How do I learn time management better? My preceptor is more than unhelpful (its a problem, its been addressed, it isn't changing and I'm going to make it in spite of this abusive type relationship - I have 21 shifts left with them).
My school was great at teaching us about the diseases, their processes and what not. From that I have a decent grasp on patient priority. What I didn't get so much of was learning to do "the things" and how to get the things in a neat package. I'm using a documentation system that is different from the 2 I used in school and I'm slow there (fixing to you tube videos to help there). I'm getting familiar with the order sets and that's making it a little easier as is just continuing to do it. I was taught to do thorough assessments and in the ER assessing only the problem, the system above and below is a brain shift and "not having time" to adequately listen to a patient is a problem for me. My preceptor and many others where I'm at don't even bring a stethoscope to work and for me personally that isn't OK. I feel that I need to get myself in a position where I have time to listen to every patient.
Can you offer suggestions on things I can do to help me get my time management under control. I also need help on keeping myself organized, so when its time to give report, I don't have to sit down for 10 minutes and figure out what I need to give. My charting slows me down a lot, but the more I do it, the more I remember, the easier it gets. I'm also learning that charting in the room usually takes longer than charting at the nursing station. Oh - we do have a test documentation environment but I can only assess it at work and I'm not allowed to work over and if I'm at work I have to be clocked in. Due to our residency program, I'm at 40 hours every week and usually have to work my last shift of the week short in order to not go over - so going in to specifically practice charting is not really an option. Nor is taking time away from my shifts because when I'm there, the patients are mine - period. So if I went away, someone else would have to pick up my patient load and that's not fair.
I'm sure over time I'll just figure it out, but I don't have time on my side or a preceptor that is any bit of helpful. If someone would like to message me about ways to successfully deal with my preceptor, I'd appreciate the advice. Management is aware, but I'm portrayed as the "anxious new grad" instead of the new grad that has been approached multiple times by other nurses who felt the need to apologize for the way I'm spoken to by my preceptor.
No, don’t gaslight yourself. You have correctly identified her as manipulative and abusive. I’m sorry you’re having this experience- there’s so much she could be teaching you and helping you learn. Before the meeting I would write everything out, focusing on factual and not emotional things, and go in prepared to state that x y and z is happening and it is not a good fit for your learning needs. Why is this person your preceptor and not someone else?
As far as the other stuff: Sometimes my sickest patients I don’t actually put my stethoscope on- because as you identified, the priority is getting the md to the bedside, enacting the orders, getting them the treatment. The ED is very much a team environment- think about traumas or resuscitations: someone does the assessment and calls it out while other people are tasking and someone is documenting everything. The pediatric asthmatic patient with audible wheezing and increased work of breathing I can see through clothing and oh crap did I leave my stethoscope at the nurses station? Throw on the monitor, get the doc for triple neb and steroid orders. My visual assessment is enough to know that an intervention is needed more than I need to track down my stethoscope and listen to the wheezing I can already hear without it.
As far as time management goes, I try to eyeball new patients ASAP. Even just visualize them in the room, because their status could have changed since triage or the triage nurse could have undertriaged them. As mentioned above an across the room assessment can provide you a lot of information. Sometimes things become higher priority because they’ve waited a while while you’re doing something else.
I found the ENA classes really helpful for giving me a framework of assessment and prioritizing. Are they having you take TNCC or ENPC? I was at a peds hospital and took ENPC on my own when my educator told me not to worry about it since it was for experienced nurses. It was expensive to do on my own but very worth it.
I think there is a fine balance between speed and making sure you are learning things the right way as a new grad. I do think you should listen to heart and lung sounds on the cardiac and respiratory patients or the higher acuity patients.....especially early on. It’s part of learning. As far as speed and charting, everyone has to find what works for them. As an example, if you have a pre-alert (such as a patient coming in by EMS) with a possible sepsis or stroke, get EVERYTHING set up - monitor, IV and blood supplies, EKG, dysphasia screening, etc. Take care of your patients first and chart later. I tended as well to chart at the nurses station....with the exception of the super critical patients.
I am sorry that you don’t have a patient preceptor. One thing I do want to mention is a lot of ER preceptors are burnt out - they aren’t bad nurses or bad people....just exhausted. I know because I loved precepting along with many of my coworkers....the problem is that the same nurses were used over and over again to precept. It has a tendency to cause exhaustion over time. It’s actually a really hard role. I am not saying that to cause friction but to demonstrate some perception - you are stressed as a new grad and your preceptor is likely stressed over her role as well.
Specializes in Student Registered Nurse Anesthetist (SRNA).
Some coming from someone who isn't ages ahead of you...
ER is a different beast than med/surg and almost all of nursing school. Sure, somethings from school apply, but not most. Most ER nurses don’t bring stethoscopes. But bring your stethoscope, listen, you can spare the 30 seconds, I promise you. No, don’t listen to every patient, but you'll figure out who to listen to and who you don't. Watch who the docs listen to, go in your room when they’re doing their assessments, you’ll learn a lot from them and their assessments, including how to weed out the BS. Plus these days, diagnostics do most of the diagnosing. Sure, you can listen and hear absent breath sounds and suspect a pneumothorax, but what’s gonna be the tell tale? A CXR, which you’re gonna get whether you listen to or not.
In regard to assessments, no you don’t have time to do a full head to toe, skin assessment, ADL assessment, etc. You do focused assessments. That’s the nature of the beast. That doesn’t mean you don’t assess other areas, but not as depth as a head to toe med/surg assessment, and sometimes not at all. I listen to heart and lung sounds on most patients, but not all. I definitely don’t do a head to toe on almost any patient, my concern is their life threatening condition that brought them to the ED, their SOB, their chest pain, etc.
Get the Sheey’s Manual of Emergency Care by ENA. Spend the $60 on it. It has the most common things you’ll see in the ED, s/s, diagnostics, , treatment, bring it to work and use it as a bible. It also has assessments in there and what you should do for a cardiac assessment, a neuro assessment, a GI assessment, etc, as well as what tests to expect, what treatment to anticipate. I used it religiously when I started and still do when I’m not super familiar with something.
Time management, ironically, takes time. I don’t know a new grad that hasn’t struggled with it. When I was a new grad I asked in all 7 new grad interviews I had, what do you see new grads struggle with the most and is there any way I can prevent it? EVERY SINGLE INTERVIEW, the manager said time management, nothing you can do but to get time and experience on the job.
The big things you need to keep in mind in the ED is priorities. There’s always going to be so much to do and if you work in a busy ED, you’re always going to feel behind. What you need to do is learn to prioritize…who is the most acute patient? What are the tasks? EKGs are usually high priority, as are emergent medications. Giving labetalol to a patient with a BP of 230/140 is more important than giving Pepcid to a patient with a gastric ulcer or morphine for someone rating their pain at 10/10 who isn’t diaphoretic and looking like they’re about to die.
What to give in report comes with time. In a few months, you’ll be able to give report without much notes. When I first started I”d highlight and write stuff down, mainly because I didn’t know what I was doing. But you’ll get it in time.
Being a new grad, especially in a specialty, and being an RN in the ED regardless if new or not, is stressful. It’s just gonna take more time to be more comfortable.
In regard to your preceptor, it’s been my experience or the experience I’ve seen of others to just keep your mouth shut, your head down, and keep trucking along. Raising issues usually don’t do any good and makes you look like a complainer, even if that sucks and is unfair. Welcome to the culture of the ED. And as a side note, if she’s just sitting at the nursing station, she either trusts you that you’re not going to kill someone, or she’s extremely lazy and complacent, and if she’s a preceptor, the latter is unlikely. It feels unfair and like they don’t care, I was there too when I oriented, but trust me, if you were a mess and a liability, they will be ALL over your behind. It'll get better, the ED is a hard work environment and even harder personalities, especially as a new grad, best of luck!
@HiddencatBSN I had my meeting today and I was as prepared as I could be with facts. I admitted my faults, accepted responsibility for my failure/inability to communicate and expressed what I think I need in order to learn and succeed. I tried not to point the finger at her because I didn't feel that was fair. She was doing her best to teach me in the best manner that she could at this point in time. Even if she wasn't successful in her attempt, I don't think she meant for me to have the experience that I did. Instead of trying to throw her under the bus, I expressed how I've felt differently by having a different preceptor for a couple days. I have had 3 days without that preceptor and my days went SO much better. My anxiety disappeared and I felt like I was capable of performing as a nurse. I have had a couple critical patients, and while I wasn't alone - I did well in the situations. One of them I was responsible for documenting while everyone else did the tasks, and then in another situation the Dr. said "K Bomb", I was on the orders and had the calcium hung within 5 minutes. I grabbed my (new and temporary) preceptor before hitting the start button just to make sure I didn't make a mistake, and when she said "hit start - good job", it finally became real for me at that moment.
Also, I did have a conversation about an external online orientation program (maybe through ENA??) and apparently that may come at some point in our future. I do plan to get the BCEN review program shortly, but I was just so overwhelmed with my situation that I just felt like anything above existing assignments was too much.
@speedynurse I am sure that my preceptor is burned out - she had told me she was. She told me that she probably shouldn't be precepting and I was as understanding as I could be. Even now - with her situation - my heart just breaks for her. I did my best to stay there and try to work it out -but it ended up being decided for us due to outside circumstances that were beyond our control. This also happened in a way for management to replace her as my preceptor without everyone in the department thinking anything of it. I was told today that her not precepting had been discussed, but she thought it would help keep her mind off some of the things going on in her personal life. I don't know what those things going on were - but they aren't the direct reason for why she won't be my preceptor in the future. She's having a rough time and she needs all the help and love she can get right now.
@ER_BiscuitStripes Thank you so much for the details! I did buy Sheehy's but I bought the digital version - so I'm thinking that maybe I need a paper one. I also have the Fast Facts for ER Nurse (both paper and digital). Like you said - I did assume I wasn't doing horrible because she wasn't all over me. They asked me today if I thought I was on track with my peers and I couldn't honestly answer. I asked for one week with my new preceptor to determine if we needed a corrective action plan. I have been such a basket case that I just honestly don't know. I felt that 3 shifts won't make that much of a difference in the time line and it would give my new preceptor a chance to have evidence to build a plan around the skills that I would need in order to catch up.
Hmmmm they might be talking about the Emergency Nurse Orientation through Elsevier. I’ve worked at some places that use it. It’s a ton of modules and I think it follows Sheehy.
the ED is tough for a new nurse - you have to multi-task there is no way around it - the more you do it the more it will become natural - example - obtain VS while listening to the patient story - I wish I had time to truly give patients my undivided attention but we simply don't most of the time unless we want to get behind - you have to keep it moving in the ED - because ANYTHING can come through those doors at any moment -- I agree with mostly everyone's comments - the ankle sprain does not need breath sounds to be assessed or a cardiac assessment - also one big thing I do that is helpful before going into a room CHECK your orders/touch base with doc -- "hey I'm going into room 5 - do you anticipate any meds/labs for them-- CLUSTER your care - get it all done at once if u can - then move on to the next patient. Good luck!! its hard ED can be a culture shock - doesnt help that your preceptor sucks -- but stick to it - keep at it.
also let your manager know you are struggling with documentation - perhaps you can have some extra time to JUST practice with that without the distractions of patient care etc.
HiddencatBSN, BSN
594 Posts
No, don’t gaslight yourself. You have correctly identified her as manipulative and abusive. I’m sorry you’re having this experience- there’s so much she could be teaching you and helping you learn. Before the meeting I would write everything out, focusing on factual and not emotional things, and go in prepared to state that x y and z is happening and it is not a good fit for your learning needs. Why is this person your preceptor and not someone else?
As far as the other stuff: Sometimes my sickest patients I don’t actually put my stethoscope on- because as you identified, the priority is getting the md to the bedside, enacting the orders, getting them the treatment. The ED is very much a team environment- think about traumas or resuscitations: someone does the assessment and calls it out while other people are tasking and someone is documenting everything. The pediatric asthmatic patient with audible wheezing and increased work of breathing I can see through clothing and oh crap did I leave my stethoscope at the nurses station? Throw on the monitor, get the doc for triple neb and steroid orders. My visual assessment is enough to know that an intervention is needed more than I need to track down my stethoscope and listen to the wheezing I can already hear without it.
As far as time management goes, I try to eyeball new patients ASAP. Even just visualize them in the room, because their status could have changed since triage or the triage nurse could have undertriaged them. As mentioned above an across the room assessment can provide you a lot of information. Sometimes things become higher priority because they’ve waited a while while you’re doing something else.
I found the ENA classes really helpful for giving me a framework of assessment and prioritizing. Are they having you take TNCC or ENPC? I was at a peds hospital and took ENPC on my own when my educator told me not to worry about it since it was for experienced nurses. It was expensive to do on my own but very worth it.