Hi everyone, I know this is all about Nclex but I just want to share with everybody my experience. This site helped me a lot when I was studying for my nclex and I will answer some questions of nclex as well if anyone has questions. All I want to say is working as a new RN is as hard as passing nclex.
I graduated from a BSN school in May 2012 and passed my nclex at the end of june. I got hired as a RN in a rural hospital at medical unit before I graduated. It takes an hour and twenty minutes to get there so yes, I commute. I started my job on 2nd, July and the orientation was supposed to last a month. Everything worked alright till this wednesday morning. My director told me I was not a good fit for their unit and I didnt know how to waste narcotics and I wasnt pay attention to details enough. Besides that, I also totally made one patient feel uncomfortable. Here is my side of story of that compliant of one patient:
I got complaint from one patient as he stated that he was not comfortable with me being in the room. what happened was he aspirated and almost choked three times when I gave him medications because he didnt turn his head to the right side. He has COPD and right side weakness so he was supposed to turn his head to his right when he was eating or drinking. I was not aware of that situation(his right side weakness) and I was totally panic as there was nobody with me at that time. I didnt get report from last shift nurse as well so I dont know should myself be responsible for that his being choked accident???
As for narcotic waste, I didnt know if you only give half dose, you are suppose to waste half doses, but after the nurse I was orienting with pointed out, I was doing the right way afterwards. so in summary, I didnt actually make any medication errors so I was assuming she meant potential med errors.
The director also said I am too hyper, not calm enough and the fact was I wasnt nervous with every single patient (she said shes not gonna go from there). She also pointed that I didnt have good IV skills I was supposed to have from learning at school. The point is IV skills staff like that is not gonna be perfect just by learning at school, right? Practice makes perfect and now I feel like I am such a loser!!
I am here to hear everybody's thoughts and dont afraid to say harsh things. I like different opinions. Thx
I am surprised at the number of posters who are blaming the patient for not turning to the right to take his medication. Sure, it would be great if our patients were all in a position to care for themselves. But, if they could, they wouldn't be in the hospital. If you have a patient who has difficulty swollowing, it is vitally important that you assess what is going on rather than continuing to push through.
As for the IV skills, I wonder if the manager was talking about IV starts since you said you didn't have any while you were there. IV skills encompasses so much more than simply starting IVs. Appropriately hanging meds, pushing, documenting, assessing sites, ensuring that there are not compatibility issues, etc. Given your description of your difficulties with oral meds and narcotics, I wonder whether she was perhaps referring to your skills at IV medication administration/documentation rather than starting IVs.
As a newly licensed nurse, I would have expected your school to have instilled in you the importance of protecting your license. You cannot protect your license if you simply pass medications without first assessing a patient. You were not at a clinical site. You were the nurse. There is no excuse for not knowing what is going on with your patients.
I am surprised at the number of posters who are blaming the patient for not turning to the right to take his medication. Sure, it would be great if our patients were all in a position to care for themselves. But, if they could, they wouldn't be in the hospital. If you have a patient who has difficulty swollowing, it is vitally important that you assess what is going on rather than continuing to push through.
As for the IV skills, I wonder if the manager was talking about IV starts since you said you didn't have any while you were there. IV skills encompasses so much more than simply starting IVs. Appropriately hanging meds, pushing, documenting, assessing sites, ensuring that there are not compatibility issues, etc. Given your description of your difficulties with oral meds and narcotics, I wonder whether she was perhaps referring to your skills at IV medication administration/documentation rather than starting IVs.
As a newly licensed nurse, I would have expected your school to have instilled in you the importance of protecting your license. You cannot protect your license if you simply pass medications without first assessing a patient. You were not at a clinical site. You were the nurse. There is no excuse for not knowing what is going on with your patients.
When I was reading your post, I kept asking myself did I miss anything when I assessed him, here is how I did my assessment for that COPD patient:
"I walked into the room with the nurse, he was eating breakfast(did not turn his head!) and I introduced myself and the nurse, asked how did he sleep and how was he doing; he answered he was doing well. He knew the nurse I was orienting with because he was an old patient. He was alert, awake/orient; I listened to him, lung sounds were diminished and heart sounds were normal; there was no swelling; IV site was intact, no infiltration/infection; he was on O2 @2L/min; the LBM was yesterday. I passed my meds afterwards and he did well.
The situation happened during lunch time and I explained in my previous post and I remember there was another old nurse came into the room who took care of him before when I was panic. I told her what was going on and she smiled and told me he would be fine and just leave him alone. He finished lunch without any assistance. I did not have a chance to sit down till about 12ish that day cause we had five patients and there was another patient in ciritical condition so we were staying in his room more than we did at the COPD patient.
I kept asking myself, what could I have done better to avoid missing such things happen in future. He was moving head freely and he was pretty independent. Again, I think he was more mad at me because I told him he could not have the nose sprayer till late that night. I asked the nurse I was orienting with and she told me to tell him that. I feel so bad:( Patient's safety is the priority, but the nurse I was orienting with told me to tell patient to wait and I should have done better. I totoally regretted my decisions and I am responsible for my own actions!!!
again he took his morning pills just fine..so I assumed he just drank water too fast:(. Again, I will never assume anything. For IV, I was clumsy when I hung the IV and before I figured sth out she already pointed out. I just do believe I should have be with one experienced RN throughout the orientation. But I wont make excuses for the mistakes I made!
cdga- well said. I whole heartedly agree and have been saying this for my 32years as an RN. I am an old diploma grad as well.
new RN - thank you for disclosing the answer to what I suspected about your preceptors experience level- you were being oriented by an RN with only 3 years experience and another who just graduated this May. This is the blind leading the blind. This is what us old crusty old bats are up in arms about. This is a perfect example of the hospital administration's philosopy of hiring all new lesser experience nurses and getting rid of their crusty old bat seasoned experienced nurses. This is where cheaper gets them. The hospital is responsible for the major "bad" here and all in the name of saving money. Thier money saving endeavors should be focused in other directions like hiring case managers and Utilization review case managers and nurses skilled in billing and coding and not scrimping on the direct care patient staff nurses and the orientation of new nurses- new grad nurses or new to the facility nurses.
NewRN: You should also write a letter of complaint to the Board of Health and your state Board of Nursing informing them of the totally incompetent ill planned orientation you received as a brand new nurse beginning your first job as a nurse, Include in that letter of complaint the lack of one designated experienced crusty old experienced nurse to give you a good orientation, the length of time it was before you gave out meds( you did post 9 shifts) the experience levels of the nurses precepting you, everything. First consult with one of you old nursing instructors or the Dean of Nursing at your college or university you attended for their opinnion on you writing this letter to the Boards first- see if you can make an appointment to speak with one of them. Begin by making an appointment with your Dean of Nusing at your college or University and if an appointment is granted, tell the Dean that you wish to make the State Board of Nursing aware of how new nurses are being oriented into these hospitals and everything detail of your orientation and what happened to you, and that you want to write a letter of complaint to the State Board of Nursing about this new nurse orientation experience and ask which is the best way to go about this. See if the Dean can advise you on if this is a good idea or if this would place you in jeapordy of Nursing Board action. And proceed as the Dean advises you. These hospitals and other facilities are creating unsafe conditions for both patients and nurses in their mission to save money. And it is going to take a Regulatory body to stop them. I am sure you are not the only new nurse this has happened to- just from reading these threads on All Nurses. It is all your complaints to these Boards and healthcare commisions that can start making changes and putting laes and regulations in place to stop the unsafe conditions that exist for patients and nurses in today's healthcare institutions. If these regulatory bodies get enough complaints form the nurses these practices have hurt and effected, it will light the fire under their butts to make legislation- rules, laws and regulations, to stop these unsafe practices. It will force these hospitals to act more fiscially responsibly and hold them accountable for the money decision they make.
thankskcmylorn the nurse i was orienting with the night shift before i got fired was an lpn for about 6 years in that hospital but she got her license this may. i dont know if i still count that as just new graduate or not. i will take your advise, and talk to the dean of my school program and see if i need to write a letter or not. thx so much!!!
I agree one hundred percent with Ruby. I will tell you that you are not the only one who makes mistakes and it will get better. One time I was at a facility and I gave whole pills and water to a pt. who was supposed to be on thickened liquids.
Even though it was documented, it simply slipped my mind and I forgot. Thank God the pt. was okay but it was pretty scary as he choked and could have aspirated or even worse died. Before giving the pills this patient stated he could swallow them perfectly fine. The lesson learned is to not always rely on the patients ability to determine whether they can swallow pills or not. Sometimes, even alert patients are not oriented to their current abilities. Yesterday, I had pt. choke after I gave her pain medicine. I immediately, notified the NP and got orders for swallow eval, npo, and etc. I warned my preceptor that the pt. choked on pills but my preceptor decided to listen to the pt. and over the rest of the meds, the pt. choked again and required a breathing tx.
After the first time that should have been a red flag. Learn from your mistake, no more excuses.
Op, I read this thing and I don't see that anyone assured you of this thing: That COPD/right-sided weakness (if permanent) guy is gonna choke, and often, probably even on his own spit. So.
Yours is to help try and make the swallow process go as smoothly as it can, but unless new onset, this is something the patient understands. All you can do is to educate, support, and intervene if it appears the patient just cannot recover from an episode on his own. He'll have to learn to recover. Look into another route for meds especially if these are only temporary doses (while in hospital). Also this can become an emergent situation, you need to learn to recognize what that would be... and get a response going.
Remember, if there is a problem, that is when you go into action. You gotta root it out and see if it has or can be addressed.
newRN- in the scheme of things- she was a practicing LPN for 6 years, if I remember correctly she was the one who the narc count/waste/documentation issue occured. It happened under her turtorage. That she should have known, no excuses, hands down! That is a basic skill in working clinical nursing on any license level and if she has been a licences practicing LPN in that hospital for 6 years she would have most certainly have known that. She knows how to start IV's, insert foleys, program pumps, she knows basic nursing skills. She is not able to instruct, she is now still learning herself. An LPN should never be prcepting an RN. In the scheme of RN- she is also still a new grad/new nurse and should have never been put in that position of precepting another new grad/new nurse. The LPN/new RN is also just learning her RN critical thinking, her RN judgment and RN priority setting. She cannot guide you as she herself doesn't know the RN role yet.
The Nursing Practice act has made a clear deliniation between the role and scope of practice of the LPN and the role and scope of practice of the RN. These 2 licensure levels are not one in the same and that is where the LPN/newRN is at. She too is still learning the distintion between these 2 roles. You are at a greater advantage point because you were not an LPN prior to being an RN. There is no past learning to 'muddy up the waters', so to speak. LPN's who become RN's have an LPN base point, mindset, that gets in the way of learning the new RN role that is often difficult to manuver through. That LPN body of knowledge and role responisbilites make it difficult and it becomes a huddle they have to pass over. You are operating on a one frame of reference with no past reference point.
Was it the LPN/new RN- preceptor, who let you go into that COPD patient's room alone? Did that happen on the night shift?
Hi, just a few of my own thoughts, from a hundred years ago:
First of all not to throw the baby out with the bath water:
Did that patient who aspirated, have a temp at anytime before/after that?
Did anyone order a speech eval because obviously the patient needed more teaching about swallowing, etc.
Also were any chest xrays done, even if no temp to rule out pneumonia after the aspirations?
PT/OT/Speech personnel are very helpful, get to know them.
Now for thought provoking stuff:
There is a really good book that was used in my BSN course. It is called: From Novice to Expert by Patricia Benner. This book was like my bible when I finsihed with BSN after ADN. You may want to review this book, ESPECIALLY in the back, where no one says to go and read. There is a little section called Guideline for recording critical incidents. This is a wonderful guideline to sit down with (even after it is memorized) to make sense out of ANY situation you may come across.
Here is the cliff notes version:
A. What constitutes a Critical Incident:
An incident in which you feel your intervention really made a difference in patient outcome, either directly or indirectly (by helping other staff members)
An incident that went unusually well
An incident in which there was a breakdown (ie, things did not go as planned
An incident that is very ordinary and typical
An incident that you think captures the quintessence of what nursing is all about
An incident that was particularly demanding
B. What to include in your description of a critical incident:
The context of the incident (e.g., shift, time of day, staff resources)
A detailed description of what happened
Why the incident is critical to you
What your concerns were at the time
What were you thinking about as it was taking place
What you were feeling during and after the incident
What, if anything, you found most demanding about the situation
C. Personal Data:
name (optional)
title
institution
Amount of time on current unit
Amount of time in nursing practice
Unit where incident took place
D. Describe incident in detail addressing part B questions
F. Describe a typical day at work you had recently
G. Describe a day at your work that was unusual in some significant way.
This little guideline will help to refocus your thoughts back to solving the problem and thinking in the right direction.
hey kcmylorn: the COPD pt happened was the day I was with the nurse who had three years (she told me she had been there for three years in that hospital so I am not sure if she worked in other hospital or not). However, she was not in his room with me when all the coughed/aspiated situation occured. and yes you are right, the LPN(of 6 years)/new RN was with me when the narcotic wasting/count happend and she prob the one told my director I was not detailed enough.
Thanks Parkerone:!!!!
Did that patient who aspirated, have a temp at anytime before/after that?
We didnt take his T and I believe we looked over his chart and he was fine. He was a vietam veteran so his neck got injuried by then I thought. He was an old patient (came to hospital couple of times/month) so some nurses know him well enough. As I mentioned before, one older nurse came into the room and I told her what was going on, she said he would be fine. I really what else I could have done to prevent that.
Did anyone order a speech eval because obviously the patient needed more teaching about swallowing, etc.
I dont believe so. He had breastfast and took morning pills well so I was so concerned when he spilled some water out of his mouth. I should have been more cautious.
Also were any chest xrays done, even if no temp to rule out pneumonia after the aspirations?
He is supposed to get pneumococcal vaccine before he got discharged. The last time he got vacinnated was four years ago so he was not supposed to have another shot till next year. They didnt think it was a big deal because it was normal for him. I was panic because this never happened to me:(
As for the book, I will take a look at it. Thx for the recommendation.
I agree one hundred percent with Ruby. I will tell you that you are not the only one who makes mistakes and it will get better. One time I was at a facility and I gave whole pills and water to a pt. who was supposed to be on thickened liquids.
Even though it was documented, it simply slipped my mind and I forgot. Thank God the pt. was okay but it was pretty scary as he choked and could have aspirated or even worse died. Before giving the pills this patient stated he could swallow them perfectly fine. The lesson learned is to not always rely on the patients ability to determine whether they can swallow pills or not. Sometimes, even alert patients are not oriented to their current abilities. Yesterday, I had pt. choke after I gave her pain medicine. I immediately, notified the NP and got orders for swallow eval, npo, and etc. I warned my preceptor that the pt. choked on pills but my preceptor decided to listen to the pt. and over the rest of the meds, the pt. choked again and required a breathing tx.
After the first time that should have been a red flag. Learn from your mistake, no more excuses.
Thx so much for sharing with me of your experience. Next time I will trust my instinct form gout and yes, no more excuses!!!!!
You can't teach experience-hopefully you can learn from mistakes or situations that could have been a mistake. Take a methodical approach, don't be pressured by time if rushing or circumventing would lead to harm. Ask for assistance, make your best assessment, and proceed. If you have a bad outcome, talk it out soon after before it becomes a huge issue. Ask for continued observation until you feel comfortable with the process. If they won't assist you with your own personal intervention, then ask for a transfer where the pace may be slower, where more observation would be offered and available and you won't be sticking your neck out for the chopping.
Seems like there is a wave of superiority of nurses who think "you should know better, etc" In some cases that is true, but most times it's a teachable moment between experienced and non-experienced that can make the difference in a new nurse's career. Every nurse on this blog has made some sort of error-or squeaked by by the skin of their teeth. We are all capable of making errors on any given day.
To me-firing a new nurse is not the way to go. Work with people you invest in! Someone valued your resume' contents in order to give you a job. It's very disheartening for a new nurse to be treated in such a manner so early in a career. Such an investment in hiring new nurses must be bolstered with more training, repetitive activities towards mastery of a procedure or process. If that can't be accomplished in some way, then we as a profession are facing a bad outcome in many ways. Loss of new nurses, patient safety and ultimately the management. So for new nurses, best to sniff out the workplace before your commit. Know your weaknesses and ask if there are opportunities to learn. It's a scary workplace these days and having a termination on your history is tough to recover from-and in my humble opinion unnecessary punishment.
It does not sound like you were mentored appropriately.
You have learned a big lesson. DO NOT render care until you have rec'd report! That is C.R.A.Z.Y. Do not allow yourself to be put in that position ever again, and shame on that institution/preceptor for allowing that to happen. Many years ago when I was working as LPN in a particular institution, we DID NOT receive report. We functioned as nurse techs. I was getting vital signs, and as I wrapped the cuff around a pt's. arm, she said "No, you can't take my BP in that arm, I've had a mastectomy!" I could not have possibly known that. So what did I do? I quit! And this was in my first week or two on that job. (And I had worked in enough other places to have the confidence/awareness that this was NOT the place for me.)
Trust me, there are places with appropriate orientation procedures. (As outlined by OP). Find one!
I want to compliment you on how well you have taken all the comments and constructive criticisms.
Chalk this up to a learning experience, do not list this on your resume.
At your next interview, explicitly ask about orientation procedure/length. I would not bother with filing any grievance or complaint, it's not worth it.
shortnorthstudent
357 Posts
I am surprised at the number of posters who are blaming the patient for not turning to the right to take his medication. Sure, it would be great if our patients were all in a position to care for themselves. But, if they could, they wouldn't be in the hospital. If you have a patient who has difficulty swollowing, it is vitally important that you assess what is going on rather than continuing to push through.
As for the IV skills, I wonder if the manager was talking about IV starts since you said you didn't have any while you were there. IV skills encompasses so much more than simply starting IVs. Appropriately hanging meds, pushing, documenting, assessing sites, ensuring that there are not compatibility issues, etc. Given your description of your difficulties with oral meds and narcotics, I wonder whether she was perhaps referring to your skills at IV medication administration/documentation rather than starting IVs.
As a newly licensed nurse, I would have expected your school to have instilled in you the importance of protecting your license. You cannot protect your license if you simply pass medications without first assessing a patient. You were not at a clinical site. You were the nurse. There is no excuse for not knowing what is going on with your patients.