I just can't catch on

NurseyBaby'05, BSN, RN · Sep 6, 2006

Honey-

Give yourself a break. You're five days off of orientation. I still have days like that. People who have been in the game far longer than you and I together still have days like that. The only thing that is going to make it better is time and there's no shortcut for that. You're just starting the majority of your nursing education. School was only scratching the surface. Give yourself at least six months to a year. You still won't feel completely comfortable, but at least every shift won't be the shift from Hades.

:icon_hug: :flowersfo

P.S. I take that back. You're only on five days of orientation! It will probably get a little worse when you're on your own, but it won't be that way forever. If you're being left to your own devices on Day 5 of orientation, speak up! If you don't you will be left hanging out to dry. If you speak up and are still left to your own devices, get out of that facility as fast as you can. They are doing you a horrible disservice. :angryfire

fgoff · Sep 6, 2006

Sorry that you had a rough time! I get the feeling that you are still in orientation mode on the job & should not have been left alone. I sit possible to speak with your nurse manager????

youngatheart · Sep 6, 2006

Brooke, I feel your pain, I have been on orientation for over 8 weeks on a medsurg/telemetry/detox/anything goes floor. I have had over 4 preceptors now, not by choice, several times they were also charge nurses and couldn't give me anytime when I needed their help. Feel like I am also drowning, During days have to keep up with doctor's orders, lab results, people going down for test, meds to give. I am up to 5 patients now and really feel that at times I am running around like a chicken with its head cut off. I read one post where the nurse said she does three rounds, the first to introduce herself (write name on patient board) then second round with medication and to do assessment, and third round in am to discuss with patient about care plan for day. This has helped me somewhat organize my day, Then check out doctors orders. Allow yourself at least 10 minutes charting on each patient before lunch. I will be on days (12 hour, 3 days a week ) for another 2 weeks then move on to nights 7p-7a I am really looking forward for nights (even though I am a day person) because it seems less stressful and easier to get organized. I know what you mean about lunch to - sometimes I only get a twenty minute lunch and no breaks throughout the day. Good Luck I really mean it!

chelli73 · Sep 6, 2006

Hi everyone,
First off let me tell you that I am on day 5 of orientation on a med-surg floor, so I know there are still a lot of things that I need to learn. But Sunday was just a miserable day for me and I'm still thinking of things that I missed and needed to do.
I took 3 pts with an LPN on my team. Plus I was doing any procedures that came up on the rest of the team for learning. I was doing pretty good I thought, getting everything done and keeping up on things. Then I hung a IV antibiotic and hooked my pt up to the wrong channel on the IV. I started up channel 3 to give the IV and hooked him up to channel 2. Nothing happened except the med ran onto the floor. Channel 2 wasn't turned on. Well I was supposed to call pharmacy to let them know I had an accidental wasting, but one of my pts had a emergency and I went to that and forgot to call pharmacy. I remembered today.
So, then I was thinking about what else I probably forgot and this came to mind. It was 7:30 and one of the Docs came in. I was late leaving the floor just doing one last minute thing and he asked me a bunch of questions about how my pt was doing. So I was so happy with myself that I answered all his questions and knew what he was talking about. Then he said that he was going to go ahead and order a laxative for the pt. He was writting in the chart when my other pt started calling out for me. So then I went to take care of him and my preceptor told me to come on it was time to leave. So I just remembered that I didn't take the chart up to the desk to secretary to put the order in the computer.
I was doing OK while my LPN was with me. She showed me more then my preceptor has shown me since I got on the floor. But then at 3 the census on the floor was low so they sent her home. I was on my own and I sure felt it.
I'm just so frustrated that I can't keep up with things. I feel like the whole floor is moving in fast forward around me and I'm out of the loop. I keep missing when the Dr.s come on and new orders get written. I just don't feel like I'm catching on. I'm sorry if this post sounds like a huge whine, but I'm just so frustrated. I keep telling my preceptor and other nurses that I feel lost, but they only tell me that I'll catch on. I'm just so frustrated.
I'm hoping that when I get to go to nights things will be better, I will have time to slow down a little. I feel like I'm on a dead run from the time I walk on to the floor until end of shift. I'm lucky if I get a 10 minute lunch break. I know that it's supposed to get better, but I don't know how to learn to make it better. How often in the day are you supposed to check orders from the docs? That's my biggest problem I think. I can get the assessments, procedures, meds done, but then I miss things. For example my preceptor asked me what time my pt was being discharged and I didn't even know that she was being discharged.
Thanks for listening. I htink I just needed to vent my frustrations. I just feel lost. ~B

I am sure you are doing the best that you can, and I will pray for it to get better for you ASAP!!!! HANG IN THERE!!!!!!!!!!!! :nurse:

Brooke13-RN · Sep 6, 2006

Thanks everyone for the encouragement. I like the 3 round plan for the morning. I'm going to give it a try youngatheart. I guess that I can just take it one day at a time for the next couple weeks and then hope I get a chance to learn my routine once I get on to nights. Thanks again everyone.

RNLisa · Sep 6, 2006

Hello, Brooke, I feel your pain too. Some of you may remember me when I posted last month about my new job as a new grad on a very busy floor. Well, it got worse for me. On my 3rd day, I got a new preceptor (not by choice, I ended up having 5 different ones) and one of my patient's needed blood. Preceptor asked me if I ever gave blood, which my response was "No". We got the blood together, verified the blood and patient together, then she handed me the blood bag, saline bag, tubing, and said "I'll be out at the desk if you need me" WHAT THE ???? I said "UH, NO, you are going in with me, I said I have NOT given blood before". She was annoyed and went in with me. There were so many other times that I was pretty much left hanging. I felt like I was bugging my preceptors when i asked questions. I still asked though, that's how you learn. The floor was so busy, and when giving assignments, the charge nurse would NEVER take into account the acuity of the patients. So, for 3 weeks, I had almost all the high acuity patients and I could NOT get caught up. I would drive to work, think about it, my stomach in knots, by the time I got to work, I would have to walk very quickly to the bathroom so that I could either have diarrhea or dry heaves. I was miserable, they wanted me off orientation in 4 weeks, of which I was just starting my 4 weeks. I was so upset and sick that I finally just had enough. There were so many other instances that I haven't mentioned here because I'd be writing a book if I did....LOL

Anyway, I resigned my position. AND within 15 min. I got a phone call from a much smaller hospital that I had interviewed with before I got this other job, and they offered me a position with the same hours. I took it and start in a week!!! The nurse to patient ratio is much smaller, the acuity is much less and I think I will learn better and have time to breathe in between.

I so think that new grads are left to fend for themselves way too often and are thought of as "stupid" at times by other nurses. I do believe nurses eat their young, some of them. I think new grads need much more time than 4 to 6 weeks of orientation. Nursing school is a foundation, and we don't know everything contrary to alot of nurses beliefs. We are NEW grads, that means NEW nurses. You all were at one time. Give us a break out there and be patient with us. We are learning and we are YOUR future caregivers! I think people forget that aspect. We are the ones who will take care of you when you are older and ill, don't you want us trained properly???

Just a thought...

Dempather, RN · Sep 7, 2006

On one of my days during orientation, I took my patient's IV out and forgot to tell the nurse coming on the next shift that the patient didn't have access. I figured she would find out, but I got nervous... and of course, all of this didn't hit me until I was home, having dinner. I called up the unit, from home, to update the nurse - feeling extremely stupid in the process. But... after talking to her the next day, she just laughed and mentioned how often all the nurses on the floor forget SOMETHING and remember it later on that day/night, after they've already reported off and gone home. Hearing her say all that, it made all the sense in the world. How can we possible retain and remember ALL the information during the shift (god forbid, we forget to write something down) when it's chaotic half the time and we're doing so many things at once?.. Figures, the moment we remember that REALLY important thing we should have said during report... it's when we're home, and have begun to clear our minds. I know it's hard to believe now - but we'll get through this. :)

Pediatric Critical Care Columnist · Sep 7, 2006

One day about a year ago (when I was very definitely NOT a new nurse) I got half way home before I remembered that I had the code pager in my pocket. I was on a limited access route and had to continue on for another mile or more before I could turn around and take it back to the unit. No way I wanted that going off in the middle of the night in my laundry hamper!!

ZASHAGALKA, RN · Sep 7, 2006

This is a copy of the post youngatheart was talking about. This is some advice I've given in the past for new nurses (long):

Look at the 'first year in nursing' forum. I think this is, indeed, a common sentiment. It's a reality check, eh? But, it's also a gut check.

Some environments are better then others, but there WILL be a push for you to time manage 5-6 pts instead of just 2. And that IS a learning curve, for all new grads.

Don't freak because you aren't 'in your comfort zone'. You're not supposed to stay within the 'comfort zone' you learned in school. The way to expand that zone is by learning to push and exceed your own limits. Worry more about being in a 'danger' zone. Work on knowing your limitations and balancing against working to expand your comfort zones without being dangerous.

If you feel you're being dangerous, set limits with those pushing you along. But, don't presume that you can set those limits to the same comfort zones you learned in school.

I'm fond of saying that nursing school arms you with the skills and tools to learn to be a nurse. OJT is what actually teaches you how to BE a nurse.

~~~

Until you know your way around practical pharmaceuticals, never give more than two of ANYTHING: vials, pills, etc. without double checking w/ a more experienced nurse.

Some of the biggest med errors in new nurses that I have encountered had something to do with "I didn't know 3 of them were too many". And let's face it, doctor's aren't known for clear handwriting and intent with their orders. . .

(There used to be a chemo med that required 10 pills per dose. After the FDA approved it, the off-label use required a much higher dose. There are times when 4 or 5 or 10 pills IS the right dose. But, you're better off being able to say, "I checked the dose with the charge nurse.")

~~~

At the end of a shift, decompress the shift before you leave. Spend 10 minutes going over everything you did and didn't do. Critique how you 'time managed' with the goal of learning from what you did right - and what you did wrong.

Then, give a follow-up report if needed (so you don't have to call back) and THEN, let it go.

Nursing can be so stressful you HAVE TO LEARN when to leave work at work.

~~~

More than anything else you learn, learn to chart as you go along. Consider having to 'stay and chart' to be a time management failure that you have to work on improving.

Too many times, you have 10 things to do at any given time, and that will completely take over your shift. Charting must be a higher priority item in that list.

Besides, I find that, by taking 'time outs' to chart, I can get a better handle on the chaos. Humans work better when they can take a few minutes and decompress and reanalyze their situations. A few minutes here and there charting does JUST THAT FOR YOU.

If you want to learn to 'work smarter, not harder', then learn to chart as you go. DECIDE that 10 minutes of every hour is 'charting' time and ONLY pain meds and emergencies can invade in that sacred time slot.

Remember: you don't HAVE to chart EVERY assessment in one sitting. Break it out, take it one bite at a time.

~~~

Find an older nurse or two you trust and enlist them to be a 'mentor'. Not a 'preceptor', but someone you can turn to to help you analyze a situation. Someone you trust there is no 'stupid' question you can't ask.

~~~

Respect your contribution. You can only work so hard. Work diligently and learn and be proud of what you are doing.

All of us have situations that overwhelm us. Just don't let those situations overwhelm the value YOU place on your efforts.

~~~

Don't get so caught up in your own routine that you can't find the way to observe the 'learning' stuff that happens on your unit. Get in to see the codes, the central line placements, etc. Watch not just in awe, but with an eye as to the nursing roles you see going on about you.

~~~

Start every IV you can. Make sure everybody knows that YOU will try their IV first. My first job, I was REQUIRED to try twice on every IV on my unit before anybody else could look: no matter how busy I was.

Stressful to be sure, but 500 IVs my first year as a nurse, and hey, I'm fairly good at it.

~~~

Ask nurses from other job types (OB, ER, OR, med/surg, etc.) about their jobs. Learn not only what they do, but get to know THEM. Network. It'll make you a better known nurse around the hospital, and it will give you insights about where you might like to end up.

~~~

Grab all the certs (ACLS, PALS, TNCC) and CEUs you can. Your hospital will probably even pay for most of them.

~~~

Volunteer for committees, especially P&P (policy and procedure) committees. Being a voice there will not only help you make a real difference in YOUR job, it'll give you insight into WHY things are the way they are. Besides, your manager is always looking for such volunteers: the brownie points are just a bonus.

~~~

Smile and never seem hurried in front of pts. I won't go so far as the goofy "how can I help you, I have the time" campaigns, but nursing is as much acting as it is caring.

Spend 2 minutes 'acting' the calm unhurried part (even though you're frazzled and falling apart) and the reassurance you give your pts is worth hours of your time.

I can't tell you how many times I hear in report, "so and so was on the call bell ALL DAY". When I get out of report, sure enough, call bell. I'm johnny on the spot. Five minutes later, call bell - johnny on the spot again. Now, once that pt knows I'll materialize when called, they don't feel the need to hit the button NOW JUST IN CASE they need something in twenty minutes.

It never ceases to amaze me how the pts that are 'always on the call bell' never bother me again after that 2nd or 3rd call that I promptly answer.

~~~

Nursing as acting: never admit you don't know something to a pt. Their confidence in YOU is based on your competence. Always front that competence. If a pt asks me a question I don't know, I'll say something like "give me a sec to take care of xxxxx, and I'll come back and explain it to you." Then, I go look it up.

~~~

ON the same topic: never give a med if you don't know what it does. Always look it up again until you learn it. Nothing is more deflating then a pt asking you what x pill does and then getting a blank stare from you.

After all, if YOU don't know what it does, why are you giving it to ME?!

Exactly.

~~~

When I first started out, on a medical unit with 10 pts, I organized myself into 3 first rounds. The first time through, I just introduced myself and stated I would be back soon.

That way, I could make sure that everyone was where they're supposed to be (not on the floor) and nobody was in acute distress (my first priority on everyone).

Then, 2nd rounds: I'd go back through and do my assessments (and vitals if that is your job).

3rd rounds, med pass and taking care of 'creature comforts'.

I found that those 3 'first' rounds organized my shift better, highlighted the priorities more soundly, and gave me time to 'impress' my pts. Nursing is at least part an acting gig. You can't 'take the time' with x pt when you don't know anything yet about 'y patient'.

I never stopped until my 'first rounds' were complete. But, at that point, my shift was well organized.

~~~

When a new med comes out, ask the pharmacist to send you a package insert and read up on it. You can learn all kinds of things that way.

For example, did you know the molecular wt of Viagra is 666. Don't believe me? Look it up!

Also, I used to drive my co-workers crazy by sing-songing about the drug, integrillin, "eptifibitide, the cyclic heptapeptide!"

~~~

When you are doing assessments and giving report think in the following terms in the following order:

1. Overall appearance: Stand back and take in the scene - in distress? talking on the tele? Annoyed (means a little emotional massaging from you)? etc.

2. Neuro - most important specific assessment, yes? Whether chronic or not, a pt 'not with it' is in a high order of distress. Act on that.

3. Cardiac - even if not 'on tele', you can make quick assessments about circulation, cap refill, pulse, etc. Look at the skin color of extremities as a CARDIAC assessment. A mottled pt should either be on 'comfort measures' or, your highest priority. (or have a severe and long hx of uncontrolled DM or Raynaud's DX - NCLEX hint: look it up.)

3. Pulmonary - look at 'work of breathing' not just 'lung sounds'. Working hard at breathing will tip you off to all kinds of problems, not just pulmonary ones. When YOU'RE STRESSED, what happens to your breathing? (I'll tell you: your metabolism kicks into overdrive, dramatically raising your lactic acid production which has to be blown off by the lungs in order to maintain metabolic balance. Breathing hard is a tip off to a pt that is stressed or in distress, whether the root cause is pulmonary - or not.)

4. GI - bowel sounds, dietary intake, mental note of NPO status/restrictions, etc.

5. GU. Eyeball the foley bag NOW so later you can compare to see how much is 'flowing'. Start thinking in these terms: the kidneys are often the first hint YOU can observe to impending general organ failure. If the kidneys aren't working, your thoughts should be: what ELSE isn't working? (But don't call a doc to tell them that their anuric dialysis pt isn't peeing. Please. I've seen that happen before. It's never a pretty sight to behold.)

6. Integumentary - skin, et. al.

7. IVs and 'lines'. - patency, fluid, rate. Your first few times w/ things like chest tubes - ASK. Those are not 'stupid' questions and you'd be surprised at the discomfort level even EXPERIENCED nurses have with uncommon 'accessories'.

This not only organizes your assessments by priority, but your reports. This assessment order is very specific, and by priority of system: neuro, cardiac, pulmonary, gi, gu, etc. Start THINKING in that order.

During report:

1. name

2. dx (why are they HERE)

3. allegies

4. docs

5. general info (nursing home pt, PIA, etc.)

6. Assessment in the above priority. (this will include things like diet, IVs and O2 status)

7. Upcoming tx and procedures next shift needs to know about

8. A summary of what happened on your shift.

Quick and to the point. Leave out trivia and cut to the chase. Each pt should take less than 2 minutes. If not, work on honing in on what's important. I consider 'reading the doc orders' to be a useless report. I CAN DO THAT.

Start to think like this. If you build a 'mental template' of what you are doing and in what order, it is a foundation to build upon.

~~~

Never apologize for or diss co-workers EVEN IF YOU AGREE WITH THE PT'S ASSESSMENT OF THEM. 1. Nothing will cause you more interpersonal co-worker grief. 2. Some pts just love to manipulate and play off the 'changing of the guard'. It's pretty flattering to hear 'what a great nurse you are', but if that is in the context of 'as compared to the last nurse', then, however true that might be, you're being played.

~~~

The pts and families that most loudly complain "I'm going to report you", are, in my opinion the least to worry about - at least as far as being reported. The ones that report YOU for your honest efforts, have already reported 4 more for real concerns and yet again, another 3 that worked as hard as you did. That lends to discredit them.

Answer their concerns, but don't be put off by, "I'm going to report you". I always respond, "My name is Tim and I'm the only Tim that works on this unit. My manager will know to whom you are referring to." And then I smile and say, "But, I'd be happy to do whatever is WITHIN MY POWER to resolve your concerns, NOW." Key phrase: within my power. That does not mean I'll kiss your booty, but that I will deal with you professionally and courteously.

~~~

Trust your gut and be assertive about it. If 'something is wrong', then 99% of the time, SOMETHING IS WRONG. Every experienced nurse out there can tell you about the 'steep' learning curve of not 'trusting your gut instincts". You KNOW more than you think you know, and lots more than you consciously know. Otherwise, you wouldn't have gotten this far. ACT ON THAT.

~faith,

Timothy.

ChiaLing · Sep 7, 2006

Timothy, THANK YOU for posting that!

I'm in my final prelicensure semester, and your advice is GREAT! I'm saving a copy for future reference.:)

777RNThatsMe · Sep 7, 2006

Tim that's great info! Is this a sticky? It needs to be a sticky!