luna]

1 minute ago, Pixie.RN said:

Were you told you would get the orientation you envisioned, or did you just kind of expect that? What level is your NICU?

I would suggest speaking with your unit educator, and you will probably have to do some study on your own time about basic neonatal care. You have entered a difficult and amazing specialty, and I would expect anyone new to the NICU to feel like they are all thumbs at first. I don't have any specific advice for you, except please always be diligent with hand hygiene, it can save lives.

Does your NICU offer any courses like NALS, NPR, or STABLE?

I had a scholarship during nursing school that affiliated with specific hospitals, so I have a contract with them. During our last weeks of nursing school, we were given a broad lecture about what to expect after graduating and how we would spend half of our time in classes, and half in clinicals, but that it varied in the different units. I guess my unit is very different.

My NICU is a level 2 and 3. Before interviewing, I did a lot of research and had learned about level 4 NICUs, so out of curiosity I asked a nurse where babies that needed to be transferred to a level 4 NICU would go, and she said that level 4 doesn't even exist. O.O (I live in Florida, by the way).

I have started reviewing basic neonatal stuff, I'm really trying to do my part in just trying to tackle content wherever I can and watch youtube videos on skills but there isn't much information for NICU nurses that I could find. My nurse educator is all about just doing shifts...

My NICU offers STABLE, which got postponed for a month later, due to the hurricane. NPR is in a few weeks.

Also, thank you for the reminder about handwashing. My hospital takes scrubbing in very seriously. Thank you for your reply. ?

[Lunah, MSN, RN]

12 minutes ago, Luna said:

My NICU is a level 2 and 3. Before interviewing, I did a lot of research and had learned about level 4 NICUs, so out of curiosity I asked a nurse where babies that needed to be transferred to a level 4 NICU would go, and she said that level 4 doesn't even exist. O.O (I live in Florida, by the way).

Huh? Maybe not in your area, I guess? Our hospital (in Georgia) has a Level IV NICU. (It always trips me up because I have always done trauma, and trauma levels are opposite from NICU with Level I being the highest, haha.)

Hopefully you will feel a little more confident after STABLE and NRP. I suppose your educator thinks that exposure to the babies is the best training. I would request periodic meetings with your preceptor and educator for time to sit down and discuss concrete goals/milestones, progress, etc.

Best of luck!!

[Jory, MSN, APRN, CNM]

If your preceptor is telling you on Day 4 you are "too slow"...you have a bad preceptor. That's a horrible way to start.

Speed takes time and the more she rattles you, the harder it is going to be for you to pick up those skills.

It won't take very long, but I seriously question the choices many managers make for preceptors. Your most skilled nurse is not always your best choice.

[NICU Guy, BSN, RN]

11 hours ago, Luna said:

I asked a nurse where babies that needed to be transferred to a level 4 NICU would go, and she said that level 4 doesn't even exist. O.O (I live in Florida, by the way).

In some states, the numbering only goes to Level III, but their Level III is equivalent to a Level IV in another state.

2 hours ago, Jory said:

If your preceptor is telling you on Day 4 you are "too slow"...you have a bad preceptor. That's a horrible way to start.

I agree 100%. Speed comes with experience. Look into getting a different preceptor.

12 hours ago, Luna said:

It's even hard to even navigate in the incubator for me, just through the doors and get through all the cables with these tiny babies

I have wide shoulders, so I open the side of the isolettes when I do cares. It would be difficult for me to work through the portholes. I turn on the "Boost Air Curtain" (on the bottom left side of the control panel). It provides a warm curtain of air to prevent the isolette from getting cold.

12 hours ago, Luna said:

How do you guys go about your touch times? How was your experience as a new NICU nurse? My orientation is only three months which is another downer for me because I already feel behind.

I had about 5 weeks classroom and 7 weeks preceptor time (total of 12 weeks orientation). My experience was the same as yours. But, each day it gets better. It took me 18 months to feel fully competent in handling any assignment.

[Luna]

2 hours ago, NICU Guy said:

In some states, the numbering only goes to Level III, but their Level III is equivalent to a Level IV in another state.

I agree 100%. Speed comes with experience. Look into getting a different preceptor.

I have wide shoulders, so I open the side of the isolettes when I do cares. It would be difficult for me to work through the portholes. I turn on the "Boost Air Curtain" (on the bottom left side of the control panel). It provides a warm curtain of air to prevent the isolette from getting cold.

I had about 5 weeks classroom and 7 weeks preceptor time (total of 12 weeks orientation). My experience was the same as yours. But, each day it gets better. It took me 18 months to feel fully competent in handling any assignment.

Wow, thank you. Thanks to you I was able to learn about the "boost air curtain"! I was able to look up the manual and it REALLY helped me understand the temperature settings. My next shift is on Friday so I can't wait to put down the doors and do my touch times. Thank you so much, you honestly have no idea how much your post helped and for simply offering my advice, it really made my day better. ❤️

4 hours ago, Jory said:

If your preceptor is telling you on Day 4 you are "too slow"...you have a bad preceptor. That's a horrible way to start.

Speed takes time and the more she rattles you, the harder it is going to be for you to pick up those skills.

It won't take very long, but I seriously question the choices many managers make for preceptors. Your most skilled nurse is not always your best choice.

Unfortunately my nurse educator is very set on the preceptors she chose, but thank you for reminding me I'm not the only one. I find that I'm comparing myself to other skilled nurses or other new hire-ees and that I'm not on their level, so it's always nice to see someone reminding me that being slow on day 4 isn't bad. Thank you. ?

[JKL33]

15 hours ago, Luna said:

I had my fourth shift today, and my preceptor is always telling me I'm too slow with my touch times.

This is not my specialty but I have a general comment.

Make sure that you are not mistaking the nature/spirit of your preceptor's comments. IOW, don't go out of your way to make them more than what s/he might mean.

I try not to use verbiage like "you're too slow with [x]" but I have said essentially the same thing when, overall, it is important to patient care (and to the orientation itself) that we look to speed up [x] thing as a matter of priority.

Does that make sense?

For example, in the ED, new grads might really belabor a full H>T assessment. So I will try to pleasantly convey that in order for them to get up and running (or even have the time to focus on any of the other stuff that is part of the orientation) we are going to speed up our assessments overall. In fact, we are going to eliminate the full H>T assessment and we are going to do a rapid general assessment and then a focused assessment. As part of this conversation I might actually say "We are taking too long on this" (which is the equivalent of what you are reporting, essentially) - - because, in addition to trying to be pleasant and constructive, I also know that if meanings aren't clear then the words are useless and people still don't understand what you wanted them to understand.

Make sure you are communicating the things that you are doing to move yourself toward goals.

I hope for your sake that your preceptor is not a negative person in spirit....but before you travel that road try just taking what s/he says at strict face value. Not as a personal insult. Don't forget to be interactive! When making small talk or reviewing your day you could ask something like, "In your experience, how long does it take new grads to get faster with [x, y, z/touch times]?" Be conversational about it, you know? That's a very, very low-key way of showing your preceptor you are thinking about it and placing importance upon it while also silently reminding them about the reality of the situation [you are new].

Best of luck!

[Jory, MSN, APRN, CNM]

On 9/4/2019 at 10:33 AM, NICU Guy said:

In some states, the numbering only goes to Level III, but their Level III is equivalent to a Level IV in another state.

I agree 100%. Speed comes with experience. Look into getting a different preceptor.

I have wide shoulders, so I open the side of the isolettes when I do cares. It would be difficult for me to work through the portholes. I turn on the "Boost Air Curtain" (on the bottom left side of the control panel). It provides a warm curtain of air to prevent the isolette from getting cold.

I had about 5 weeks classroom and 7 weeks preceptor time (total of 12 weeks orientation). My experience was the same as yours. But, each day it gets better. It took me 18 months to feel fully competent in handling any assignment.

Just a couple of FYIs:

The difference between a Level III and a Level IV is not so much the number of weeks gestation, but in the fact the Level IV's tend to offer ECMO. You'll almost never see ECMO in a designated Level III NICU. Level IV also offers the most complex of care (think layered congenital disorders and advanced cardiac and neuro abnormalities) and has the specialists to take care of them...this means babies from Level IV centers are rarely, if ever, transferred anywhere. They accept rather than send out.

Dropping the sides of the isolette was a big no-no in my former hospital. It's not only the temperature but the humidity. It can take up to 30 to 45 minutes for both to reach the ordered settings. Micro premies are especially susceptible to temperature changes and the "air boost" can still stress them. The only time I ever used it was to warm up before a bath or when I had to drop the door to change linens.

Working through the portholes can be done by anyone of any size....it just takes practice.

[Jory, MSN, APRN, CNM]

On 9/3/2019 at 10:19 PM, Luna said:

My NICU offers STABLE, which got postponed for a month later, due to the hurricane. NPR is in a few weeks.

Also, thank you for the reminder about handwashing. My hospital takes scrubbing in very seriously. Thank you for your reply. ?

Here are a few tips that I wished I had known as a new NICU nurse:

1. Make a list of the drugs they use and go home and research them. Know them inside and out. Don't go nuts...just make a list as you go along for the babies you care for including meds used during NRP. NICU actually doesn't use that many medications...which is a good thing. They are very repetitive. So understand not only what you are giving, but WHY. Example: Erythromycin is given quite a bit..it's an antibiotic...but it's not only given when a neonate has an infection...what other properties would help? Things like that.

2. Infusions...almost every baby has them. CLASSIC rookie mistake...I'm sure you'll check the pump settings but anytime you take over a baby assignment, but be sure to FOLLOW THE TUBING to make sure that the tubing is in the correct channel with the correct rate with the correct med. The tubing can be a mess and transposing channels is an EASY mistake for even an experienced nurse to make.

3. When you have some downtime, spend some time with the respiratory therapist and understand why they change oxygen delivery systems and what they do.

4. My biggest pet peeve is nurses that cannot keep their area clean. We had a table to work on for each baby and some nurses would just set all their meds out directly on the table, etc. When I came in I wiped everything around my isolette down and made sure everything was straight with my babies during the first assessment. We used a lot of washcloths and I always set down a clean one on the table whenever I prepared meds or got supplies for lab draws.

You'll get there. Just try to deal with this preceptor you have the best you can and just get through. I think too many pass judgement on students that post on here that are having preceptor difficulty that it's automatically the fault of the student. Some nurses are just witchy and they enjoy going through life belittling others...it's a huge problem in the profession. The fact you are asking what you can do differently tells me you are open to suggestion...that is all you can do right now.