Help me deal with the 'tough love'

[nursingjudgment]

Hey everyone,

I am a new grad who started in the ICU in February. I have been off orientation for about two weeks, and it's been tough. I felt relatively confident in the weeks leading up to coming off orientation (and my managers gave me great feedback) but I feel different being on my own. I feel worried that I will hurt my patients, so I double-check and ask the more experienced nurses about everything (even things that they probably think I should already know, like how to mix Levophed or for tips on how to unclog an NG tube). I worry that this makes me looks less competent, but obviously I want to be safe so I keep asking.

My real problem, though, is that when I do make mistakes (and obviously I have been making them), it's hard to deal with some people. Now, to be clear, the nurses on my unit are actually the best. I love them and they have been incredibly supportive. But, as an example, the other day a mid-level practitioner got angry at me in front of two other people for not following an order-set, telling me that I needed to be professional enough to ask questions if I didn't know something. I apologized, even though I was really confused because I had just checked the order-set minutes before and was pretty certain that I had done it correctly. After she went away, I re-checked the order-set and I HAD followed it correctly. She was the one who didn't know it.

One of the nurses who was watching told me that the mid-level felt like she could treat me like that because I appear too apologetic. But I don't know how to avoid this. I feel as though I have lost all the confidence that I had before I came off orientation, and now I am setting myself up to have people ream me even when I haven't made mistakes. I know that they say that, "No one can make you feel inferior without your consent," but I am terrified that I really am inferior. Everyday I go home and research everything I did, and I am horrified by every small thing that I did wrong. I worry that I shouldn't be in the ICU because I am not safe enough, or smart enough, or don't have a good enough memory.

I can't be the first person who has felt these things. Does anyone have suggestions on how to have more reasonable expectations of oneself? How do you know that you are safe? I know that I care, and that I care to learn, but what if that isn't enough? I sometimes feel as though the stress of the unit makes me forget all of the knowledge that I can so easily access when I'm at home.

[letterwritingman]

I too feel exactly like that and I'm in the same position being a 'New Grad'; I have recognised that I appear maybe hesitant or 'timid' especially around what I consider safe nursing but I've been told that I need to be more aggressive in my approach to weaning etc. I think that all the horror stories of inept nursing, unsafe practice etc leading to disciplinary action as told to us by nursing lecturers throughout Uni has caused many of us to triple guess our actions leading to a lack of confidence in our own practice; I never lacked confidence in my previous military career but wow these days.....

[icuRNmaggie, BSN, RN]

Ask to speak to the provider alone and say " I did not like the way our last interaction went. You openly reprimanded me in front of others and said i was unprofessional when I had followed the protocol precisely and verified everything with my colleague."

If she has a conscience she will apologize and leave you alone in the future.

[nursingjudgment]

Letterwritingman, I agree that I think horror-stories have something to do with it. I worry about everything: am I charting enough? Am I charting appropriately? Did I chart in a way that protected me? Am I meeting the standard of care? In school, I memorized every detail of so many things because we were constantly told the terrible dangers of not doing each thing a very specific way. On the floor, I see that things are rarely done the way I was taught (and I see that no one I work with actually remembers EVERYTHING that they learned), but I still feel as though I should remember everything and do everything correctly, even when it's impossible. Because every worst-case scenario I learned in school seems just a well-meaning error away.

I have become so focused on the need to know everything (or else I am an 'incompetent' nurse) that I feel like my worry paralyzes me so that it's hard to use even the knowledge I do have.

[icuRNmaggie, BSN, RN]

Starting off in an ICU is terrifying because of the tremendous responsibility and vast amount of skills and knowledge to be acquired.

You sound like you are right where you should be at four months into it and that you need to work on some communication skills.

Doctors are understandably leery of inexperienced people taking responsibility for their critically ill patients. It is not unusual for one of them to say to me "would you keep an eye on her, she's new here. " Focus on the working relationship.

There are a few simple things you need to make part of your routine:

Be prepared to give a quick update when the Doctor appears. They need facts and numbers.

After they have seen the patient ask "what's the plan for Mr Jones?" and more specifically ask which drip to titrate down first, or what range he wants for the BP etc.

There will always be the one who talks down to you to make herself feel important. Just say "I am well aware of that" and go on about your business.

Take "I'm sorry" out of your vocabulary.

You read about Critical care when you're at home, so you must have a passion for this kind of nursing. You sound like the perfect new grad orientee.

If you keep on applying yourself in a year or so you will be much more confident, if just from sheer repetition. In the ICUs we generally see the same number of limited situations over and over again. If that helps to make it seem less daunting.

[nursingjudgment]

icuRNmaggie, thank you so much for that advice. It is really heartening to have someone tell me that it sounds like I am where I should be -- it's so hard to tell. Your suggestion about clarifying the plan with the care team is also really helpful; it seems obvious now, but that is a great way of getting from them exactly what I need in order to plan the rest of my day. I haven't been doing that, but I will certainly start.

And I will try to take "I'm sorry," out of my vocabulary (or at least to lessen its use)! I've been told to do that before, but somehow it seems to always slip back in. Thanks for the reminder.

[weirdscience]

Our NPs (some consider the term "mid-level" derogatory) are VICIOUS to new ICU RN's--often meaner and less approachable than the docs. I can't figure it out...I think perhaps they get so much pressure FROM the docs that we become their targets, and also they hold us to a higher standard because they were RNs once, too.

I know that's not super helpful, but maybe it does make you feel better to know that it happens to a lot of us, new or experienced.

[ArmaniX, MSN, APRN]

As far as being reprimanded in front of other staff by the provider I would personally never allow it.

If they are insinuating that you did not follow the order set I would pull it up in front of them and go over step by step what I did per the order. If you're confident that you did it right you must defend yourself. Not in a threatening manner, professionally, but stern.

When I was on a SDU I had a doctor talk down to me in the middle of an RRT for "not following his admission order" an order that was never placed. I immediately pulled up the order list and asked him to show me where his "order" was.

Stick up for yourself. And definitely ask questions when you need the reassurance. I also started icu in february. I still ask fellow staff for confirmation when I'm not 100% and they don't look down at me for it. The best nurses ask questions.

[MaryAnnD]

When I was new in ICU i had a little indexed note book. Put stickers in each relevant page eg Adrenaline, then the relevant info eg 5mg (5 x 1ml amps) and 45mls 0.9% saline 100mcgs per ml. Very basic but it worked for me. Each new drug went in the book, plus very brief description of how it worked. It made me feel less needy. Might be worth a try. But 4 months in is very new, and sounds like you're doing great. The Dr on the other hand may need a lesson in professional courtesy.

[nursingjudgment]

I have a notebook too! It's the best. I actually have two -- one for drugs and one for miscellaneous information that I want to remember.

Also, I didn't realize 'mid-level' was derogatory. I won't use it anymore!

[cnmbfa]

Hey everyone,

One of the nurses who was watching told me that the mid-level felt like she could treat me like that because I appear too apologetic. But I don't know how to avoid this. I feel as though I have lost all the confidence that I had before I came off orientation, and now I am setting myself up to have people ream me even when I haven't made mistakes.

Along with cutting way back on the apologies, maybe try this: Just say "OK." so they know you heard them. Then just don't say anything more. If they push you, say "I need a minute to take this in and think about it." Refuse to let that person get your goat. Then go back later and say "I admire you and would one day like to be as good as you. When you have time can you share with me how you would handle ______."

I did this once with someone who was trying to grind me down--it worked like a charm, and he went out of his way to start mentoring me.Reply

[icuRNmaggie, BSN, RN]

Everything is not the nurse's fault.