Fired. Help me better prioritize...

[Evolving_Nurse, ADN]

I know this is a long post, but I kind of just needed to rant/vent and I also need some advice. I'm a new grad and I took my first job as an RN on a med surg floor in a level II trauma center, which is the only trauma center for hundreds of miles. Due to this being the regional center for critical patients, the patient acuity on med surg is somewhat higher compared to other similar facilities with the same designation because the ICU is constantly admitting more critically ill patients. Upon being hired I was upfront and honest and I let the hiring mangers know that I had taken a year off (I needed a mental break from nursing/school) between passing the NCLEX and finding a job and I felt that I may need a little bit more time on orientation. They assured me that I could take a few extra weeks on orientation if I felt like I needed it, they told me how great they are with new grads, and they just really reassured me. I would also like to point out that this hospital has a union. So, after the first 90 day probationary period, the union will protect their staff nurses from disciplinary action/termination. I would also like to mention that the charting system used at this facility is confusing and is reminiscent of windows 95. Providers use a different system than nurses but nurses have access to the system and can view assessments, print the h&p, and do med rec's.

My orientation was set to be 12 weeks long, which included one week of computer training for documentation and how to use the MAR. The managers had me orient with a different nurse every shift so none of the nurses really knew where I was in regard to my skills and competency. Each time I went with a new person I basically had to start over. After 8 weeks on orientation the mangers pulled me aside and talked to me about how it was going and how many patients I had been taking (which was 2 sometimes 3). I told them I was fine taking 3 patients but I struggled if I had patients with scheduled procedure off the unit in addition to the patient being a higher acuity level (if I had total cares or if patients needed more monitoring). I had a hard time with integrating the patient preparation for transfer in between my other responsibilities because I wasn't familiar with the process or the paperwork or how long it took for me to complete the paperwork or get the patient prepped for transfer. (When patients have dialysis or a surgery, paperwork is to be printed and filled out to put in their paper chart. It's different for each procedure and I wasn't familiar with patient preparation or paperwork for specific procedures, I.e., going to the OR requires a CHG bath, H&P, labs, type and cross match, vitals & glucose within 30 mins of transfer, etc. Compared to a patient going to dialysis, only a transfer ticket needs to be filled out along with a set of vital signs. I also wasn't sure if dialysis patient were to be given morning medications prior to going. I just wasn't sure about things that an experienced nurse probably already knew.)

After 8 weeks of orientation and being bounced around to different people. The managers said that they were concerned that I may not be able to take on a full patient load (5 patients) at the end of orientation and they thought it would be good to just put me with one person for the rest of orientation (the final 4 weeks). The girl I was put with was great at answering questions, but towards the end I felt like she was frustrated with my inexperience and was there just to observe me and assess my fate. Of course she would take over if I was falling very behind or if a patient's life was in jeopardy.

Fast forward to week 11, which ended up being 9 days before reaching the end of my 90 day probationary period....... I was fired because I was having difficulty prioritizing and getting tasks completed on time. My manager told me she didn't think I was a good fit and that I struggled to take a full patient load. I mentioned that they told me I could stay on orientation longer and she said that she just had to trust her staff and their judgment. I asked if she had any advice for me or if she would give me a good recommendation. She said she would give me a good recommendation and suggested the rehab unit, inpatient psych, or working in a clinic. Despite her good recommendation, at this point I just feel like a failure. I feel like an incompetent nurse and I don't feel like I have the confidence to apply for another job right now. However, I also don't want to wait and potentially lose the skills that I just gained from this experience.

This scenario is based off of my last day working med/surg:
1. patient transferred from ICU (the night before) who was previously septic.
2. Patient w/ respiratory prob, to be discharged.
3. Patient w/ influenza, to be discharged.
4. Patient w/ human pneumometavirus.
5. Patient w/ pneumonia.
6. Patient w/ scheduled surgery

7. New admit, acute cholecystitis

So, I started the morning doing the usual. Checking labs, getting blood sugars & vitals, getting breakfast trays set up, giving insulin & then I started passing the 0900 meds at 0800. I told myself to start giving meds to the people with blood sugars so I could administer their insulin and then give meds to the ones I knew would be quickest. I get patient 1's meds and realize one of them isn't stocked in our omnicell, so I'd have to run to a different wing to get it. I told myself I didn't want to get behind on everyone else's meds, so I would give everyone their meds and then come back and get that last med after everyone else was all set. Patient 1 had a BP med, so I verified the BP (121/80) & HR (88) prior to giving. It was a little low but not concerning and it had been consistently trending in that range. I did a quick head to toe assessment and jotted down some findings on my report sheet. On my way back to the omnicell, I answered 5's call light since I was walking by. The pt had a BM that looked like brown (but almost black) tarry stool. I took a mental note of that and moved onto patient 4. Gave meds and did a quick assessment, verified new orders for patient 6 (a stat order for packed RBC's), and then went back to the nurses station to tell my preceptor that we had to give stat blood. I've only given blood 1 other time, so I'm not completely confident at this, so I'd rather have my preceptor guide me through the process than look up the policy/procedure. While at the nurses station, I notice the aide talking to the provider. The aide says to me, "did you give pt 1 their lasix?" I said, "yes, why?" The aide said, "well their BP is 50/80". I said, "umm what?! I looked at it this am and it was 121/80. Did you check the BP in a different location?" The aide said, "yeah". So I said, "Next time, can you please let me know when someone's BP is that low?" Then, the provider informed me they were going to put in an order for albumin. So, I tell my preceptor about the blood and that we could hang it after I assessed pt 1 and got the albumin running. I go to patient 1's room with the albumin. I assess the patient: neuro check, manual BP & HR, asked how they're feeling, any dizziness, taught them to sit up and stand up slowly and to call me before standing or if they needed anything. I explained that the albumin would shift the fluid in their body and that we were giving it because their BP dropped. While I'm in patient 1's room giving albumin, I have dialysis calling my phone about patient 5, saying they'll be ready in 30 mins. (keep in mind, I still have to fill out paperwork to transfer patient 5 to dialysis, the patient still needs morning meds & insulin, and I have to notify the provider about the stool). Then patient 5 calls and tells me they have to go to the bathroom. Patient 2 calls and asks when they'll be discharged. THEN my preceptor pops her head in and says, "hey the new admit is here." So....... WHAT AM I SUPPOSED TO DO FIRST?

The thought running through my mind:

- The new admit needs to be assessed.
- Patient 1 shouldn't be left alone. I still have to grab their last med from a different omnicell.
- My other patients morning meds need to be passed on time.

- I need to administer insulin to a few patients after breakfast.
- I don't want patient 5 to soil their bed, I need to get them their meds before dialysis, fill out their paperwork, notify the provider about the tarry stool.
- Patient 6 needs those stat PRBC's.

- I need to call PreOp back and let them know about the packed RBC's.

Seriously. How do I learn how to realistically prioritize when I haven't really been taught how to do so? Sometimes prioritizing is common sense, but other times, like the above scenario, it can be very difficult. Especially because I don't have prior experience. I've only done an admission maybe 2 times, so I can't just whip right through it and go fast. Can you guys give me tips on how to plan and prioritize?

How would you handle the above scenario?

How do you organize/start your day?
What type of patients do you see first vs last?
When do you get your assessment charted?
At what point do you perform your assessment? (I.e., During med pass, during report, after passing morning meds?)

Do you write down your assessment on paper in a certain layout/format?

What kind of questions do you ask during a quick assessment vs a head to toe or focused assessment?

When do you perform daily care such as brushing teeth, bed bath/shower, catheter care, etc.?
Realistically speaking, when it comes down to it, do you let a patient sit in stool or urine while you're getting more important things done?

Any tips would be greatly appreciated.

[CKPM2RN, ASN, EMT-P]

And why are nurses leaving the bedside?

[SweetBabyJames]

This is nuts. That is so much stuff going on. I'm a new nurse, too. Reading this post stressed me out, LOL. All I can say is you need to delegate the ADL stuff. Ask an aide to get the patient to the bathroom and take that patient's vitals before dialysis. That's within their scope. If someone is admitted while you're in another room, does your team situate them? If so, the patient is OK for a few mins while you start albumin. Tell that patient to remain in bed and not to get up. You can't stay in there with them forever. Also, did you mean 80/50? Regardless, recheck that BP. Aide could have done it differently/used the cuff wrong/etc. Then I would start PRBCs and then assess new patient. Go back and check PRBC temp after that assessment, so you're doing the proper blood admin checks. Also, what is this med that's off the floor? I don't think you should be leaving the floor for a med unless it's life-saving, which a life-saving med would never be. I'd call pharmacy to get it to you, and give it later. It's not your job to run around the hospital for one pill when the morning bonanza is going on. It's literally pharmacy's job to get the proper meds in the machine for you. Make sure you're only doing as much as you have to.

I also had a crap orientation, I was on ALL nights, and didn't get hardly any admission, tests, or results-review experience. I'm in an ICU that's lower acuity. When I got off orientation, I started immediately on days.

I'm still working on asking for help and asking questions. Even if no one can help you, it's better than assuming you have to do everything yourself. Cause that's just not possible.

Also, I agree with comment above; this job is nuts.

[CKPM2RN, ASN, EMT-P]

1 hour ago, SweetBabyJames said:

All I can say is you need to delegate the ADL stuff. Ask an aide to get the patient to the bathroom and take that patient's vitals before dialysis.

The med-tele floor on which I work usually has 2 CNAs for up to 33 patients. Sometimes we're fully staffed to 4 CNAs, but not often. One cannot delegate if there's no one to delegate to.

[SweetBabyJames]

@CKPM2RN

Even though the original poster didn't mention short staffing, it might be true. Either way, it's an important task that should be high on the CNA's radar if it means getting to dialysis on time.

[Evolving_Nurse, ADN]

2 hours ago, CKPM2RN said:

The med-tele floor on which I work usually has 2 CNAs for up to 33 patients. Sometimes we're fully staffed to 4 CNAs, but not often. One cannot delegate if there's no one to delegate to.

Yeah, that's similar to how it was where I was working. We don't get a CNA unless we have 5 patients or more & sometimes we just don't get one. However, the CNA answers call lights for all nurses & not just my patients. So, sometimes it's faster for me to just do things myself than to go hunt down the CNA. Our med/surg unit is divided into wings, so there's a north, east, and west. Each wing has 24 beds or so. Basically that one CNA answers call lights on any of those 24 beds in our wing.

[TriciaJ, RN]

First of all, buy your manager a lovely parting gift for firing you; she did you a favour. I can't imagine five high-needs patients on day shift with no CNA. It doesn't matter how well you prioritize; too much is too much. If others seem to be managing, I suspect there's a bit of fudging and corner-cutting going on.

I would try the rehab unit. You would be building your med-surg-type skills in a unit that's hopefully a bit less crazy. Good luck!

[Swellz]

Something that you will learn is that there is the care you want to give, and the care you are able to give. My first job was in a very busy but typically well-supported unit. When I started travel nursing, I learned how things really were. You cannot give high quality care in low quality circumstances, and that is not on you. I hope you find an environment that allows you to learn how to do your job well and supports you to provide the best care you can.

[Sharon626]

This sounds like my life each day I work. I am a new nurse,(out of school 5 years but licensed only 2), hired into an Observation Unit ( 1st job). Before we finished all of our classes Covid-19 happened. We didn't complete Telemetry testing, Acute care or Wound/Skin classes, or CPR classes due to this pandemic. I was thrown into Covid patient care, full PPE thankfully. I really wanted to get some experience, but not like this. I struggle with consistency daily. I have a routine, however, I still seem to miss something here and there. I feel like mgt is just waiting on me to quit. But my resource nurse has been awesome. I don't have the confidence just yet to be on my own. Working on that. I try to be swift, but the charting takes a while and is never done quickly. I wish there were set ways for everyone to learn, but everyone has to find their own way I'm told. I hope you don't leave nursing, but maybe find another floor. I spoke to my boss weeks ago and let her know this was not what I expected because at my interview she stated that if I felt I needed to be on a different unit she would help me find one. Yeah, I don't see that happening either. I'm nervous about putting myself out there again. Oh, I'm also on my 2nd preceptor because the teaching style of the 1st one was NOT conductive to learning. I'm glad to know I'm not the only one who feels this way. Plus, how would you add this to your resume or would you. Keep us posted. Good luck.

[Crystal-Wings, LVN]

Welcome to America where capitalism is king! The more patients they admit the more money they'll make, never mind that you're understaffed or have inadequate training.