I've hit the wall--suggestions?

[wannabecnl]

This is likely a question for my colleagues, particularly my former preceptors and a few very experienced nurses who have shepherded me through my first year, but I'd like feedback from you all as well.

I'm about 13 months into my new-grad job in the PACU. I do phase 1 recovery only, and I was in this unit as a student as well. I work per diem, so I don't get a lot of hours.

For months, it felt like a constant uphill climb, especially getting coordinated with orders, labs, and the "process" of PACU nursing, along with gaining assessment skills. It was slow going, but I made headway and am now doing most types of cases on my own, moving the patients through efficiently and carefully. I love my job most days, and my patients do fine; they are my reason for working in the PACU!

However, since I passed the 1-year mark, I feel like I've hit the wall. I'm not getting any better anymore (though I have a LONG way to go), and I can't figure out where the problem is. I've plateaued, and it feels like the only way off the plateau is over the edge to an office nursing job!

Maybe it's the weird variety of issues that can crop up--did they all hit at once this month or something? You know what I mean--the patient who should go home ends up with some weird rhythm, and the EKG tech is backed up, and cardiology can't come, and we can't get the admit orders to come up in the EMR, and the patient is on precautions so bed assignment takes a year, and I need to take a 2nd patient but that will just grind me to a halt with the first one. But that's the job. How do I manage that better?

Or maybe the patients really are sicker, and I just don't have the breadth of experience to figure out what's going on. How do I get that experience more quickly--work more shifts? Jump in with the tough patients? That doesn't work well now that I'm off orientation--jumping the line is verboten, so it's the luck of the draw.

Our "rhythm" seems to be off as an organization these days, too: patients roll out of the OR one after another after another (yesterday we had 3 come out in less than 5 minutes), which pushes the PACU to the limits in personnel and space. I feel it acutely because I don't do well with 2 patients yet, especially if once of them has just come out. I didn't notice this 6-12 months ago, but it is giving everyone fits and makes me even more of a liability to the unit. How do I organize my time better so that 2 patients don't stay twice as long as they need to?

Maybe I'm just whiny. Maybe I'm not that good at my job. Maybe all nurses feel this way and go home and come to allnurses to lament, too. Or maybe they come here and vent about incompetent not-so-new grads they have to put up with all day. I don't know; I just know I'm not a new grad anymore, and I need to do better. I love my job, but I can't seem to get off this plateau and keep working toward being the nurse I want to be.

[brownbook]

I think you are being to hard on yourself. It is hard to work a few times a week or month and really get the hang of a job.

A task that takes a nurse who works their every day 5 minutes can easily take you 10 minutes just because you don't have the "routine" down. You forget which cabinet the such and such in kept in, you have to look up phone numbers, you have to find a co-worker who is not too busy and ask, "who does this, or who do I call for that" when the regular staff just automatically knows.

I don't want to teach you bad habits but perhaps you are over doing, over thinking your patient care/assessments? Are you assessing lung, heart, or bowel sounds on every patient? The patient may not have the need, and you may not have the time.

But I may be wrong, you might just be at a plateau, it will pass, and you will move on to feel more comfortable (for a while, until you reach another plateau, ha ha.)

[emain86]

I worked in the PACU as a medic when I was in the militiary and this is my first job out of nursing college. I am literally going to retire from this job. I'm sure you are doing fine and the other person who commented is absolutely correct you will be slower because you are PRN. I was originally going to say after a year you should have most things down... but I swear things change monthly half the time.

You have two jobs in PACU and one all encompassing job.

1. Airway

2. Pain

Your main job is to just notice if something is wrong.

You mentioned that patient with the bed delay and what not. By the time you did all that... the patient is stable and been there plenty long enough. So at that point the fresh post op coming out takes priority. Sometimes that fresh post op will come out with an oral airway in, resting comfortably ( I do a quick assessment, and let that patient sleep it off) and finish what I was doing with the other patient. The worst truly is when you have two patients going down the tube. At that point you just need to ask for help no matter how much you think people will get annoyed.

I'll tell you what as far as nursing goes I know NOTHING. I told this nurse the other day" No really I'm not even going to bother trying to put a foley in a female so you go ahead and do it before you leave cause if not someone else will". I mean I probably could... Art Lines --- I can zero it and draw labs... What's going on with all these tubes and drains and everything else... um who cares your breathing and stable ( for the mostpart ).

I could go on and on about why I love being a PACU nurse. but really you will NEVER know about every single surgery and its unrealistic for us to be expected to know whats going on with each. Its good to have a general idea about whats going on. You can't control bed delays/ transport delays or the ammount of patients that roll out at the same time. You can only control how you deal with it.

[wannabecnl]

You have two jobs in PACU and one all encompassing job.

1. Airway

2. Pain

Your main job is to just notice if something is wrong.

I love this and have taken it to heart these past few weeks. I also talked to a couple of trusted and experienced coworkers to get their take. One said not to get discouraged but to work as many shifts as I can to get comfortable with all of it more quickly (and retain it better, too). Another said she learns something new every single day after being a nurse for probably 30+ years, so learn from each day and keep moving forward! The past 2 weeks have been much better; I am learning and growing and not stagnating so badly, probably because I'm mindful of it.

[azhiker96, BSN, RN]

All of the suggestions are excellent. More shifts will help because more experience helps things stick.

I've worked in three PACUs; a mixed turned adult PACU that may do up to 100 cases a day, a pediatric PACU that did about 20-30 cases qd and a mixed age PACU that does 25-40 cases a day. All three work within ASPAN standards. If you are not a member, join. If you are a member, buy and absorb the current standards. There have been times I've been skipped because it would not be safe to give me another patient, ie current pt was still intubated.

I totally agree with not skipping the order unless you want more experience with tougher cases. Talk with the charge about this. You are not likely to have anyone complain about letting you get the vented patient on drips so they can have a simple general surgery outpatient. Some parts of nursing are scary but I've found the more I learn the scary times get less and less.

Also, some days seem to have a theme. Monday it seemed like I was the designated cysto nurse as those kept dropping into my spot. Some days it's gyn or ortho. I love the days when it's general surgery bx with excellent local coverage of the site. Those folks look more refreshed than me!

[emain86]

You have two jobs in PACU and one all encompassing job.

1. Airway

2. Pain

Your main job is to just notice if something is wrong.

I love this and have taken it to heart these past few weeks. I also talked to a couple of trusted and experienced coworkers to get their take. One said not to get discouraged but to work as many shifts as I can to get comfortable with all of it more quickly (and retain it better, too). Another said she learns something new every single day after being a nurse for probably 30+ years, so learn from each day and keep moving forward! The past 2 weeks have been much better; I am learning and growing and not stagnating so badly, probably because I'm mindful of it.

It made me smile that you liked my post . Glad it helped. I'm new to this as well, but like I said did it in military. I try to tell that to every one.

[wanderlust99]

I switched from ICU to PACU and at first I felt that way in the PACU! I'm not a new nurse either. It took me a couple months, but everything you said still happens to me on a busy day. I do feel comfortable if something goes wrong but I have experience. It takes time. You'll build your confidence as the days goes by. Some days I get frustrated with the waiting for beds, always having to find a doctor to write the correct orders that they forgot, chronic pain patients who stay for hours, etc.. But I'm getting better and less stressed. It's taken me about 4 months. So I can imagine as a new nurse it would take a bit longer. Hang in there.

[wannabecnl]

Flexiseal, I am so glad you are enjoying PACU! We have several former ICU nurses in our unit, and they are an incredible resource. One was hired right after me, and she is amazing; I love to watch her with the really acute patients because she is just in her element!

I think we have 3 that have come from the ICU, several from cardiac/telemetry (go find them for weird rhythms), one from the ED (she knows a vast range of info and has some truly wild stories), and a bunch from med-surg, especially ortho (that's who taught me to find pedal pulses!). Everyone has their area of expertise; even I am the research geek that people talk to about doing Medline searches and making sense of statistics! :)