ED orientation: struggling

[StazzieRN]

I am a Dec. 2006 grad who was hired to work in a busy ED (200-260 patients per day). When I was hired, I was told I would have 3-4 months of orientation with a preceptor along with a 7-day ED core class (I also had a 4 day Nclex study class). I now have some concerns about my orientation program and am looking for some advice.

During my orientation I have literally been with 15 different preceptors. I also have a mentor who is supposed to meet with me weekly and also assigns me with preceptors for the month. I haven’t seen my mentor since the third week in February; she was promoted to a higher position on a different shift and so far hasn’t assigned anyone to precept me for the entire month of March. So each day when I come into work, I’m not listed on the assignment board and have basically been tossed between different “preceptors”. I expressed my frustration to my nurse educator, who said “this is just how it is”. I even said I would rearrange my schedule so I could have a consistent preceptor, but I was told that I couldn’t do this. I also discussed whether or not I was going to be assigned a new mentor since we now worked opposite shifts, and she wasn’t sure of the plan. Our conversation ended with the nurse educator saying that I need to jump into new situations and “just do it”. I also believe the nurse educator brought up my multiple preceptor situation with my mentor who I personally don’t like ; I feel that she puts me in unsafe situations, nags me, and makes me do things that she doesn’t want to do herself. For example, she was charge nurse one day and I was caring for an ICU hold patient who was diagnosed with having a brain bleed and I needed to infuse PRBC’s. So, I was discussing the transfusion policy with a collegue (when to take vitals, what to document, etc) and my mentor came up to me saying “you can help out around here and discharge some of these patients since you’re not doing anything and everyone else is busy”; she didn’t even care to ask what I was doing, she just assumed I was sitting around picking my butt.

So this past weekend I was assigned with another preceptor who I never worked with, and I took two rooms (I ended up caring for 3 rooms because she was busy with an ICU hold patient). Well, these three patients ended up being discharged and the ICU hold went up to the floor. We got rid of one room because of a shift change, and we now had 3 rooms which were all empty. Just as I finished my charges on the discharged patients a call came in: PNB coming in, 8 minutes out. I told the charge nurse that I wanted to go help out with the code, and she agreed that I should. So, I said to my preceptor “I really want to get in on that code; here’s my pager number, all our rooms are empty – I’ll be in on the code and if things get out-of-hand out here, call me”. I joined in on the code and helped with some documentation, sorted through the patient’s meds and wrote them down, got a BG on him because he was a diabetic, drew blood cultures, ABG’s, and learned how to set up a central line kit. Just as the MD began inserting the central line, my pager buzzes. I find my preceptor, and she tells me “we have three rooms that have to be assessed”; I told her that I needed experience with codes and her response was “you first have to learn patient care before you help out with codes”. Keep in mind we had 3 rooms, none whom my preceptor had assessed (I have no idea what my preceptor was doing the entire time I was in the code because these patients were waiting to be seen by an RN for at least 30 min).

So, I do my assessments on the three patients and another RN came up to me saying “your preceptor went to lunch, so I’ll be your resource person”. My preceptor ended up taking a 50 min. lunch break and didn’t even come to tell me personally. :angryfire I was really upset that I was pulled out of the code by my preceptor so she could get out of caring for these 3 patients and so she could go to lunch (it is only 11am at this point so it’s not like she took a late lunch). I later talked to my preceptor and told her that I would have liked to get experience with the PNB and told her that was encouraged to participate in these type of experiences by my nurse educator. She blew me off, saying the same statement “you first have to learn patient care”.

I was called into the nurse educator’s office yesterday and I discussed the code ordeal with her. I asked “how am I supposed to seek out new experiences and be assertive if my preceptor won’t allow me to participate in them?” She agreed that I should have been allowed to participate in the code and that the preceptor was wrong to pull me out of it.

Now, I’ll be the first to admit that I was hesitant the first few weeks with my role as a new employee. But I feel like I’ve come a long way – my documentation is great, my assessments are thorough, and I’m getting better at handling multiple patients. I’m slower at my skills but am improving with my IV starts. For the past two weeks I’ve been taking 2-3 patients on my own (some of the “preceptors” I’ve been with have just ignored me and my patient care, while others have challenged my thinking, checked my charting, gave me tips, etc.). While I was in the office with the nurse educator, she gave me a sheet of paper which said that I was to start caring for 2 patients on my own (which I have been doing for the past 2+ weeks). It also said I was supposed to seek out new experiences and participate in these experiences (which I have been doing). She canceled me out of my 3-day EKG class next week so I could “focus on patient care”. I have the feeling that my mentor is behind this whole thing because I get the feeling that she doesn’t like me, and I’m sure she was on the defense when confronted by the nurse educator regarding my orientation experience. The nurse educator also said "the other graduate nurse is doing great and she'll be off orientation the first week of April...I'll see if I can get you an extension into the second week of April". I felt like crap.

I am upset at this whole situation; not counting the classroom activities, I’ve been on the floor for probably about 6 weeks. I’ve taken care of more critical patients (chest pain/MI, MVA, thoracic aneurysm, acute MI transferred up to the cath lab, brain bleed, etc.). I have no idea where all of this is coming from. I am hurt because I feel like I’m not performing as I should be, although I have already met these new objectives. I don’t know if I’m floundering or what I’m doing wrong; I’ve always been safe, given the right meds, documented thoroughly, and I strive to provide excellent patient care (just the other day my patient and her husband thanked me for my excellent care and said they were going to tell their friends that they were treated with respect and well cared for by the hospital I work for). I just don’t get it – can someone give it to me straight: am I oblivious and behind in my performance, or am I doing everything that a new nurse on orientation should be doing?

Thanks for your time.

[NotReady4PrimeTime, RN]

It sounds to me that you're getting a raw deal. Having multiple "preceptors" is a bad situation because none of them know very much about you or how you work. They only know their own bit. And you would be surprised at how many people don't understand the preceptor role.

pre-cep-tor (pr-sptr, prsptr) n.

An expert or a specialist, such as a physician, who gives practical experience and training to a student, especially of medicine or nursing.

The American Heritage® Stedman's Medical Dictionary

Copyright © 2002, 2001, 1995 by Houghton Mifflin Company. Published by Houghton Mifflin Company.

When I precept a new nurse, I know that s/he isn't there to do my work for me; I am there to teach this nurse how to function in our unit, a responsibility I take very seriously. I actively look for new experiences for my preceptees. In fact, I sometimes will ask newer staff no longer on orientation if they'd like to assist or watch what's going on with another patient and I'll look after theirs so they can go. Recently my patient had a gallop, something not often heard in peds, and I invited anyone who'd never heard on to come and check it out... with the child's parent's approval of course. You know your own education needs far better than any of these so-called resources do and you're only being proactive. Keep going!

Do you have the opportunity to evaluate your orientation on a recurring basis? This post would be an excellent inclusion to your evaluation. When you have your formal performance evaluation with your manager, all these things need to be brought up, or nothing will change. Your nurse educator is totally out of touch with what's going on in your ED, and that has to change too. It may be too late to fix your orientation, but maybe not too late for those to follow.

[Hoozdo, ADN]

I can relate to your orientation woes - had most of the same problems you did with my orientation. All the different preceptors make things very difficult. Throw in one or two lazy preceptors and it tends to rub you raw! :trout: Nursing educator......I only met mine once and that was by accident. My nursing manager was no help, he just said "that's the best we can do now." For much of my orientation I had NO preceptor at all. I usually got stuck with a nurse that had a back injury and thus could do no lifting or prolonged standing. Not much help at the bedside :angryfire

I can only tell you what I did......stick it out and learn all you can. You are going to have to take whatever satisfaction you can about doing things all by yourself while, what is supposed to be your preceptor, is yakking all day at the nurses station, or at lunch, or wherever she is NOT supposed to be.

Learn who likes to teach that you work with and go to them with questions. Believe it or not, there are nurses that like to help newbies! Stick around for as close to a year as you can stand and move on to greener pastures.

[traumaRUs, MSN, APRN]

Hi there and welcome. I worked for 10 years in busy level one trauma center. Our new grads got 12-16 weeks of orientation with several classes too (ACLS, TNCC, ENPC, PALS, etc). It is not right to have 15 preceptors. However, I am trying to be realistic here. Since you said you could be flexible about your orientation in order to remain with one preceptor, I would again throw this out to the educator.

In order to be a successful ER RN, you have to have a solid orientation. Good luck and hang in there - it does get easier.