Getting used to my new job - I think the CNM thinks I'm incompetent (long)

[klone, MSN, RN]

I'm an L&D nurse with several years of experience. Until last month, I only worked at one facility my entire life. It was a smaller community hospital with a handful of OBs. At night especially, the OBs really only wanted to be called if the strip has gone bad and mom needs a C/S (at which point you would call the OB and tell them "You need to come in and section this mom") or the baby's head is on the perineum and you need them to come in for delivery (and several of them would be just fine if you delivered the baby too). The nurses had a LOT of autonomy/responsibility, and were expected to pretty much fully manage the patient's care without bugging the OB for every little thing. If your baby has a deep decel, you do what you need to do to resolve it, and if it resolves, great! As long as the baby continues to look okay, you wouldn't call them at home at 2am to tell them about that decel. Anesthesia was not in-house. If a woman needed an epidural, you had to call them at home at 2am, and they were generally pretty pissy about it. It was just part of the job you got used to. You did not call anesthesia for "frivolous" reasons.

So now I'm at a teaching hospital where you have CNMs in-house 24/7, as well as the OB attending and OB resident. You have anesthesia residents and CRNAs in-house 24/7 as well. They're just a page and a 2-minute walk away. It's taking some getting used to on my part, to know that if I have ANYTHING funky going on with a laboring mom, I don't have to manage it myself. In fact, I'm not expected to or wanted to manage it myself.

So the other night I had a primip who was being induced because of prolonged SROM. She had received cytotec throughout the day and we had switched her to Pit at around 2000. By that point, she was going on 24 hours ruptured, but was not showing any signs of infection. Around 2400 she requested an epidural, which she received. She then had a hypotensive episode and baby started getting really flat, with some lates. Anesth. gave her two doses of phenylephrine and one dose of ephedrine before mom's BP went back up, and baby perked up and started having accels again. CNM was in the room this whole time, so was aware of the hypotensive episode. After the meds, mom's pulse went from 80s into the 110s-120s, which I expected as a reaction to all the BP meds she received. I was keeping a close eye on her temp, taking it about every 30-60 minutes.

After the BP meds, baby started having some big, prolonged accels into the 190s, again, something I figured as secondary to the meds. Baby's variability remained great, and as long as she stayed in RL or LL position, no more lates. Baseline had been around 155 throughout her labor. Over the next couple hours, baby's baseline went from 150s to 160s. Continued to have great variability, no decels, and mom was afebrile, so I was not extremely concerned about it. It was something that I felt worth mentioning to the CNM when she checked in (she had left to take a nap, by now it was about 0200), but not something that I felt worth waking her up for. At one point, baby had a strange decel into the 90s, which resolved after about 60-90 seconds. The charge nurse and I changed mom's position (she already had O2 on), the decel resolved, baseline creeped up to high 160s, but still had great variability, lots of accels, and no further decels. At that point, I decided that I would grab a quick bite to eat (hadn't had anything yet to eat or no break) while watching the strip outside the room, and if the baseline went up any further, I would call the CNM, otherwise I felt comfortable sitting on it and waiting for her to check in.

The CNM then appeared while I was sitting down eating my lunch (which I'm sure probably looked bad). She asked how the mom was doing, and I said that the baby has gotten a bit tachy, and we had one prolonged decel but we got it resolved and baby's variability continued to look good. She went into the room and I followed her, and she looked at the strip and said "This baby has been tachy for over an hour now". I really felt that it had only been about 20 minutes, since the recovery after the decel, but yes, the baseline had creeped up a bit after she got her epidural and had the hypotensive episode. She kind of looked at me like "why didn't you call me sooner?" She didn't SAY that to me, so maybe I was just reading into things, I don't know. But I felt like she was wondering about my competency, and why I didn't immediately notify her of the baby's status. At my old job, if I called at 2am and said baby's baseline has shifted from 150s to high 160s, the doctor would have said "Is there variability? Are there accels? Is the mother febrile? Then why are you calling me at 0200 to tell me this? The plan of care is not going to change." Okay, so lesson learned. It's okay to call the care provider at 0200 to give them status changes, even if they're not earth-shattering.

So then at about 0645, the patient is complete and about -1, feeling very pushy. Her epidural PCEA meds ran out at that time, but she's still numb. I let the charge nurse know that she's complete, feeling pushy, and her epidural has run out, and I said out loud that I wasn't sure if I should call anesthesiology to come in and replace the meds. She said "Of course you should call anesthesiology and have them replace the meds! Why wouldn't you?" Well, because at my other job, if I called anesthesiology at 0645 (when they're getting ready for their first case) to rebolus a woman who is complete and pushy and her epidural is still providing relief, they would absolutely have a cow and basically tell me to take a flying leap.

Turns out, I didn't even need to call anesthesia, the CRNA who was taking over at 0700 automatically came into the room to check on her, and she saw the bag was empty and replaced it without being asked or asking the patient's status. Amazing!

It was good that she did that, too. As it turned out, right at 0700 we tried to trial push the mom and she wasn't bringing the baby down at all, so the decision was made to let her labor down some more (baby continued to look okay with good accels, even though baseline was in the high 160s/low 170s).

So if you made it this far, thank you for reading. I just needed to kind of process the situation somewhere where other people would understand (my husband just looks at me blankly). It's such a learning curve, going to a new place and learning the routine and the preferences of the medical providers. I hope that CNM and the charge nurse I worked with don't think I'm totally incompetent or unsafe.

[SmilingBluEyes]

You sound fine to me.I have worked at 4 hospitals and practitioners vary as do policies. Harder still, are "unwritten" policies that you need time to become familiar. I never mind asking other staff or practicioners what their preferences are. When I am unfamiliar, for example, I will ask the charge nurse or other staff what the dr/midwife wants to be notified of, and what can wait. As you know they vary. Some want to be told of EVERY SINGLE CHANGE. Others, like you said, if you handle it and all goes well, don't want to hear anything until it's time to have a baby.

Don't beat yourself up and don't think the MW thinks you are incompetent. IF you are worried, have a talk with the MW and ask tell what you said here. Tell her how others preferences have been where you were before, and get straight from her what she expects/wants from you. Nothing like hearing it from "the horse's mouth".

I remember way back when I started a new job, I was working with a MW for whom everything seemed different. It seemed I could do no right. So I waited for the right opportunity and pulled her aside and asked her my questions and told her I was sorry if I missed anything. Turned out, she DID have concerns with me but after our frank talk, was reassured and did NOT think me "incompetent". Being open and frank goes a long way to mutual trust.

So have that talk if you are still concerned about this in a couple of days. There are many fine points, preferences and "unwritten rules" that we must learn when working any place that is new to us. Try to find coworkers you trust to guide you and just keep asking those questions until you are comfortable. There are VERY big differences between large university systems and small community hospitals, in my experience. I function much more independently in the smaller hospital. In the teaching hospital, not so much so. You will learn the fine points before long, and be fine.

Do NOT beat yourself up! Those of us who have been working several different places have been there, trust me.

[PostOpPrincess, BSN, RN]

Sounds like you've been independent for so long, that shifting thinking gears will take some adjustment.

I think you did fine, and I wouldn't have a problem with you.

[HeartsOpenWide, RN]

Remember that, although you are very competent and know it, you are at a new work place and this CNM does not know you or your skill set yet. In addition, it sounds like your new environment requires less critical thinking and having to work things out on your own and this is what she is use to.

[LDRNMOMMY, BSN, RN]

It is hard changing jobs and getting used to what each provider wants. I can relate. I went from working in a teaching hospital to a small, military hospital. It was quite a change and I had shifts where I felt the same as you. I ended up asking each provider what they prefer and it helped make the transition easier.

[llg, PhD, RN]

It's hard to switch from one facility to another -- for just the reason you described. At your first job, you learn how to do things "the right way" and get really competent and confortable with their way of doing things. Then suddenly, what you used to think of as "the right way" is no longer right -- and you feel on shaky ground.

I have coordinated the orientation of many experienced nurses who have had this problem (in NICU, not L&D, but the issue is the same). What usually works in this situation is to be totally open and honest with everyone about this. Tell people that at your former employer, you did not have the same resources readily available and that you need to learn how to work best in this new environmnet. There is nothing wrong with that. And there is nothing wrong with asking someone you don't know well, "When exactly do you want to be called? At my last hospital, we called only for really significant events, but the situation was very different there. ... blah, blah, blah."

Another suggestion is to find a couple of people in your current environment who came from a similar background -- or who have worked with orientees who came from a similar background. (Another staff nurse, educator, etc.) As you talk openly about this issue (see above paragraph), you may find that there are colleagues who understand your dilemma. It's a common education problem when experienced nurses change work settings. Ask them for some guidance and support.

Good luck!