I'm a relatively new grad and have a target date of Sept 18 to be off orientation on a busy medical/tele floor in a big city hospital.
I've had a few different preceptors due to scheduling--no big deal. Lately, I've been with one that can sometimes be really supportive (you're fantastic!) and sometimes really harsh (you really need to multitask. you're distracted. you have to be able to keep more than one thing in your head).
Basically, I try to stick to a routine (check on patients in am, do assessments, get meds out starting at 8:30am). Well, sometimes that plan gets all out of whack! Yesterday, I had 5 patients and all 5 of them had to go for procedures in the AM and none of them had consent for anything! The OR called for someone to go at 8:30am and the pre-op checklist wasn't done and consent wasn't obtained. Plus, the patient is screaming for pain meds (starting the calls to OR,"can I give the meds or can't I?). It's a teaching facility so it always takes a while to figure out which intern/resident to call for what and you have to wait until he/she gets back to you.
Anyway, I ran around the whole day (5 minute lunch at 2pm) trying to manage interruptions, track down missing lunch trays, get consents, hang blood (had to do own vitals-techs nowhere to be found), fetch ice water, put people on the potty, medicate for pain q2 hours etc. Plus, I had a transfer and an admission in the afternoon. I didn't get my assessments charted until 2pm and didn't start my notes until 6pm before night shift came in.
So, here comes the comment about multitasking, etc. from the preceptor. I'm a bit sensitive as I've always worked very hard and have never been told that I can't multitask. She mentioned at end of shift that I didn't do some things she told me to (like hook someone up to IV). I did need help w/the blood and I didn't get to a dressing change. and my charting was late. She said that these 5 patients were easy.........how is it going to be when I have 6 hard ones? As for being distracted..maybe so. I was exhausted by 6pm and couldn't remember a blood pressure I took and, yes, I did forget a few tasks as other things seemed to be a priority.............I felt like saying, "If I cannot multitask, how did I get all the meds into people at the right time and remember to do those assessments and not stay after an hour for charting, etc.". I just said, "uh, huh".
Anyway, I'm really discouraged at this point and really don't know what is going on. On other days, I've had 5 patients and things have been fine. Other preceptors didn't really have any complaints and mentioned that I'm pretty independent.
I CHOSE this preceptor because I thought she was supportive. I guess she's looking out for me in a way and making sure I'm ready to be on my own but I sort of feel like I'm being whipped. I have a feeling she wants to extend my orientation and I feel that there are some good days and some bad days.
This is the first day following a shift that I'm thinking and worrying about work and nearly in tears.
I believe that, until things change in the provision of modern healthcare, if you want to work in a hospital environment that you WILL have to learn this. And, you will. Other areas may have less patients, but the time management skills and training you are getting will not be any less needed.
I'm a fan of med/surg the first year BECAUSE I believe that med/surg is the instrumental basis upon which all of hospital nursing is built.
I've posted this before and looks like a good place for it again:
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.
Okay, I am printing this up and memorizing it! Thank you :)
On my unit consents and pre-procedure checklists are done by the night shift...of course, there's always the unexpected procedure thrown in on days that we have to consent/check, but in general the scheduled procedures are consented on nights.
When you have 5-6 patients and several of them have procedures first thing in the a.m. there's no way you can get all that done in time.
Nursing is a 24-hour job.....or else we wouldn't need to work shifts
Sorry you're having such a rough time.....the new grad fellowship I'm in counsels us on the stages new nurses go thru. What you're feeling is expected at this point in your career. They promise it does get better:lol2:
Hey guys, i just had to add to all this good advice. I too am a new nurse working in med surg (LVN) for nine months now. I feel like giving up some days. I have 11 patients normally but sometimes as many as 14. I am on team nursing RN/LVN/Nurse Tech and it is overwhelming even though I do not do the assessments. The accuchecks alone (some days 8 patients on insulin) keep me running. I am trying to stick it out for at least a year to get the needed experience. I am also finishing my last prereqs to go into the RN program (at 49 can you believe it!!). My daughter is in the RN program now. I did not think I could do it, but it I can do it you can too!! And I realize that my time management and skills get better each day I do it. I feel like if I can handle this stressful med/surg environment I can do anything after this. Even with this unrealistic patient ratio. I am going to print out all the advice I have read here, because it is so helpful. Thank you to all for sharing. This new nurse rookie really appreciates you all. You are all my heros. Sincerely, new LVN in med/surg in California :) :)
:) Hi I just read your post and decided to say: I am in the same boat! I am on a tele floor in a big city hospital too and about to come to the end of orientation. I am pretty uneasy about this and I have heard so many others have felt this same way when they were in my shoes-one nurse of 2 years said that she felt nauseated before every shift. It is so hard sometimes to multi-task a million things at once. Hang in there! and just so you know, you are not alone f/soulsearcher
Yep! Sounds like a typical m/s day. And they wonder why there is a shortage??? I still feel that way practically every day but, in my opinion, it is actually easier, in a way, on your own, because you work at YOUR pace and you don't have to wonder exactly what your preceptor did and what you have to do. To me it is a lot less confusing because you are not backtracking so much. hopefully you will feel the same.
Clarise
88 Posts
Okay, I am printing this up and memorizing it! Thank you :)