I apologize, this is long. I feel that the more I explain and the bigger picture I paint, the more someone will be able to share with me. I realize that some of this might identify me if my coworkers are here on this board, but... honestly, I want help at becoming a better nurse. I want to become better at being able to handle situations like what I am experiencing. I need to know how I can be better, and I can't do that by not being factual.
Again, this is LONG.
I received a pretty rough "review" at work. I was called into a meeting for topic A, which I knew about going in so I didn't bother taking a union rep with me. The manager just had a couple questions for me about a consult I had made. It was a short, "oh alright, we'll get this issue fixed" meeting that took 10 minutes. I was then blindsided with "While we're here, there is this other concern that was brought to my attention". I should have known better. This was done to me before, which I was explain.
I've been at my job at the hospital for almost a year now. I work on a "step-down"/progressive care/tele floor. Mostly cardiac and stroke, sepsis, AMS, CHF, and other things thrown in. We also take acute patients when the acute tele floor is out of bed. I am a new nurse (2 years), I worked 8 months SAR before this job, which was my first job.
My first "incident" happened two weeks after my 12 week orientation ended and I was on my own. I had a near-miss. It was a rough night that had multiple things going on that night for me. I didn't really get at the time it was a "near-miss". I didn't even really "get" what a near miss was. The incident in question is that I nearly gave a medication (acetylcysteine) that was meant for a neb, as an IV med. I didn't read the order well enough, and I missed the "(neb)" at the end of the order. I pulled it, scanned the patient, scanned the med, drew it up, flushed his line, started explaining the patient what medication I was giving him as I hooked it up to his line. The RR was right there and went "that is supposed to be for his neb!" (which was currently on him). I hadn't pushed on the plunger, but my thumb was on it so just in case anything went in, I aspirated the line, connected another flush, flushed the line, disposed of the medication. I called the nocturnist, told him what happened, and then went into the chart and uncharted it. I thought... alright. Scary, but handled that. I thought nothing more of it until that morning, right as she was walking out the door, my charge nurse that night went "I know about that med error you made, and you're gonna need to talk to management about it". I was stunned, and floored. The RR, after she told me I was incorrectly about to administer a medication, left the room, was standing in the hall and as I came out of the room, she left. She had gone to report the incident to my charge nurse. It didn't occur to me that I should mention it to her, because I had already called the nocturnist about the incident. Yes, I do understand now that I should have told her about what happened, and I do now understand what a near-miss is. My manager did do an investigation, because I was told I was not the "first" person to have done this, and several preventatives were put into place to prevent this from happening again to another nurse. One was that now the Omnicell flag's "neb" medications with a popup notice that the medication is meant for "neb" use. Another issue had been that the RR did not scan out the medication, which had enabled me to be able to scan it out. So, everyone was educated that we are to scan out medications when we give them, and if the patient refuses or doesn't take it we can go back and unchart it. Prior to this, some would scan and given, then sign, others would sign, scan, and give. It was just nurse preference. And yes, I have learned since to double check every order, read it in full and make sure I follow the five rights.
I did mention that this night had multiple things going on. This night was my first STEMI. The patient was in the ER on a nitro drip. Pain unrelieved. At some point, they decided her pain wasn't chest pain and just indigestion, stopped the drip and set her to me. My charge was worried about this patient from the start, and told me to keep a close eye on her. So the patient came up, no pain, she had just got a GI cocktail in the ED prior to coming up. I get her in bed, settled, and about 45 minutes later she's complaining about indigestion again. She's telling me, she takes nexium, and they gave her "the fake stuff" and that she needs nexium. I ask her all the stuff to assess her pain, try to see if she's having chest pain, or if it's indigestion. She's complaining of epigastric burning and belching. Okay. I am uncertain. I ask my charge nurse, and she only says "women have different symptoms". Right. So I call the nocturnist and discuss with him if he wants me to start chest pain protocol and treat this as chest pain, or if he still thinks this is gastric pain and wants me to try another GI cocktails. He says he will order another GI cocktail. Okay. I go check on the patient. Same complaints. Still demanding nexium. I walk back up front and my charge nurse says "I talked to the DR. We're getting an EKG, and starting CP protocol." I was like.. Okay. Started the protocol, while the Teletech got the EKG (it took her 20 minutes; 5 to "finish what she was doing" (when I was tired of waiting and went to get the machine myself she jumped up and grabbed it), another 5 minutes for her to get to the room, because she "couldn't find the stickers" (in the drawer), another 10 to get the patient hooked up because she was trying to untangle all the wires and having a conversation with the lady in A bed. Me and two other nurses physically had to take the device from her and practically shove her out of the way to get this EKG done. She finally handed it to me. I called the MD, let him know that it is done, let him know I identify ST elevation. I call a rapid and walk to the front to let my charge nurse know the EKG is done, and I am calling a rapid... I don't get anything other than "I got the EKG" and she grabs it from me, looks at it and starts "OMG IT SAYS STEMI, DID YOU TELL THE MD!?!?!" I said "no..". and she runs off before I can finish saying "I just said I saw ST elevation". I was told in orientation that when we do an EKG, we can tell the MD what we see on it, our own interpretation, not to go by what it says at the top or that the machine interpreted. So, RR team arrives... MD arrives... she's a STEMI; transfered to the ICU. Needless to say this charge nurse sent an email to our manager on how I didn't respond properly to the patient's pain, didn't act appropriately, wasn't taking the situation serious, and claimed I purposely delayed her care by "holding onto the EKG and not informing the MD". My manager actually had to collaborate with the MD to affirm I did notify him within minutes because the RR was also recorded as being called within 3 minutes of the EKG being printed. I was unaware about any of this until management called to talk to me about the near-miss. I thought at the time, I was handling the situation as best as I was able with my skill and knowledge.
The incident involving the near-miss happened on the same night; about a half hour after I got back on the floor. When management called me in to talk about the near-miss the meeting followed with a "we'd like to talk about what else happened that night", when is where she brought out this three page letter from the charge nurse that night. I ended up on a performance plan aimed at preventing near-misses, and medication errors. The STEMI thing ended up being a "lets talk about how we better handle next time", which involved in me being more... involved in the "team" aspect of nursing. At SAR I was the lone soldier at night... there was no one else. I had to "handle things" on my own. It took a lot of breaking that habit and realizing that.. I am no longer alone. There is an entire team aside me. So.. I opened up, started relying on my team, asking questions, bouncing off ideas... embracing the team. Still, the STEMI ended up being an "oh yeah, while you're here" part of the meeting that I and the rep had been informed was to discuss the near-miss.
This all occurred back in September, and... everything has been going very well. At least, in my perspective. I like my unit. I felt that, me and this particular Charge Nurse have done better at working together and getting along. I didn't have an issue with her before. I had only worked with her a couple of times. But, that night I felt very attacked by her at first. Almost like she was purposefully unsupportive, knowingly giving me a patient I was far too inexperienced to have, and then rather than addressing the issues with me, went behind my back to the manager.
So, the past seven months have been.. good. I felt like I was learning, growing, I've been questioning, helping, trying to get involved with everything I can just to learn. These last two-ish months have been a struggle.
In the beginning of May the "second incident" occurred. A patient of mine coded. My first actual code of my own patient. I had been with this patient for 4 nights, I had built up a good relationship with her and her family. She was a stroke patient who had, had a massive stroke, but was improving. She was doing so very well, until she wasn't. The day prior to the code, the daughter was concerned about the treatment of her mother by some of the aides. They were being rough and disrespectful. She didn't say anything until that night, to which I informed my charge nurse (same one as above), and we assured the daughter this would be handled. Manager spoke to her the next day, she was moved to a private room. That night, she coded. I was actually with a new admit that had just come up, when I walked by the room and saw a bunch of people in there. She had a second stroke while being cleaned up that night, and a rapid had been called. It was no sooner than I walked in she had a massive stroke and coded. Ensue all the chaos of a code. I called family in and they were in the solarium. They didn't want to be in the room. Understandable. When they finally did walk into the room, the intensivist made a "joking comment" about something, and several people chuckled. Right as the daughter, who had previous concerns of her mother's treatment, walked into the room. Of course, after all was said and done... she wrote a scathing letter to everyone in administration that she could on how her dying mother had been disrespected and she walked into a room with everyone laughing over her naked, dying mother. It was "investigated". I was named as one of the people who "laughed", not by the family, but by one of the ICU nurses present. I don't remember "laughing". At all. I am.. adamant that I didn't. I was upset, and practically crying... I didn't know what to do and I felt so useless. Still, apparently one person named me, despite that other reports say yes, some people laughed, or no, no one laughed. My manager felt that "maybe I did, because, at the meeting, I had a "nervous laugh", and that I had laughed a couple of times during the meeting and that maybe I had a nervous laugh that night". There was no write up and nothing "official" on record. I was asked to do a "sensitivity class" sort of thing. And I did. Which was really just sitting down and talking to another Manager on professional presentation, remembering that at all times, even when we think they are not, patients are always watching, so are their families. During this meeting, I was asked what I was doing during this code, and I commented "I felt like I was just in a corner crying". It was a flippant answer, I realize. I didn't answer the question honestly, and I didn't really think about the question. I was actually by the wall, near the door, still tearful and upset, and feeling useless, but there answering questions, getting whatever supplies needed that I could, and relaying information. This is what I should have said. I didn't.
So this morning... when I was asked to meet about a "quality concern", I was like.. okay, no problem. I knew what it was about. As I said it wasn't a big deal, I mean.. the concern was, but me speaking to the manager without a rep was not. I didn't think I needed one. This was an easily explained situation. And that part of the meeting went... just fine, as I expected it to. I clarified the situation, and that was that. And then... she pulls out additional papers and wants to talk about a subject... completely unrelated. At this point I probably should have said, look, I think I need a rep now. I don't know why I didn't.
Prior to "incident #2, the code". In fact, it was two nights prior to that. I had what I could easily call my worst night ever as a nurse. I came onto my shift with a sepsis patient with a BP in the 70's. Sepsis protocol hadn't been started in the ED, and the day shift nurse who had spent all her time trying to play catch up with the ABT's never given. The fluid boluses were missed. Walking onto shift, she was already several boluses behind. I wasn't even done finishing report when I was called into the room. The day shift nurse was still there, so we switched the ABT over to the fluids and started those. I called the MD, had them at the bedside. It was an unofficial RR. At this same time, my other patient across the hall (alcohol withdrawal, there after a recent surgery), was becoming irate, and irritable. He'd been complaining of pain ever since the surgery, unrelieved, and the doctor was going to start him on a new medication. Well, the patient wanted it "NOW". I had been planning to give it to him as soon as I could, right at 8pm..... but then... the other patient was septic and her BP kept falling, and just... nothing seemed to be working for her. The MD kept putting in new orders, new fluids, new rates.... All the while, my patient across the hall is becoming more and more wild. He's calling for his medication over and over and over, and... I'm trying to find a spare minute to get out of the other room and give him medication, but I can't. So, after a while, my charge nurse (same one as incident 1), goes to give him the medication. I was like, great! Thank you! I had her his other meds too, since I had pulled them already with intentions of giving them to him. Meanwhile, I was still with my sepsis patient. I ended up calling an unofficial Rapid because she was just getting worse and worse. My charge nurse wanted ICU to come evaluate her before the intensivist left for the night.
Across the hall, there are several nurses in the room with patient B, trying to calm him down because he climbing up out of bed, was screaming about wanting his Foley out, his back hurting, wanting to leave... so, I get pulled from patient A (as ICU is in there eval'ing her with the MD), to help deal with him. My charge nurse came over, and so did the nursing supervisor. I was asked "what can he have" I said he has ativan for CIWA. I did a "quick" CIWA and I was like, he has 1mg IM or PO ativan. They looked at me like I had four heads and asked "if I was sure". They felt I underscored his agitation, okay. I had scored a 4 for agitation, and they believed it was more a 7. I explained that, it's hard to judge what part of his agitation is withdrawal and what was him responding to the pain he was in (his CIWA was reportedly 0 all day and the day shift nurse had given him no ativan all day). I was going by what the "example" of the score in cerner, but... okay, I changed it to 7, which then increased his score to where he could have 2mg PO or IM ativan. They weren't happy still, and called the MD to get IV ativan. He ordered 1mg IV. Meanwhile... another nurse takes over pushing her ABT's and hanging new fluids. As the rapid for my septic patient ends the charge and nursing supervisor call the ICU team over to evaluate my other patient because... he's just not right. He's confused, he's highly agitated, the ativan hasn't touched him, he's in increasing amounts of pain, and the bruising surrounding his surgical sites is increased from not only the day before (the MD was aware during day shift), but also from when I started shift. When we did shift change, I had looked at it because day shift nurse wasn't sure herself if there had been an increase in the bruising and wanted me to confirm. I did. When I looked at it again, though the bruising had not only increase, it had become firm and very hot. Took his vitals; his temperature had become elevated. He ended up going to the ICU. At this point, my sepsis patient was mostly stable.. thanks to the nurse who took over to hang ABT and run fluids while I was with patient B.
As I get back to the floor. A rapid was called on MY THIRD PATIENT. She was "unresponsive and complaining of chest pain". And... it was an entire scenario of... a very, very, very overly dramatic patient, wanting attention. A few days prior they tried to move her off the floor, but she didn't like the room, so she essentially... faked chest pain and SOB and "passed out" to get sent back to our unit. The night I had with her previously, she had started crying telling me about how she just wanted more cookies.
So, there's all these nurses in there, terrified and concerned. My patient has thrown herself back on the bed, is gasping and clutching her chest, then "having a seizure" and shaking... and I am standing there, completely not concerned. I knew at the time, it looked terrible, but the patient had already been cleared by cardiology, and I knew she was a very.. dramatic person when she wasn't getting enough attention or cookies. And I knew, they didn't know this, they weren't familiar with her. So I made the comment on how "she did this yesterday too". I tried to get the patient to talk , to explain what was going on, what was happening, but she played out the whole thing, even sitting up in bed gasp/choking and then falling back like she was "dead" and not responding to us, then acting like she couldn't move her arms or legs and doing nothing but whimpering. Rapid team gets there... the House Supervisor walks in, and she goes "Oh she pulled this crap last week". I felt... like, at least I wasn't the only one familiar with how she was acting. Nothing was done.. the MD even just shrugged his shoulders like... what is this... and walked out. An hour later, the patient asked me "can I have cookies now". I documented this entire scenario.
So... back to this meeting. Suddenly it went from a "quality concern" to a concern about that particular night and how I managed it, or didn't manage it. The charge nurse that evening (same one as all before), as well as the nursing supervisor, had emailed to share concerns about how every time they came to the floor (during the rapid, or to help out) I appeared have been just "standing in the hall", Or that I "had to be hunted down and pulled into the patient's room", and that I "didn't appear to be concerned" about the patient. Apparently my charge nurse said one of the aides came to her and said that I wasn't concerned about my patient's BP being in the 70's and I "had to be hunted down". I tried to explain that I was in report with the other patient across the hall and they "pulled me into the room" with septic patient as I came walking out of the room.
She said this, combined with the "past incidents" and added in the comment I made to the other manager I had spoken to about being in a corner crying during the previously mentioned code, displayed a poor clinical picture of me that I can't handle critical situations.
It was hard to figure out what to say. I was really, blindsided by all of this, especially since it's been over a month since it happened. I explained that, my comment about the corner wasn't, literal. I wasn't in the corner. I was against the wall, but I was still upset. There were 15 people in that room. I didn't know what I was supposed to do. I felt useless, like.. this was my patient and I was just standing there, doing nothing. She said I am supposed to be "the wealth of knowledge" about the patient because no one knew the patient like I did. I didn't looked at it like that.
I tried to explain that... I was "pulled" because I was trying to handle two rapid responses at the same time. I was with one patient, and literally pulled away to deal with the other, so another nurse took over for the previous. I thought... I did the best I could that night. I didn't think that the take away from that night was me standing in the hallway doing nothing while all these other nurses are caring for my patients. I mean, I can't say why I was in the hallway at the particular time a person walked up to see what was going on. I feel like I was everywhere that night; the patients were right across from one another and I was trying to keep track of what was going on with both of them.
So now, there's a "peer concern" I am going to miss things. I am not going to properly be able to care for my patients. That, I cannot handle these types of situations. And, I have had other rapids. I've called other rapids. To my knowledge... no one has said anything about my inability to handle things.
I told my manager I don't... understand why something wasn't said to me that night. Why someone didn't point out to me what I could have done better to handle a double rapid. If I was doing so, so terrible a job... what took this a over a month to come to light? I honestly felt like that night was... Okay, despite that it was a terrible night. It was... intense, and it was hard. It was the first time my job has made me cry on my way home from work. But, I felt supported. I felt like I worked as a team with my other nurses. Now I just feel... betrayed, broken, and hurt. I have... no idea what I could have done better, or differently.. and no one else seems to either.
My manager says she "doesn't know what to do about this or how to help me grow clinically, but that a nursing supervisor also shared these concerns that it holds some weight". She's planning to talk to the clinical educator. And there is a "mock RR and code blue sim" that she wants me to go to. Which is fine. I was planning to anyway.
It doesn't feel fair to me, to be judged by someone walking onto a floor and seeing two seconds of what was going on, and not even bothering to question me personally on "what are you doing" if they had concerns about what I was or was not doing. I expressed that I feel almost like I was being called out for the very opposite of what I was called out on before, in my first incident, where I didn't utilize my team, and this time I did. She said it's not about "that" (asking questions, bouncing ides, even asking for help), but about "having to be pulled into being involved with the patient" and how I "wasn't concerned about the patient" and that the appearance that I "shell up" when "things start to go down hill". Again, because of my comment about crying in a corner during the code, and when "looking at these previous incidents".
There was also concern that I "delayed calling the MD" because I asked if it would be faster to page them, or practice unite them to come to the bedside. I was also called out for not properly evaluating the patient's CIWA, and for not "noticing that the patient was pouring electrolytes out of his skin" (the supervisor's email's words).
I kept asking, what I was supposed to have done differently, or how I could have done things differently. My managers only suggestion was that I had maybe said "look I am dealing with patient A, I need you to deal with Patient B"... but I feel like, that's what I was doing. I was with Patient A when I was pulled over to deal with patient B. It didn't occur to me that "I can't, you deal with this" was an option. She then just kept asking "what would I have done if I were alone"... like, when would my other patient have gotten her antibiotics had the other nurse not given them, or... what I would have done about his CIWA had no one been there to question my score. And, I told her, the ABT would have been given after I finished with Patient B, or I would have asked someone to please give them. As for the CIWA, I would have called the MD to discuss it with him, because... as I said, it was hard to tell what was withdrawal, and what was his response to pain, especially considering his CIWA had been 0 all day.
I said I didn't feel it was fair being called out on the third "rapid" that night because the Supervisor herself was aware of the patient's actions previous. My charge nurse had taken my "she did this last night" comment, as my patient had previous complained of chest pain and became unresponsive and I didn't say anything to someone. I clarified that, no, I meant she'd been dramatic. She cried for cookies. And that I was only "pulled into that room" because I had literally just walked back onto the floor from taking the other patient to ICU. She seemed to agree in looking past that incident happening because of the nature surrounding it, and that the main concern was just a misunderstanding of something I said and how the charge nurse interpreted it (she didn't ask me at the time to clarify what I meant when I made the "last night" comment). But, I am not sure I feel like she believes me over the charge nurse.
I am supposed to reflect on ... how I can grow, what I can do different, how I can be more involved and present, and what I can learn from these situations while she attempts to "figure out what we should do from here". And I am just.. lost. I feel almost broken. Like... this is really how my coworkers see me? Am I really just.. this horrible a nurse? Unreliable and incapable? How does someone handle two of their patient's being a RR at the same time? How can I become better if the people telling me I need to be better can't even tell me what I can do to be better.
Again, I know this is really, really long. But, I could really, really, use some outside perspective, some advice... because I just don't know what to do at this point.
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RatherBHiking, BSN, RN
591 Posts
I agree with everyone else. Get off that floor asap! Ask your manager if you can transfer to a lower acuity floor since you are "struggling". It seems to me they are going to continue to throw you under the bus until they can somehow get rid of you anyway. If you can't transfer, start looking elsewhere for a new job. You have 2 years experience so you should have nice options by now.