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.

[CodeNurseBrown]

First off, give yourself a little grace. The ICU is a hard place for any nurse, and especially hard for a new graduate. You're not going to know a lot of things... somebody told me when I was new that it would be two years before I really had a grasp of what I did and didn't know. I think that was a pretty fair estimate. Take each day, learn everything you can from it, and throw away the rest of the baggage. I threw up every morning before work for at least a year because I was so afraid of mistakes and the lateral violence from other nurses . Now, more than 5 years later, I love my job and can't imagine doing anything else. It gets easier. The fact that you're here asking for help tells me that you will go so far in this field! The one's who are dangerous are the ones who let their ego get in the way of asking for help. Everyone has something to learn. Kudos to you for asking!

When I was a new grad in the ICU, I was given a book by Nancy Diepenbrock that condensed the information I needed to have readily at hand. It was very easy to navigate and let me get the down and dirty information on something quickly. From there, I could go intelligently ask for clarification or guidance from my peers or doctors. Having that foundation to start with was less frustrating for me because I didn't feel so amateur about the topics or issues.

I encourage you to assert your feelings. "I appreciate that I am new here and that I don't have the intimate familiarity with the order sets that some of the more experienced nurses do. I am learning, and would appreciate your patience while I learn and I welcome any constructive feedback you have for me. That said, I don't feel like our encounter the other day went well. I would like to take a moment and go over that particular order set with you because what I'm reading and what you're telling me are conflicting. Can we please clarify this so we don't have any more misunderstandings?" Then have the order set in hand when you talk to her. After you talk, tell her, "Thank you for taking the time to review this. I appreciate your expertise, and again want to thank you for your patience with me." A lot of times if you thank people for what you *want* from them, it'll diffuse their defensiveness. She might not be particularly patient with you, but by putting that word out they're you're subtley bringing it to the front of the conversation and if she chooses to be impatient, it has to be done consciously.

Statements like, "When you said _____, I felt/was confused by/was frustrated by ___________." are often helpful. Also, "Can you help me understand ___________" when you're not sure they're in the right forces them to lay it out. Sometimes it's just as simple as that's the way they've always done it.

Hang in there. You're new, but you deserve to be treated with respect because you're a person and you have value. Respectfully demand that of those around you. You'll all be better off in the long run for it.

[salvadorgalvanjr]

I believe your doing great. as time pass by, you will learn those things passively. Keep in mind that even doctors whom studied for many long years also commits mistakes.

For your memory

I think the reason that you are having a hard time recalling things is because you failed to store it in your long term memory. I mean, when you have a question you just browse and read for answers, you fail to imagine doing the concept. you just read and make the "okay, now i know" which actually doesn't work. because textbooks are ideal, and the hospital scenarios are mostly not.

Thus, give yourself time to rest. I am exactly like you before, i want to be the 'know everything' guy. But honestly, it only made me worse because i sometimes over analyze a simple situation. But its actually a great goal. Its much easier to gain trust and respect from colleagues and patients if you know many things

[Larry3373]

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!

At my hospital the term midlevel is used of PA and NP and comes from corporate in writing. I do not believe it is considered derogatory to them, but I do see NPs on this forum getting offended by that. I'm not a NP yet, but I don't find the term offensive. Just keep the paychecks coming, lol!

[Mattskiematt]

If I were in your case, I would accept the criticisms as constructive. However, if I ever feel that that specific person is picking on me, I would stand-up and defend myself (especially when I know that I am doing my work correctly). It takes time to determine which is which, but you need to make sure that these people are not pushing you over.

[sommer0515]

I'm in the same boat. New grad in critical care unit who is told to ask questions but sometimes get the "sideways" looks and even when I run a hypothetical across to gather knowledge for my critical thinking.. It seems to only turn into a "you're-not-as-smart-as-you-think" situation. Frustrating as is, I'm trying to take it in stride.

[hawaiicarl, BSN, RN]

ICU is different from any other floor in the hospital with the possible exception of the ER. Knowledge isn't the only requirement, a strong personality is required as well. As the ICU nurse you are expected to display leadership, and instill confidence in your patients. Often you are the resource for the entire hospital including anything from hard IV starts, to obscure equipment questions, to leading the codes until a physician manages to show up, to anything really. It takes a certain toughness of skin, not everyone has it. It is hard for a beginning practitioner to know if they have the stuff. Have confidence in your knowledge, don't be afraid to ask questions, be aware that no one knows everything, and don't be skeered! Sometimes, it is all in how you ask a question. As an example, you said that you asked someone how to unplug an NGT, this probably got you some sideways looks. If you would have said, "My NGT is clogged, I tried a manual flush, I tried cocacola, I tried warm water. Do you have any other tricks? Or should I just yank the thing and replace it?" This comes across entirely differently, shows you know your stuff, and are just consulting a senior nurse.

Good luck!

Cheers