How to handle nurses who "Don't get it"....? (Kind of long)

[JSRN81]

I ran into a situation last night that I wasn't quite sure how to handle. I work in a CCU/MICU and was in charge last night, which is actually the norm. Anyway, a fellow nurse, who is rather new, had a patient with respiratory failure who was vented, but not sedated nor restrained. He was extremely anxious and only getting Xanax q6hrs. Anyway, at one point, she went to tha back part of the unit to help someone else with their patient. While she was gone, her patient put on his call light and began to violently shake his bedside rails. So, I went in the room to find out what he needed. He had copious amounts of thick secretions coming out of his mouth, his SPO2 was low (about 90%) and his HR was 140bpm. He was also holding onto his ETT and OGT. I quickly suctioned out his mouth and then happened to notice he had what looked like TF coming out of his ETT. Now, seeing as he had just been pulling on his tubes, I really didn't doubt that this was the case. So, I suctioned him very quickly until his tube was clear, and realized I suctioned out about 200ml of TF-like substace. Since I was in charge and she was no where to be found, I paged the doc and immediatly got a chest x-ray and stat treatment ordered for him. Once she finally reappeared, I filled her in on the situation, and for the most part let her handle the situation from there seeing as it was her patient. She seemed lost, and I really mean lost...she just stood there. So I asked her if she had had high TF residuals or problems earlier and she said no. I told her to check her OGT and if it didn't seem right, just to pull it (better safe than sorry) and put a new one in, and the doc would be up soon. The doc called a few min later, and I told him the patient was much better and seemed okay (and we got him sedated). Anyway, he came up about a half an hour later to check the chest X-ray. As he was checking it, he called me over and asked me to look at it with him, and asked where the OGT was....it was mid-esophagus...and it was clearly in the wrong spot. So he told me to tell the nurse to go pull it...which I did (and had already done 45 min earlier). Soon after, he went back in the room, and the tube was still in! Finally, he told her to pull it as well and she finally did. I guess my question is how would I handle this type of situation? I've been up in the unit for about 3 years, so I in no way consider myself an expert, but to me, she seemed not to get how serious the situation could have gotten had no-one caught it...or how serious an aspiration pneumonia can get when you have a chronic venter. Any advice?

[canoehead, BSN, RN]

She sounds shell shocked to me, walk away and your patient immediately has a crisis...then come back in the middle of it. It's tough to take over, although she will have to learn.

I assume the ng feed was turned off immediately. Why not advance it to the stomach and leave it intact for later feeds? Why pull it if the patient will need nutrition later?

[CardioTrans, BSN, RN]

How new is she? Is she a recent grad, or new to CCU/MICU and just off orientation? Did she have a "seasoned" nurse with an assignment close to her? Maybe she really doesnt understand what could have happened. Maybe she is one of those that is afraid to ask questions fearing that she would look "stupid, or it be a "dumb question". Did she correctly check placement by auscultation as well as checking residuals.

She could be having a hard time but is afraid to really let anyone know. The units can be overwhleming even to a seasoned nurse new to the unit. You could take her aside and ask her in a non judgemental way if she is comfortable, or is there anything that she needs help with and let her talk. She may just need to someone to offer some help.

I have seen nurses who "appear" comfortable on their own that had to go back on orientation for various reasons.

[JSRN81]

Cardiotrans- She graduated last May (May 05), and came up to the unit as a new grad. She was on orientation for 4-5 months. I didn't check over her charting, but I certainly would hope she had checked for placement as part of her assessment, although, like I said, I didn't check her charting. Last night, I didn't want to pull her aside because I didn't want to make her feel uncomfortable, so instead, I more or less prompted from the sidelines you could say. There were a few "seasoned" nurses who were assigned right near her, so we were there to jump in to help. I guess what I DON'T want to do is make her feel like she did something wrong or like she can't ask questions, because I know everyone needs to learn and has a different learning curve and style. I have held back from giving her "overwhelming" assignments before because of a situation she had when she came off of orientation, and she had a patient who had been crashing for a couple of hours but she didn't recognize it before it was too late and the patient ultimately passed away. I do try to coach her because she doesn't appear to be the most ambitous, which is why I am cautious of the situation, I didn't want to appear overbearing and pushy, and wanted her to handle the situation, but also wanted to see her go in the right direction.

And...Canoehead- I immediatly turned off the TF when I saw him coughing violently and the secretions in the ETT. Also, for my own practice, if I put the tube in, I will advance it because I have an idea as to where I put the tube to begin with, but if I didn't place it, I like to do my own "measurement" and replace it. Seeing as it was an OGT, it'll cause less trauma and an NGT plus that was the way I was taught and the general practice of our facility. I'm sure it varies from place to place. It's just the way I learned how to do things.

JS

[CardioTrans, BSN, RN]

Cardiotrans- She graduated last May (May 05), and came up to the unit as a new grad. She was on orientation for 4-5 months. I have held back from giving her "overwhelming" assignments before because of a situation she had when she came off of orientation, and she had a patient who had been crashing for a couple of hours but she didn't recognize it before it was too late and the patient ultimately passed away. I do try to coach her because she doesn't appear to be the most ambitous, which is why I am cautious of the situation, I didn't want to appear overbearing and pushy, and wanted her to handle the situation, but also wanted to see her go in the right direction.

JS

Ok, so she has been off of orientation roughly 4-5 months. which should be sufficient amt of time to be "ambitious". What concerns me is that this is the 2nd time in 4 months that the patient has had or could have had a bad outcome. I also know that each patient is different and there were different situations, so bear with me. Not questioning you as a nurse or charge at all.

You know as well as I do, sometimes the unit can be downright awful, wide open, and things change in an instant. There will be days when you wont be able to hold back on her assignments due to the nature of the ICU beast.

Does your unit have a Clinical Nurse Specialist that does all of your education for new nurses, inservices, etc that may can talk to her or set up some kind of meeting to discuss her progress? Not saying to single her out, but see if the CNS maybe could do it with all the recent new hires? I know shes been there almost a year, but maybe now that she has been there that long, she can identify some of her own weaknesses or areas that she needs help with. And if she sees that other new hires are "having these meetings" she wont feel singled out or "picked on". You could voice your concerns to the CNS, and have her talk to her in an anonymous way.

The last nurse that was put back on orientation in my unit had been OFF orientation for 5 months and was not "progressing" as she should have been.

[JSRN81]

Actually, I can tell you've at least seen the situation before because you are addressing other concerns I have as well!!

I don't think you're questioning me at all...don't worry...I'm relatively new at this and want to be good at what I do! I have been the Associate Nurse Manager on our unit for about 6 months...so I take all of the advice I can get!

Like you said, there are going to be times where I can't curb her assignment just because I don't think she can handle it...you are absolutely right on that. When we orient our new nurses, we actually have a program, probably similar to many other states and units, in which we send our nurses to critical care classes (our particular classes are called Consortium). They do this with their first few months of employment on the unit, and then they need to take exams at the end. This is also another issue I have been attempting to address with this particular individual. I believe that she finished her classes around the August/September timeframe....and as ANM and the co-chair of the staff education committee, I am aware that she did not pass all of her exams. As soon as I became aware of this (probably around December time frame) I brought it to my NM and alerted him that she needed to re-take her exams. So, I talked to her and informed her that she needed to schedule a time and re-take her exams. Up until this point, she has not done so- without any repercussion from the NM. Often times, I find her sitting at the desk reading a book or doing a cross-word puzzle. When I do find this, I will hint or ask if she has taken her exams again or if she has any question on the material. This has yet to prompt her to pick up a Critical Care book and study. I realize that some people are not as ambitious as others, but at what point does it become a problem? We do have a Nurse Educator, who I work with fairly closely on many education issues, which is why I try to

encourage this particular individual to study and ask more questions.

Recently, per my NM, when I see her reading or what-not, I have asked her questions regarding different procedures or conditions and will have her look up the policy or information about it. She does not do it willingly by any means, but I think she gets the hint that I'd rather have her doing that then sitting there doing nothing. Like I said, I've brought this to my NM a couple of times and thats the best he could come up with. I can't force her to read policies and books...but I can insist that our patients are in safe hands and receive the care they deserve. I just don't know where to go with it any more! I don't want to see her fail...but up until this point, it appears as if my attempts to help have been futile.

JS

[CardioTrans, BSN, RN]

Id address it again with the nurse manager and speak with the CNS. Has she had an eval yet?

At our yearly evals we pick 2 people to do peer evals, then the manager picks 2 people. Each person answers honestly about how things are working, the competence, etc of the person. When our picks turn them in, the name of the person is anonymous. We know who we picked, and the NM knows who she picked, but thats it. Some comments from peers are put on our eval, but we have no idea who said what.

Id definitely readdress these issues with the NM and speak to the CNS about recommendations of what to do now. If this nurse doesnt voluntarily re take her tests, schedule her a day to take them. We also send nurses to the consortium and have to take the tests at the end. We dont send anyone to it until their orientation is over, that way it kind of makes sense as they have been on the unit for at least 12 weeks. Thats just us though.

If the issues are not addressed appropriately by the NM now, it could be a disaster later.

[nsgstudentjen]

Although I can't help you on how to handle this situation, I wanted to add my 2 cents from my view point. I am a new grad, and I am shocked to see someone behave like this! I don't think the situation was that hard to figure out, honestly. You sound like you clearly explained what had transpired in the time she was gone, and she at that point should have sprung into action. If you can't think quickly, you don't belong in the ICU (just my honest opinion). It wasn't a overly technical and complicated thing she needed to do at that point in time, I don't see why she couldn't handle it.

[DhornRN]

That's why you don't put new grads in ICU.

[Guardian Angels]

Ok - Another thought - What type of education does she have? How many hours of floor experience? I don't approve of her behavior - but with the push to pull in nurses during the shortage - I have to wonder what kind of quality we as a profession are loosing due to the accelerated programs.

I also have to wonder WHY a new grad is in Intensive Nursing! The new graduates need years of basic work on medical and surgical units. It isn't fair to the staff, the patients or the new grads to place them on intensive units.

I would address the situation with my manager and ask if possibly she could be able to work on a general unit for a few months to build a foundation.

It sounds as if she was overwhelmed, afraid, and just lost. We need to work together as a profession to focus nursing specialities as exactly that - specialties with EXPERIENCED nurses.

I believe when there are issues and they are addressed with management - a solution should be brought to the table. As written above - that would be mine...

[nsgstudentjen]

I think new grads can work just fine in the ICU. Many of my classmates went to work in these settings. I, on the other hand, prefer to work in a step down unit because I don't feel 100% comfortable yet.

I also did an accclerated BSN, and have to say although SOME of my classmates are truly not ready to take on a fast paced environment, I think, my previous degree and years of work experience make me a better RN than a 21 year old with little to no real world experience. I know how to work as a team with my co-workers, and take iniative, where many younger nurses do not (I am 29)

Ok, off my soap box, sorry, carry on...:offtopic:

[TennRN2004]

That's why you don't put new grads in ICU.

Not all new grads have problems in the ICU. It is a harder adjustment being new, but there are just as many nurses who have plenty years of experience who "don't get it". I think it comes down to a few things (a) being willing to listen/learn- ie seeking out education not sitting at the nurses desk goofing off (b) not being afraid to admit when you're in over your head and say "hey I need some help" © working in the ICU requires us to be proactive nurses- anticipate problems before they become dangerous for our patients, to do this, we should be carefully monitoring our patients and be quick thinkers whenever there's a sign of trouble

Some of the new grads at my hospital do better than the older nurses. One of the reasons being they are on top of new ways of doing things and want to stay current. New nurses worry so much about knowing they don't know everything many will go the extra mile to try and hurry their learning curve along.

Sadly, in a case such as this it may take a poor preventable outcome before the management does something.