Mistakes in the ICU

[ICURN1980]

Hey guys, I've been doing a nurse residency program in the ICU for the last few months. It has been a combination of general nursing orientation classes, critical care classes, and days on the unit orienting. Overall, in the last 5 months I have had about the equivalent of 3 months on the unit (around 36 shifts). I feel as though during this time I have had my share of challenges, but things still come up that I "fumble" on and have a difficult time with. I try to remind myself that I still have very limited experience, but my preceptors are usually very critical of me. Don't get me wrong, I absolutely appreciate hearing constructive criticism and want to improve. I truly value their feedback and take it into consideration and work on these areas of weakness. However, occasionally I fumble on certain tasks or make minor mistakes that shatter my confidence and my preceptors are especially harsh on me. I know that as a new grad and a nurse in general, mistakes can (and will) happen. However, I also know that in the ICU where patients are extremely sick, these mistakes can have much worse consequences than in other areas. Some of these mistakes are so simple that I feel like they should not be an issue in my practice at this point in my career. Granted, 5 months of experience is not enough time to be completely comfortable or confident in my skills and I try to remind myself of that. However, when certain things happen it makes me question my ability to be an awesome, competent ICU nurse.

For example, a few day ago I had a very sick 1:1 patient. septic shock, 2 pressors (levo, vaso), sedated (versed for sedation and fentanyl for pain), vented, insulin gtt, and chest tubes. I felt like I had a pretty good handle on things, measuring q1h urine output, chest tube output, urine output, CBGs, etc...assessments and meds were on time, turns and oral care were on time, and I was vigilant monitoring my drips in accordance with vitals. However, the Levo bag ran dry and air got into the tubing (my mistake for not switching out the bag sooner). However, this is usually a quick fix. I just used the first 'Y'-site from the IV tubing to pull some fluid from the new bag to prime the tube. Somehow, the air got past the pump and so the pump was no longer alarming. However, I had never dealt with air passing the pump and was not really sure how to get it out. Obviously with Levo, there is very little time to mess around and a few minutes without the med and the patient would become dangerously hypotensive. My preceptor stepped in to fix the problem by clamping the IV tubing, removing it from the pump and aspirating some fluid from the Y-site to reprime the tubing. I had never dealt with this problem, and luckily I learned from it, but it just made me look completely incompetent and unable to troubleshoot the situation. I'm glad she stepped in to help me out, but I feel like mistakes like this cause my preceptors to lose their confidence in my abilities.

Another situation that arouse with a patient a few days ago. A neuro patient, PEG tube, trach, otherwise pretty stable. All of a sudden while we were in the room he vomited a pretty large amount. My preceptor went into "go mode" and asked, "Alright, this is your patient. What are you gonna do?". Obviously with vomiting, aspiration is a worry. So I sat him up and suctioned what I could out of his mouth. My preceptor immediately pulled all she could from his PEG tube and was asking what else I should do. I couldn't think of anything else, and she finally instructed me to suction his trach. All of these things make total sense when we talk about them, but in the moment and under the pressure of my preceptor drilling me, I tend to draw a blank and can't think. It definitely shakes me confidence.

Does this type of critical thinking and ability to act quick in emergent-type situation calm and collectedly come with time? Does experience really instill the reflex reaction that my preceptors seem to have? I know they have been nurses for 9 years and 14 years, and I have a measly 5 months. I am definitely slower to act, tend to think things through slower, and lack some of the critical thinking necessary to work in the ICU.

It doesn't seem realistic to me to be at their level, and I know it's crazy to think a new grad with 5 months experience would be where they are. However, I feel like they expect me to be at a level that is unrealistic. I really do want to get to that level, and I really do appreciate and understand their concerns, but should I expect these skills to get better over time? I study at home, look up meds and patho of diseases I don't know, and really do my best to soak up all of their advice. What else can I do?

Sorry for the rant. Any advice?

[SubSippi]

It doesn't sound like they have unrealistic expectations, it sounds like you have a great preceptor who is helping you learn!! She asked you what you needed to do for that patient, not to put you on the spot, but to give you a chance to think. Which you did...you acted, suctioning the patient was necessary. Don't be ashamed that your preceptor had a couple more things to add! Trust me, she didn't pull the stomach contents out of the peg due to some instinct, she did that because she'd been in that situation before (probably many times), and learned from it.

Also...if your preceptor thought you were an incompetent nurse, I doubt she'd have even given you a chance to do things yourself. She would have stepped around you, and did it herself.

One last thing: in my opinion, the BEST thing about being a nurse, is being able to get input from your coworkers, regardless of your experience level. I'll tell you how I'd imagine things would go down on my unit, even with the most experienced nurse being the primary:

Patient starts vomiting, nurse proceeds with the interventions you and your preceptor did. Pokes head out of room and asks someone to come in there. Says to secondary nurse, "The patient started vomiting...I suctioned her mouth and trach, and I aspirated all her stomach contents from her peg. Can you think of anything else?" Secondary says, "If her blood pressure can tolerate it, I'd sit her up some more. Did you check her bowel sounds? That emesis looks dark brown, I hope it's not an ileus. Maybe you should see if she has any zofran ordered, or if you need to call the attending to get her something to ease that nausea. I'll stay here in case she starts getting sick again."

Teamwork. Nobody can think of everything all the time. Believe me, I completely understand being new and feeling like you need to prove yourself. But the reality is that we all need input from each other, even for things as silly as getting air stuck in our lines (and I bet you won't let a line run dry with a pressor in it anytime soon!).

Shoot...a month or two ago I had a patient with about a dozen drips going at once, and hasn't labeled a thing (super busy, hadn't even thought of it). My coworker came in and said, "WOAH you are going to end up giving this lady a 50 unit insulin bonus!" and then labeled everything for me.

I know if I had been brand new, I'd feel like a moron. But now that I have a little more confidence, I was just grateful for the help!

[dah doh, BSN, RN]

Are they being hyper-critical or are they helping you to think through the situations? Do you understand the big picture & how to stabilize & even progress the patient or are you bogged down in tasks? It seems like you are trying, but are they being too harsh or are you interpreting their feedback as too critical?

Situation #1: the IV tubing thing...how you get the air out of the line is a preference thing as there are many different ways to do it. It's a good sign that you recognized that it had to done quickly but it's bad that you let your vasopressor bag run dry & suck air...lesson learned...don't let ANY drip run out (pressors, dilators, sedatives, pain meds, etc). It'll get negatively reinforced if your patient is very sensitive and crashes while you are getting or making a new bag!

Situation #2: the vomiting. Good that you recognized the aspiration potential, but all routes should be acted upon. Question to think about: why is patient vomiting? Answering the "why & what" will usually lead you to appropriate interventions...AKA the dreaded "critical thinking" or as I call it "anticipating the needs of the patient".

You mentioned "the pressure of getting drilled"...preceptors are different in their teaching style...I don't "drill" newbies, but I ask questions in a low key & casual manner so I can gauge their thinking processes. I tell my newbies to try to answer my questions even if it's wrong. Newbies have to build self-confidence in their abilities & to learn to trust their "gut instinct". That's part of a preceptor's role is to bring that out in the newbie. I tell them the good and needs improvement parts of the day on a daily basis. You need to show progression in the care of more complex patients & in your thinking processes.

If you have a willingness to learn, you should improve with time & experience. Don't be afraid to ask questions & look up stuff so you'll be safe. You will be slower, but should improve with time. Don't expect to be operating at a level similar to your preceptor for at least a few years. As for the calm part...not every nurse is calm...that is part personality and part experience. You've only been at it 5 months, so give yourself 1-2 years. Being in ICU as a new grad is not easy...hang in there!

[ICURN1980]

Dah Doh – I think you may be right. I really don’t think they are being too critical and they are absolutely helping me learn, although sometimes I guess I just get frustrated that I am not yet at their level and so maybe I unjustly interpret their feedback as too critical. I always humble myself and try to ask as many questions as possible. We even debrief at the end of each shift (and throughout the shift) about possible “worst case scenarios” that could occur with my patient. What would you do if he became extremely hypotensive? Bradycardic? Tachy? De-satted to 80%? Thank you for the advice, I think I was maybe being defensive and harsh on myself and therefore saying they were being too critical when they are actually just helping me to learn. I think what it most frustrated is that they almost seem disappointed or surprised that these things are not instinctive yet. They do take time, and 5 months may not be long enough to have these responses hardwired into my brain. I honestly haven’t had a lot of experience with vomiting trach patients or IV lines running dry. Now that I’ve had these fumbles, I feel like I’ve learned how to better handle the situation. Trust me, I go over these situations over and over again in my head at home and try to prepare better next time…therefore, I doubt I’ll be making the same mistake again (and heck, even if I do, at least it won’t be the first time and I can correct it).

SubSippi thanks for the advice as well. I actually have a great set of co-workers that I have no problem asking for help. Everyone has been super welcoming and helpful, so the teamwork aspect you mentioned has been astronomically helpful, and will continue to be helpful when I’m off orientation. And yes, because I am so new, I tend to be hard on myself because little mistakes or fumbles make me feel completely incompetent and I assume people are looking at me like, “This guy doesn’t know what he’s doing!”. If I had more experience and confidence, I may not be so critical of myself, take the advice, and move on (like your examples of labeling your IV pumps).

Thanks you guys, this helped put things in perspective. I think I was more frustrated with myself than my preceptors.

[Onco_NT]

@ICURN1980 Omg!! I feel so comforted reading this.. I too am a new grad in the ICU an have been for 5months just as you have! Unlike your situation, my perceptor is actually "harsh" on me smh she has great intentions an ID great at teaching but her tone and attitude towards me can be really extreme at times.. Like to the point where my manager witnessed one day just walking around the unit and called me into her office to talk about switching perceptors.. Mind you! I have been with them over half of my orienting experience (6months).. So now after switching I have had a completely different experience.. An it's frustrating because I feel like I should've switched sooner an that I impeded my own process by not speaking up.. I just felt like some nurses are the way they are an as long as I can ask questions an learn something I should shrug off the rest.. But of course NOW I realize I'm not really receptive to learning when I am being talked down on an yelled at Etc in certain situations..::sigh: vent COMPLETE! Lol

Hang in there! I can relate to everything your experiencing an it's easy to feel alone in this new world of ICU with all the 'experienced-bad-ass-competent' ICU nurses around us! ::hugs:: we will get there!

[BeatsPerMinute, BSN, RN]

I just wanted to say thank you for sharing! I have a better idea of what to do now if I ever face those situations. The critical thinking and reflex responses will definitely come with time and experience. The first time I dealt with an emergency I stood in my patient's room and froze. My mind went blank. I was useless. (Granted, this was my very first day in the hospital as a nursing student). I watched, asked questions, and learned. Then I was faced with another emergency situation (a child stopped breathing) and I knew what to do. I called for help, grabbed my supplies (O2, ambu bag), acted quickly and safely (but calmly), followed the steps I was taught, and got her breathing again.

I just started in the ICU (3rd week on orientation). It is TOUGH! So busy, so much to learn. But we will get there!!

[Mavrick, BSN, RN]

The fact that you didn't know how to deal with extensive air in your IV line is actually pretty good because it hadn't happened before now. (And probably won't happen again for a very long time!) Just like some day you will cut a central line or trach pilot balloon while being too agressive with your scissors doing a dressing change. (Well maybe you won't but one of your buddies will.) Learn from your mistakes and learn from others' mistakes too.

No, after five months, a new grad will not be a fully competent ICU nurse. Of course we try for perfection but it just ain't possible. It does sound like you are putting a lot of the pressure on yourself. Keep up the good work but allow yourself a reasonable learning curve.

I think your preceptor was giving you credit for your thinking while acknowledging that you are going to be slower in the actual performance of the task. By talking through what you see as needing to be done, you show that critical thinking and allow others to help. Letting others help is a key part of ICU teamwork too.