Help with new grad RN orientation/Added shifts

[ICU.RN23, BSN]

Hello everyone!

I currently have three more shifts with a new grad, who has already had three months of orientation, but isn’t catching on and got six extra shift of orientation.

Her preceptors for her orientation were very good and our hospital follows a skill-based orientation and we have to follow tiers based on their skill set. Her preceptor and I worked a majority of our shifts together and so I was aware of the progress she was making throughout the past three months. Confidence, managing two patients, delegating, and assessing a critical situation are some of her weaknesses so her preceptor held her back on the tiers because she couldn’t manage assessing AND passing medications at the same time.

My struggle is that we had two patients the last two days and it was like I was her crutch. I had to remind her that she had another patient, to pass meds, and just other basic stuff. She would stop people walking by to have them check on our other patient or have them get her stuff when I wasn’t doing anything and she could’ve called me and asked me.

I understand that starting out in the ICU is definitely different, especially as a new grad when you’re learning all the basics plus having critical patients, but I just feel like the hands-off approach, reminding her to do things, is giving her too much freedom to be relaxed and not focus on the tasks at hand. Does anyone have any recommendations or suggestions for me? I want to make sure she's successful, but it’s almost to the point where the ICU is too much for her unless we can find something that works for her.

[JKL33]

8 minutes ago, Silvem23 said:

My struggle is that we had two patients the last two days and it was like I was her crutch. I had to remind her that she had another patient, to pass meds, and just other basic stuff.

It's unfortunate, but at this juncture that seems like someone not well-suited for the role.

I think it is (would be) better for patients and the person themselves if we had a better way of handling this than always thinking there is some simple thing that someone else can tweak to make any nurse appropriate for any position. I just don't believe that is a reasonable thought or a worthy goal.

That just insults everyone, is scary from the patient care aspect, and is a detriment to the person who is going to continue to struggle.

[llg, PhD, RN]

It sounds to me that your unit is doing its best to help this person transition to practice -- but as the previous poster said, not everyone is suited to every role. If she can't handle it after a thorough and fair orientation, then she may need to work somewhere else for a while. Maybe she will be able to handle your unit someday in the future.

We waste a lot of time, energy and emotion trying to fit square pegs into round holes. That's not always the best use of our scarce resources. Finish out the extra shifts to see if she can improve ... but don't drag it out forever.

When I have been faced with making these decisions, I ask myself: Is this orientee actually improving? Or has reached a plateau from which she can't progress any more. If I see real improvement, I give a little time. If I see no improvement in recent weeks, then I conclude that it is time for us all to move on.

Good luck to you ... and to the orientee.

[ICU.RN23, BSN]

11 minutes ago, JKL33 said:

It's unfortunate, but at this juncture that seems like someone not well-suited for the role.

I think it is (would be) better for patients and the person themselves if we had a better way of handling this than always thinking there is some simple thing that someone else can tweak to make any nurse appropriate for any position. I just don't believe that is a reasonable thought or a worthy goal.

That just insults everyone, is scary from the patient care aspect, and is a detriment to the person who is going to continue to struggle.

Thank you for this. There’s so many of us that agree, she can handle lower acuity patients, like med/surg or PCU, but when it comes to ICU patients, it’s like she freezes.

[CalicoKitty, BSN, MSN, RN]

I wonder if she could handle 4-8+ m/s patients, some of whom can be pretty ill.

[jess11RN]

I read your post and I can't help but feel for the new grad. When I graduated from nursing school, I KNEW I wanted to be in ICU. When I wasn't hired for ICU, I accepted a telemetry position. With 7 months worth of telemetry under my belt, I transferred to ICU. They gave me a few months orientation and threw me to the wolves. I failed. I failed miserably. I told my boss that I wasn't confident, I still needed more orientation. She took me off the schedule. I felt awful, but at least felt validated after the clinical specialist came to me to apologize because she felt that they had failed me.

Don't get me wrong, some people do amazing in these areas right off the bat. But generally speaking, I just don't feel like 3 months orientation for a brand new grad in the ICU enough time. It's not fair to you, her, or the patients. She either needs more time or she needs to gain more experience in a less critical care area (I'd suggest the 2nd choice).

BUT...has anyone sat down to ask how SHE feels (without fear of penalty)? Is she overwhelmed, is she second guessing her choice, or does she think that she is doing an amazing job? What does she think that she needs? I think that factors into decisions as well.

[ruby_jane, BSN, RN]

23 minutes ago, jess11RN said:

Don't get me wrong, some people do amazing in these areas right off the bat. But generally speaking, I just don't feel like 3 months orientation for a brand new grad in the ICU enough time. It's not fair to you, her, or the patients. She either needs more time or she needs to gain more experience in a less critical care area (I'd suggest the 2nd choice).

Amen. And also thank you, @Silvem23 for your compassion. Thanks for not being in a rush to judge. What help are you getting from the manager?

[ICU.RN23, BSN]

jess11RN, the new orientees have touch base meetings scheduled with our manager throughout orientation with and without the preceptor so they can discuss how things are going. It has been discussed multiple times about time management, assessing situations, etc., but I don’t know if my manager is trying to do as much as she can before a decision can be made with management and the new nurse to find a position that could be best suited for her.

I wanted to start ICU as a new grad and I was so glad that I didn’t because I learned so much on med/surg and had that extra skill set when I transferred up. A lot of us nurses agree that new hires should have a year of med/surg experience to get the basic skills of passing meds, IVs, assessments, time management, or have extra time, but it’s not the case unfortunately.

[RNNPICU, BSN, RN]

I am just curious about the three months orientation. Most new grad orientation for ICU are about 6 months. I can understand why this new grad is struggling despite your corrective actions. It is possible that this new grad is not cut for the ICU. It does sound like you are making efforts to support this new grad. Is there a way to determine if she can handle 1 ICU patient? Does this new grad freeze or is unable to juggle the complexity of 1 ICUpatient?

[ICU.RN23, BSN]

ruby_jane, our manager is very receptive and appreciates our opinions, which is a huge plus and it’s probably the reason why she got more orientation shifts because she wants her to succeed. I haven’t talked to my manager quite yet because it was only day two and I didn’t want to come off as negative. I want to try a different approach with her; she will assess the patient in the room then chart right away, but it takes her a very long time to chart because she sees something in the documentation that she forgot and she goes to assess again. It’s very broken up and takes a very long time. She also doesn’t 100% understand why the patients are admitted either.

My approach that I would like to take is to have her assess to the best of her abilities, sit and chart all the way through, and keep track of what she missed so she can go back and do a mini assessment. It just seems so scatterbrained and also if she never leaves one patient room, how does she know what’s going on in the other room? I’m also going to make her read the H&P and the most current progress note so she knows what’s going on with her patients. I’m just hoping a few little tweaks will allow her to be more efficient and more comfortable.

[ICU.RN23, BSN]

RNNPICU, she could handle one patient, but not a critical one as of now. I had to tell her to turn off sedation for the sedation vacation. I had to tell her to titrate down on pressors since we had more than adequate blood pressures, but she only did it because I told her to and didn’t take initiative to continue to titrate. Also, I told her that any fluids running less than 15 mls an hour needs a tko (our policy) on one day, then the next day...same patient, same med, running at 2.89 mls for a couple hours and she didn’t even realize it, but said she wanted to ask for an opinion since we were diuresing. Valid statement, but she should’ve spoken up sooner because we could’ve tried turning off the pressor or ask the providers if they wanted to try albumin. Turned off the pressor, pressures dropped to 70-80’s and she was reluctant to turn the pressor back on. She’s also afraid of speaking to the providers, which the nicest ones in the world were working that day, and their recommendation? Turn the pressor back on.

I feel like I do well at helping my orientees recognize what they struggle with and try to come up with solutions, but it’s like every day we start all over again and she’s forgotten important things or she focuses on one aspect of the patient rather than the whole entire picture.

[Here.I.Stand, BSN, RN]

I hate to see anyone fail... but these types of issues don’t sound like things that can be corrected in three additional shifts.