Orienting an experienced RN

Nurses General Nursing

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I am in a new situation. Looking for some advice. I am orienting an RN with 8-9 years of experience in small community hospitals to our larger-teaching hospital. Never mind our behemoth of a computer charting system which can trip up just about any nurse with any level of experience... it is her assessment and critical thinking skills which are sadly undeveloped.

She seems to act like a nurse who is babysitting for the night. I am really starting to see how the environment in which you work can shape your practice as a nurse. We are a unit where patients diagnoses are not yet set. Tests are still being run. Good physical assessments need to be done. I almost feel like I need to have her do a full assessment on me like we did in nursing school to see if she even knows what to do. I am worried that this would insult her, but at the same time I don't want to sign her off if I don't think she is doing things appropriately. How much is just differing nursing judgement?

I am an RN/BSN with 22 months experience plus 2.5y as an LVN. All my experience has been hospital based. I consider myself good at assessments, critical thinking, and asking questions. This RN had rarely called a doctor for anything at night in all her time. And I have to question some of the things I have seen her do in assessments. Her response typically does not satisfy me.

I can't even count the number of times she has asked me about calling the doctor for something when she hasn't even asked the patient enough questions... she never asks is this pain different? does anything make it better? what makes it worse? do you think a warm pack or cold pack might help? As well as lacking the ability to sort of communicate a full picture of what is happening with the patient? Did she doze off while she was talking to you or what she up talking on the phone and eating while she was saying she was in pain? Is she getting all of her normal home meds that might help her with this pain? When you palpated her abdomen at your second assessment was it any different than the first (since pt in for abd pain)? I have to prompt all of this. Then she tells me she never palpated the abdomen because she didn't want to cause unnecessary pain and that the doctors always did this at her last job. When I asked her how she would know if something changed during her shift... got a little firmer or a little more tender, how would she know? She just stared at me expressionless.

She has three more shifts on orientation. I am certain I cannot request more orientation time. She gets a little defensive when I question her assessments. I don't think this is abnormal. I was thinking about recommending that she be required to do some of the free computer education units having to do with assessment and treatments for what we see the most of on our unit. Even when she gives report she just tells what she did all night not why the patient is here, etc. Even after me providing examples of reporting additional diagnostics and lab tests, she doesn't add it to her own reporting practice.

I know I can't teach critical thinking skills in a week... her previous 9 years of experience have not served her as far as professional development. What else can I do? There will be nights when she is the only other nurse working with another RN. Sometimes me, and she just isn't catching on. I am willing to do every computer education assignment I recommend for her so I can discuss it with her, but it is like she needs a nursing refresher course even though she has been in practice the whole time. :confused:

Specializes in M/S, MICU, CVICU, SICU, ER, Trauma, NICU.

I would certainly bring up my concerns to your supervisor. Just because an RN is experienced, doesn't mean she has the developed skills to work in a higher-acuity environment.

I know of many that I wouldn't trust my dog with, and I know of many newbies who are brilliant.

It depends on their intelligence level (yes, believe it or not some brain power and faculties has to be above and beyond AVERAGE).

Not everyone is smart, and not everyone is meant to be in a sicker environment. It is the way of the world.

Specializes in LTC, MH/MR, Home Health.

I agree that you need to let your supervisor know exactly what you wrote above. As her trainer, do you want to have a finger pointed at you for not speaking up when (and you know it will happen) she messes up and possibly jeopardizes a patient's health? Give your supervisor your assessment on her skills in writing and keep a copy for yourself just to cover your own butt.

Specializes in Med/Surg, Ortho, ASC.

I'm very curious as to how the RN feels about her own readiness to be off orientation? Perhaps figuring that out could help you determine how to proceed.

For instance, if you ask her if she feels prepared to go it on her own in a week and she blithely answers 'yes,' (as I suspect), then I would think you definitely must go to your supervisor with your doubts.

If she is as aware of her deficits as you are and owns up to that, then perhaps you can go to the supervisor together to address the issue.

Out of curiosity, why is further orientation out of the question? I've rarely seen a hard and fast policy against orientation extensions as necessary.

Thanks for the responses so far.

As far as why no more orientation... I guess money? Another nurse asked for more orientation time a few months back and received a definite "no". It happens this nurse has since left our unit. Maybe this contributed to her request to transfer, can't know for sure. I guess I can always ask. The next schedule is out with her name solo already.

I end each shift with: "How did you feel about today?" "Do you feel like you are managing the computer charting okay?" "What do you think you need to work on?" "is there anything you have questions about?"

I mainly get yes, no, shrugs... She seems to be processing information... but then no obvious return demonstration or verbal acknowledgement.

I can, in hindsight, see that I made the error in assuming the computer charting and calling residents would be the primary areas of weakness because they were her most obvious challenges. I didn't properly assess basic nursing skills. My bad. If a nurse self reports on the training form that she is at an independent level for all assessment skills, how much should I question it?

This is the first time I have trained anyone. And I am learning a ton too! I have stepped into remind her what we are looking for with the various types of patients we are getting. Her number one question is, "Is that typical?" Working with residents nothing is hard and fast. We get a new rotation every month. Different night call every week. May is nothing like July. Typical in not typical.

My unit supervisors have been asking me about her progress. I have been cautiously optimistic because I wanted to keep things positive. I have told them she hasn't been fully challenged, but doesn't seem to have a high gear. She has mastered the computer, as far as appropriateness but not speed. Unfortunately, we have only had one shift where she really needed to pick up the pace. She ended up in tears twice. The worst thing that night was her inability to ask for help. That will get her in trouble in the future. I don't think she gets what she is in for. It has been *atypically* slower than the norm.

I will definitely keep the lines of communication to the top open. The other nurses on the unit have commented she is a little slow moving and to pick up on things. I try to let the other nurses know where we are in our training program and what the learning goals are for the night. I have definitely let her know that if she needs a different explanation for something than what I can provide that we can bring another nurse into the loop to assure clarity. She hasn't chosen that so far.

As far as awareness of deficits? hmmm Good question. As I mentioned above, she doesn't say a whole lot.

Specializes in Peri-Op.

I have a new experoenced RN at my hospital that resumed 12 years of level 1 trauma surgery. She didn't know What regular insulin was and can't set up for a lap appy. These are about as basic as you can get. All I can say is that it takes all kinds........

I feel I must butt in here, to the new RN's orienting experienced RN's. Argo- in your case,I'm trying to get the senerio correct. Are you infact with only 3 yrs experience and in a periop arena and the RN you are speaking of with many more years than your self and who is just returing to practice. If so, what was trauma nursing like back in her day, could you maybe get her perspective on where her paractice was then compared to the unit she is now in? How many trauma alerts are called for -lap appy's? Is regular insulin a common drug in a ED level 1 Trauma setting some how I am guessing -not. A regular ED but not a level 1 trauma.

SunDazed- if I am reading correctly-you self admitted to 22 months of nursing paractice experience and this is your first time precepting. How many years of experience does the nurse you are now precepting have compared to your 22 months. What kind of floor did that nurse practice on- acutiy level, types of patients? Did that older RN take a break from practice?

Please stop bashing these older RN's- if you look more closely- you might just learn something.

Specializes in Peds Medical Floor.
The worst thing that night was her inability to ask for help. That will get her in trouble in the future.

This is the worst thing to me. Every type of nursing is different, depending on where you work. I hear when you start in a different type of nursing, you're like a new grad all over again. But you should always, always, always ask questions if you don't know something!!!!!!:eek:

Specializes in Med/Surg/Onc, LTAC.

Kcmylorn- Simmer down a little bit.... :D

Maybe try rereading a few of the posts. The OP is NOT bashing older RN's. She admitted her years of experience and that it's her first time precepting, and that she is still learning too. It does sound like she has survived her unit well and is pulling her weight. She is trying to stay objective over her situation but worried about when this new old nurse is off orientation.

The OP stated the nurse in training came from a smaller community hospital that is at a slower pace than the unit they are currently on. Everything that sounds snippy in your reply (and typing can be deceiving, maybe you are intending that) and your questions has been clearly stated in a polite manner in previous posts.

To the OP- Some of the OTHER nurses on this site have written with good advice. If you feel (since you are there and we are not) that her being off orientation might affect patient outcome and safety AND THAT IS THE ULTIMATE CONCERN (!!!) then it is your obligation to speak up. Hopefully you are wrong, she'll become independent and fit on the unit well. Good luck and let us know what happens.

What type of unit did this nurse work on before? Did she take a break from nursing?

We are getting tons more nurses in LTC who are either changing careers or picking up extra hours. For the most part, it is awesome to have experienced nurses.

What type of unit did this nurse work on before? Did she take a break from nursing?

We are getting tons more nurses in LTC who are either changing careers or picking up extra hours. For the most part, it is awesome to have experienced nurses.

The OP is in a larger teaching hospital, not LTC. I /think/ by residents she meant medical residents.

Specializes in CCT.

There is a saying that it is possible to have 10 years of experience, or 1 year of experience 10 times. Just because someone is "experienced" does not mean they are competent. To defend a dangerous practioner because they're "experienced" or "older" is inane. Either your able to develop into a competent provider or not.

As a preceptor it is your job to note defecincies and offer methods for correction. It is then up to your preceptee to follow through. This requires being honest and open about thier shortcomings, which is not always a comfortable position. However, if you have not been 100% up front with her about her failings, then you have failed in your responisbility.

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