Loss of Confidence

momo72 · Aug 10, 2012

I've been in the ED now for about 1.5 years. In the recent months, I've experience what I would call as "loss of confidence." I won't say that any particular incident occurred to cause this, rather a grouping of small incidents. I think I'll attribute it to "the more you know...the more you realize you don't know anything."
Firstly, I have had a few patient's recently that have opened my eyes. A frequent flyer with complaints of "pain" (pain every day all the time it seems) who actually ended up with a 90% blockage to the RCA. Another patient who was drunk and sitting up in his c-collar for the previous shift began to tell me he couldn't move his arms. He also was telling me how much of a ******* I was for making him lie down and keeping the collar on. When I came on shift and assessed him, he could move his arms initially. I did tell the physician, but thought he was partially full of it due to his affect...sure enough: central cord syndrome. Of course, both instances made me feel like crap/like I was incompetent.
Also, in recent months I made it a personal goal to improve my documentation/assessment skills. I put a lot of pressure on myself to complete at least 99% of the "required" documentation on each patient and lift myself up to a higher standard. In doing "what is required", I find myself drowning. I realize that prior to my attempt at stellar documentation/reassessments, I cut corners for a reason. Now that I'm attempting to "do things the right way" I find it near impossible to be an efficient nurse. I'm referring to things like: real time documentation (instead of doing everything after the fact.), finishing a med reconciliation, sepsis screen, suicide risk, belongings, linking gtts to I/O flowsheets, scanning all medications, women's health screen, etc... Conceivably there are about 12 different things in our navigator to complete for a patient.
If I get a nursing home patient qith 40 medications, who is altered (q 1 neuro assessment), and has increased wbcs, decreased MAP, and arrives with 3 decub ulcers I want to curl up in a corner and die.
For said patient I have to:
-Complete a full assessment.
-Complete a neuro assessment: pupils, speech, mentation, musle strength grading
-Complete a skin assessment and add a LDA for each ulcer with details of each ulcer
-Complete a seperate report for risk management stating said ulcers were evident on arrival
-Complete a sepsis screen (8 different parts referring to Increased WBC (or decreased), MAP, source of infection, febrile?, AMS?, doc notified?, interventions?)
-Update all medications (doses/frequency)
Prior to my recent attempts at stellar documentation, I would get the patient on the monitor, assess, and treat my patient accordingly (IV, fluids, abx....you know...ACTUAL nursing). THEN I would try to find a computer to finish documentation and only update important medications such as anticoagulants, current abx, and medications that could cause alteration in mentation/VS. I would always being documentation with LE (late entry) 10:00-Assumed care etc.... 10:22- PIV (20g) placed to RAC. NS bolus infusing as ordered. Full rainbow in the lab... 10:46 Notified MD of map of 49 etc...
How does the loss of confidence come in to play you ask? It seems that my coworkers are much better/more efficient documentation than I. I've asked, I've looked, I feel like they can adequately care for their patients and write volumes of free text notes without batting an eyelash. When I get the train wrecks or seriously ill, I feel like I should be ensuring their airway/circulatory stability before running to a computer to type "assumed care."
Forgive me if this is TL:DR and/or recently discussed. Any advice would be appreciated. Has anyone had any similar situations? Please share. I just want to make sure I'm not alone in this.

What trauma level are you at right now? I know it doesn't matter to much, even level 4's. Get the severe train wreck pts. But it seems like your documentation is over the top!! Is it computer charting? I felt the same way about being overwhelmed with all the charting, and trying to give the best pt care as possible. It's very hard at times. Then you throw in those stupid times for your admitted pts, that have to be in the rooms less than 30 mins. I feel a lot has to do with the nursing team as a whole, when I first started in ER fresh out of school we had a great team, would get help if struggling, fast forward to 1.5 years later and It was every man for themselves. I felt so incompetent, most days. I ended up leaving the ER for personal reasons, but was considering going to another unit, to get my basic skills mastered and the computer also. I am almost able to go back to work, still feeling the same way, like a tele unit. The ER I feel can take years to master, tho I do love the fast pace and excitement. Have you thought of going to another unit? I think once you master that computer you will do just fine in the ER. Would be terrible to lose your license due to a mistake made in pt car because you where on the

Computer trying to catch up. I'm sorry you feel the way you do. We all have at some point. Have you asked another nurse how they are able to keep up with everything ? I hope you are able to figure out what you need to do, so you are not making short cuts that are the wrong ones. Good luck & take care

brainkandy87 · Aug 10, 2012

It's very important to have good documentation and making sure that you're covering your butt. I had a pt several weeks back who was young (30-40) and in for n/v. Really a low acuity pt and all we did was Zofran and fluids. I was slammed and didn't get discharge vitals. She came back in later that night for continued n/v, coded and eventually died. Did I make a huge mistake by not getting discharge vitals? Not necessarily, but it certainly would make me look like a much better nurse if I had gotten them. So, I learned from that and always get discharge vitals, no matter what.

With that emphasis on good documentation, the priority should be good patient care. I usually document my stuff fairly quickly. I tend to avoid waiting to chart everything unless I'm with a high acuity pt or am slammed with several pts at once. I go in, make a concise charting entry, and get back to patient care. That should be your focus: concise. We need to be screening for abuse, self harm, and so on. However, prioritize. If you're slammed with a high acuity pt, is the self harm screening a priority if the c/c isn't r/t self harm (e.g. nursing home pt with sepsis)? Nope. It's always pretty to have all those little boxes on the computer filled out, but having them all filled out isn't necessary. I'm not sure what system you use, but I know in the system we use (T-system), if you open up, for example, learning needs assessment, there's this huge box with many possible selections. That doesn't mean you have to go through and pick every single little thing. Be concise. Concise, concise, concise!

Don't let it hurt your confidence though. Focus on being a good caregiver, being a good ER nurse.. all that charting stuff will work itself out.

gekner · Aug 14, 2012

I think this lack of confidence is normal at this point of your career.

You feel you should have your feet on the ground and know what is going on by now, but in reality you are just now realizing how little you know and how charting criteria can set you up to fail.

You will find your own groove when it comes to charting. You will find what you feel is actually necessary and when your organization has you documenting the same thing in multiple places.

Discuss your charting with your colleges and possibly learn from eachothers experiences.

Now that you are past your initial orientation period and real world nursing 101, it is now a great time to dive into the books and really learn the finer points of critical care nursing. Having a solid knowledge base behind you will also give you more confidence as what actually needs assessed and charted.

Keep your head up.