do I even know what I'm doing?

amy0123, BSN, RN · Nov 18, 2006

There is a way to know what you are doing:

#1: If your preceptor is telling you that you need to improve in a certain area, for example: IVs, dressing changes, documentation, etc. Write it down!! Put it in your pocket. Then take the list home with you, and make it your homework assignment. Look in your clinical nursing skills & techniques book or fundamentals of nursing book from nursing school or Barnes & Noble or go to the library in your hospital and borrow them. Read up!! Do this daily.

I don't know why I didn't think of this before! But I've just started doing this. If I continue to read on everything that I am having problems with, I will be able to know more than my preceptor and become more knowledgeable of the rationale about doing tasks and documentation.

#2 Take breaks and realize that time is needed for self care. Make time for you!! Do something really fun at least once a week or take a really nice long bath with candles. Treat yourself! You deserve it from all this stress and new learning experience. Also, try to laugh at least five times a day. Stay hydrated, drink a bunch of cups of filtered water that is provided on your floor because the air is so dry. Dehydation could be a stresser to the mind and body.

GrnHonu99, RN · Nov 21, 2006

It must be a new nurse thing! I feel exactly the same way... some days I come home I tell my husband...I am not sure I know what I am doing! It seems like the more experienced nurses just automatically know what to do & when to do it....I am amazed & can only hope one day that will be me! So if it helps you are not alone!

ME TOO!!!! I LOVE NIGHTS! I wouldnt go to days if you paid me double! I feel like nights is so much more relaxed and you dont have all the hustle and bustle around like you do on days...and less doctors to deal with. I feel like nights gives me the room to learn that I so desperately need. Must be a new grad thing:)

In reference to feeling incompetant...I hear ya...everyday I just feel like I am 2 steps behind. I had a pt. with my preceptor the other night and she started going bad. I just stood there like a deer caught in the headlights...Good thing she was t here, I had no idea what to do! It is frustrating being a new grad but I just try to remember its not bc I am stupid or that I just doint get it..its just a lack of experience and the only thing I can do about that is keep truckin through...keep learning...I try to be a sponge and absorb everything I can. Its alot and im patiently waiting for the day that I can just feel comfortable.

crb613, BSN, RN · Nov 21, 2006

ME TOO!!!! I LOVE NIGHTS! I wouldnt go to days if you paid me double! I feel like nights is so much more relaxed and you dont have all the hustle and bustle around like you do on days...and less doctors to deal with. I feel like nights gives me the room to learn that I so desperately need. Must be a new grad thing:)

Oh I wish I liked nights, but I simply hate them! :sniff: If I get the chance to go to days...stand back cause I will tear the soles off my shoes getting there!:chuckle I did my orientation on days....& yes its is busy, hectic & crazy....suits me to a T!

ZASHAGALKA, RN · Nov 21, 2006

I've posted this before, but it seems worthwhile to post here again. Not all of this applies to the ED, but it applies for some of the others here:

Look at the 'first year in nursing' forum. I think this is, indeed, a common sentiment. It's a reality check, eh? But, it's also a gut check.

Some environments are better than others, but there WILL be a push for you to time manage 5-6 pts instead of just 2. And that IS a learning curve, for all new grads.

Don't freak because you aren't 'in your comfort zone'. You're not supposed to stay within the 'comfort zone' you learned in school. The way to expand that zone is by learning to push and exceed your own limits. Worry more about being in a 'danger' zone. Work on knowing your limitations and balancing against working to expand your comfort zones without being dangerous.

If you feel you're being dangerous, set limits with those pushing you along. But, don't presume that you can set those limits to the same comfort zones you learned in school.

I'm fond of saying that nursing school arms you with the skills and tools to learn to be a nurse. OJT is what actually teaches you how to BE a nurse.

This is some advice I've given in the past for new nurses (long):

Until you know your way around practical pharmaceuticals, never give more than two of ANYTHING: vials, pills, etc. without double checking w/ a more experienced nurse.

Some of the biggest med errors in new nurses that I have encountered had something to do with "I didn't know 3 of them were too many". And let's face it, doctor's aren't known for clear handwriting and intent with their orders. . .

(There used to be a chemo med that required 10 pills per dose. After the FDA approved it, the off-label use required a much higher dose. There are times when 4 or 5 or 10 pills IS the right dose. But, you're better off being able to say, "I checked the dose with the charge nurse.")

~~~

At the end of a shift, decompress the shift before you leave. Spend 10 minutes going over everything you did and didn't do. Critique how you 'time managed' with the goal of learning from what you did right - and what you did wrong.

Then, give a follow-up report if needed (so you don't have to call back) and THEN, let it go.

Nursing can be so stressful you HAVE TO LEARN when to leave work at work.

~~~

More than anything else you learn, learn to chart as you go along. Consider having to 'stay and chart' to be a time management failure that you have to work on improving.

Too many times, you have 10 things to do at any given time, and that will completely take over your shift. Charting must be a higher priority item in that list.

Besides, I find that, by taking 'time outs' to chart, I can get a better handle on the chaos. Humans work better when they can take a few minutes and decompress and reanalyze their situations. A few minutes here and there charting does JUST THAT FOR YOU.

If you want to learn to 'work smarter, not harder', then learn to chart as you go. DECIDE that 10 minutes of every hour is 'charting' time and ONLY pain meds and emergencies can invade in that sacred time slot.

Remember: you don't HAVE to chart EVERY assessment in one sitting. Break it out, take it one bite at a time.

~~~

Find an older nurse or two you trust and enlist them to be a 'mentor'. Not a 'preceptor', but someone you can turn to to help you analyze a situation. Someone you trust there is no 'stupid' question you can't ask.

~~~

Respect your contribution. You can only work so hard. Work diligently and learn and be proud of what you are doing.

All of us have situations that overwhelm us. Just don't let those situations overwhelm the value YOU place on your efforts.

~~~

Don't get so caught up in your own routine that you can't find the way to observe the 'learning' stuff that happens on your unit. Get in to see the codes, the central line placements, etc. Watch not just in awe, but with an eye as to the nursing roles you see going on about you.

~~~

Start every IV you can. Make sure everybody knows that YOU will try their IV first. My first job, I was REQUIRED to try twice on every IV on my unit before anybody else could look: no matter how busy I was.

Stressful to be sure, but 500 IVs my first year as a nurse, and hey, I'm fairly good at it.

~~~

Ask nurses from other job types (OB, ER, OR, med/surg, etc.) about their jobs. Learn not only what they do, but get to know THEM. Network. It'll make you a better known nurse around the hospital, and it will give you insights about where you might like to end up.

~~~

Grab all the certs (ACLS, PALS, TNCC) and CEUs you can. Your hospital will probably even pay for most of them.

~~~

Volunteer for committees, especially P&P (policy and procedure) committees. Being a voice there will not only help you make a real difference in YOUR job, it'll give you insight into WHY things are the way they are. Besides, your manager is always looking for such volunteers: the brownie points are just a bonus.

~~~

Smile and never seem hurried in front of pts. I won't go so far as the goofy "how can I help you, I have the time" campaigns, but nursing is as much acting as it is caring.

Spend 2 minutes 'acting' the calm unhurried part (even though you're frazzled and falling apart) and the reassurance you give your pts is worth hours of your time.

I can't tell you how many times I hear in report, "so and so was on the call bell ALL DAY". When I get out of report, sure enough, call bell. I'm johnny on the spot. Five minutes later, call bell - johnny on the spot again. Now, once that pt knows I'll materialize when called, they don't feel the need to hit the button NOW JUST IN CASE they need something in twenty minutes.

It never ceases to amaze me how the pts that are 'always on the call bell' never bother me again after that 2nd or 3rd call that I promptly answer.

~~~

Nursing as acting: never admit you don't know something to a pt. Their confidence in YOU is based on your competence. Always front that competence. If a pt asks me a question I don't know, I'll say something like "give me a sec to take care of xxxxx, and I'll come back and explain it to you." Then, I go look it up.

~~~

ON the same topic: never give a med if you don't know what it does. Always look it up again until you learn it. Nothing is more deflating than a pt asking you what x pill does and then getting a blank stare from you.

After all, if YOU don't know what it does, why are you giving it to ME?!

Exactly.

~~~

When I first started out, on a medical unit with 10 pts, I organized myself into 3 first rounds. The first time through, I just introduced myself and stated I would be back soon.

That way, I could make sure that everyone was where they're supposed to be (not on the floor) and nobody was in acute distress (my first priority on everyone).

Then, 2nd rounds: I'd go back through and do my assessments (and vitals if that is your job).

3rd rounds, med pass and taking care of 'creature comforts'.

I found that those 3 'first' rounds organized my shift better, highlighted the priorities more soundly, and gave me time to 'impress' my pts. Nursing is at least part an acting gig. You can't 'take the time' with x pt when you don't know anything yet about 'y patient'.

I never stopped until my 'first rounds' were complete. But, at that point, my shift was well organized.

~~~

When a new med comes out, ask the pharmacist to send you a package insert and read up on it. You can learn all kinds of things that way.

For example, did you know the molecular wt of Viagra is 666. Don't believe me? Look it up!

Also, I used to drive my co-workers crazy by sing-songing about the drug, integrillin, "eptifibitide, the cyclic heptapeptide!"

~~~

When you are doing assessments and giving report think in the following terms in the following order:

1. Overall appearance: Stand back and take in the scene - in distress? talking on the tele? Annoyed (means a little emotional massaging from you)? etc.

2. Neuro - most important specific assessment, yes? Whether chronic or not, a pt 'not with it' is in a high order of distress. Act on that.

3. Cardiac - even if not 'on tele', you can make quick assessments about circulation, cap refill, pulse, etc. Look at the skin color of extremities as a CARDIAC assessment. A mottled pt should either be on 'comfort measures' or, your highest priority. (or have a severe and long hx of uncontrolled DM or Raynaud's DX - NCLEX hint: look it up.)

3. Pulmonary - look at 'work of breathing' not just 'lung sounds'. Working hard at breathing will tip you off to all kinds of problems, not just pulmonary ones. When YOU'RE STRESSED, what happens to your breathing? (I'll tell you: your metabolism kicks into overdrive, dramatically raising your lactic acid production which has to be blown off by the lungs in order to maintain metabolic balance. Breathing hard is a tip off to a pt that is stressed or in distress, whether the root cause is pulmonary - or not.)

4. GI - bowel sounds, dietary intake, mental note of NPO status/restrictions, etc.

5. GU. Eyeball the foley bag NOW so later you can compare to see how much is 'flowing'. Start thinking in these terms: the kidneys are often the first hint YOU can observe to impending general organ failure. If the kidneys aren't working, your thoughts should be: what ELSE isn't working? (But don't call a doc to tell them that their anuric dialysis pt isn't peeing. Please. I've seen that happen before. It's never a pretty sight to behold.)

6. Integumentary - skin, et. al.

7. IVs and 'lines'. - patency, fluid, rate. Your first few times w/ things like chest tubes - ASK. Those are not 'stupid' questions and you'd be surprised at the discomfort level even EXPERIENCED nurses have with uncommon 'accessories'.

This not only organizes your assessments by priority, but your reports.

During report:

1. name

2. dx (why are they HERE)

3. allegies

4. docs

5. general info (nursing home pt, PIA, etc.)

6. Assessment in the above priority. (this will include things like diet, IVs and O2 status)

7. Upcoming tx and procedures next shift needs to know about

8. A summary of what happened on your shift.

Quick and to the point. Leave out trivia and cut to the chase. Each pt should take less than 2 minutes. If not, work on honing in on what's important. I consider 'reading the doc orders' to be a useless report. I CAN DO THAT.

Start to think like this. If you build a 'mental template' of what you are doing and in what order, it is a foundation to build upon.

~~~

Never apologize for or diss co-workers EVEN IF YOU AGREE WITH THE PT'S ASSESSMENT OF THEM. 1. Nothing will cause you more interpersonal co-worker grief. 2. Some pts just love to manipulate and play off the 'changing of the guard'. It's pretty flattering to hear 'what a great nurse you are', but if that is in the context of 'as compared to the last nurse', then, however true that might be, you're being played.

~~~

The pts and families that most loudly complain "I'm going to report you", are, in my opinion the least to worry about - at least as far as being reported. The ones that report YOU for your honest efforts, have already reported 4 more for real concerns and yet again, another 3 that worked as hard as you did. That lends to discredit them.

Answer their concerns, but don't be put off by, "I'm going to report you". I always respond, "My name is Tim and I'm the only Tim that works on this unit. My manager will know to whom you are referring to." And then I smile and say, "But, I'd be happy to do whatever is WITHIN MY POWER to resolve your concerns, NOW." Key phrase: within my power. That does not mean I'll kiss your booty, but that I will deal with you professionally and courteously.

~~~

Trust your gut and be assertive about it. If 'something is wrong', then 99% of the time, SOMETHING IS WRONG. Every experienced nurse out there can tell you about the 'steep' learning curve of not 'trusting your gut instincts". You KNOW more than you think you know, and lots more than you consciously know. Otherwise, you wouldn't have gotten this far. ACT ON THAT.

~faith,

Timothy.

ERNirs33 · Dec 6, 2006

I am glad I came to this site - I am newly off orientation and work at an extremely busy ED and it is very scary, rough, run around for 12+ hours, rarely having time to even sit to chart, just charting on the go - I made a med error and I got really upset about it (it turned out ok, but still!) I come home from work now and worry about what mistake I might have made or what I may have done wrong that I could get in trouble for. I haven't been in trouble yet and have received excellent feedback to this point, but geeez, I freak out at least once at work (cold sweat and panicky heart palpitations) that I've done something wrong, is this normal (well, obviously not,) but seriously How can I stop worrying so much!

all4schwa · Dec 9, 2006

There is SO much to learn, it's like I can't think quick enough. Some nurses are able to pick up on things I hadn't even began to think about. I wonder when I'll be like that or when I can impress someone with my smarts? I feel horrible, I had been severely depressed but this past week I moved to night shift since it's what I'll be working and I LOVE IT. Point is, I know that I'll have people to ask questions if I need it, but I'm torn up not feeling competent enough!~

people expect you to ask questions, know that it is your right to do so. its not about being incompetent, it about being new. if anyone forgets, gently remind them. you can't be that incompetent if you understand what you dont understand and know when to ask questions. i love night shift, a lot goes on on nights. i don't work er, but i work neuro at a level one and get crazy admits all night! and btw, chances are your patients have no clue that youre new, since most are not in the medical field, i find a lot of patients are impressed with everything you do! that is, unless you act like you don't believe in yourself and go in apologizing for yourself from the being.

not so say this directly corrolates to you, but just a few observations ...

g.luck!!

all4schwa · Dec 9, 2006

I've posted this before, but it seems worthwhile to post here again. Not all of this applies to the ED, but it applies for some of the others here:
~faith,
Timothy.

Timothy has really put together a valuable tool...this is priceless. I have read this before. It helped me when I first started on the floor, it helped me three months later when I came across it and reading it just now makes me want to print it out and post it above my desk!! Many of this tips I have implemented myself, and other tips I forgot about untill now. Thanks again!!

:yeah:

:1luvu:

:thankya:

*do I even know what I'm doing?*

do I even know what I'm doing?