Even if you're new, remember you can think

[JBMmom, MSN, NP]

I was a nurse in long term care for a few years before I had the opportunity to transition into a hospital role through a program for both new grads and those transitioning from other areas, into acute care. I was so concerned about coming across as thinking I knew it all that I acted as thought I knew nothing at times, and took criticism that wasn't warranted, which I think contributed to my termination in the end. Looking back, had I spoken up for myself I think I might have retained my position (although it really did work out for the best that I'm not there anymore).

Here are a couple examples. I had a patient two days in a row. The first day she had just been admitted a few hours earlier, she was talking with me, even got up to the bathroom with just supervision, and seemed to be pretty stable. The second day I could barely wake her to assess her, and had to non-administer her morning medications because she wasn't awake enough to safely swallow. I notified my preceptor and the hospitalist of what I thought was a change in condition since the day before and the non-administration of her morning pills. Nothing done by anyone. My morning went on with my other patients. Lunch time came, she had a friend come to visit, couldn't really rouse her to visit with her friend. Again, I mentioned to my hospitalist that she was really lethargic. I've assessed her vitals a couple times at this point, can't see anything wildly out of order, except respiration rate was a little slow. Throughout the day, my preceptor is one-on-one with me, when she was on the floor- but she would be gone for long periods of time, I don't know where. Patient doesn't really wake up much before I leave, but I've told everyone, including second shift nurse and I head home. First thing next morning my preceptor is in my face about how a couple hours into second shift they had to call a rapid response on our patient because I didn't accurately respond to a change in condition. Clearly I'm not going to be able to adjust to the acute care environment because I'm used to stable patients in a nursing home and I did not use my critical thinking- labs drawn at the time of the rapid showed acute kidney failure and they think she was withdrawing from benzos that no one knew she was taking. I didn't even speak up for myself, but it was well documented that I had informed the hospitalist twice about her condition, and my preceptor was standing next to me during two of the interactions with the patient. If it were that critical, she should have intervened. But, I took the criticism, signed the form that stated I was re-educated, and went on my way.

The following week I had a patient that had taken lisinopril at home for years, it was held for the first couple days of hospitalization and was going to restart that morning. I took a pre-administration bp and I think it was in the 160's, which was pretty much his baseline since admission. I gave the 10mg lisinopril and went on with the day. Two hours later my preceptor asks what the follow-up bp was, I hadn't taken one. Again, at the end of the shift I'm told that I'm not able to critically think otherwise I would know that all bp meds need a follow-up reading within an hour after administration to make sure it didn't drop too low. In my head I'm thinking that I know that lisinopril might show an effect at 1 hour, but doesn't peak in activity until about 6 hours, so why would I reassess when the patient has taken it for years, and was not showing any signs of side effects. But, I didn't say anything, I signed the paper about re-education and went home.

I had quickly progressed from 2 to 3 to 4 patients, but then I started getting feedback that I was spending far too much time with the patients and not getting my charting completed. I understand that the goal was to get me to prioritize my time for a 6 patient load, where I wasn't going to have time to chat with the them about small things, but for the most part my conversations were geared towards getting information about how I could provide the best care. By contrast with this culture, my current coworkers and managers use phrases like- the computer is a tool, but the care of the patient is the most important thing- a nice change.

Anyway, after a total of 11 shifts I was told it just wasn't going to work out and I was being let go. My confidence was in the toilet with that. I questioned whether I could ever work in an acute care setting, and how did this go so wrong? I wasn't perfect, gave a milk of mag one time instead of the scheduled mylanta (there were prn MOM orders), and I know there were some other blips, but nothing huge. Just told I couldn't cut it. I wonder if I had spoken up with my reasoning in those two big re-education instances, would I have kept the job?

As I mentioned, it's all worked out for the best. My new job has been 90% positive and 10% (warranted) constructive criticism. I have great coworkers and I really can be an acute care nurse. So I just want to offer to others that even if you're new, you might be right some times, so make sure you speak up for yourself when appropriate, and don't let other people make you question yourself on everything.

[canoehead, BSN, RN]

What you describe doesn't make you a dangerous nurse in my mind. Especially the first scenario. You notified the physicians twice...as a crusty ER nurse I know to say "I'm requesting that you come and assess the patient." Then pin them down on what they think is going on, and what criteria they want you to call back for, and document the hell out of it. As a new nurse, you called, they ignored what you told them, you called again. Pretty reasonable. You can also get a second nurse, like the charge, to come and do an assessment, and put your heads together about what to do next.