My preceptor is everything they taught us NOT to be...

[Live..&..Learn]

I was hired on a med-surge floor, and have been working with a preceptor for several weeks. After questioning some of the things she is "teaching" me, I've been given a "final warning" and am facing termination over complaints made to my manager "per preceptor".

I a new grad from an excellent, small hospital based program where the instructors have tons of professional and life experience, and we leave feeling like confident, competent New Grads. I was assigned to a preceptor who has just over a year experience, and was impressed by my clinical skills, stating she didn't learn anything in school. I've noticed the following things that have caused me to question her practice and ability to precept. I would like some opinions on whether I'm over reacting, or valid in my concerns...

Pt has a stage 4 pressure ulcer on her coccyx, wet to dry dsg changes ordered q day. I observed while she changed the dressing. No sterile field, no sterile gloves, out clean gloves on, removed the dsg and packing, never changed the gloves, soaked the packing with her gloves hands, repacked and dressed the wound.

If my pt has multiple IV meds ordered for the same time she told me to scan them all, hang one, and leave the rest to be hung when it finishes. I don't sign for meds that haven't been given.

Non verbal pt has orders for blood glucose monitoring and insulin sliding scale. 0630 fingersick done, pt does not score for coverage. 0800 the tech who came on did another finger stick and pt needs 2 units. At 1000 preceptor says that pt needs coverage, I never signed off on the task (he didn't score when it was ordered). 1030 administering meds, recheck fingerstick and pt needs 2 units. I signed off on the 0700 order (outside of parameters), charted the new reading, gave the insulin at 1030 for the 1100 order. That's wrong, I should have covered him for 0700 and rechecked at 1100. I told her I don't think I should give insulin 2.5 hours after a fingerstick without a recheck. Or cannot even tell us if he's feeling off, and is npo with tube feeds.

New admission two days post discharge. Dementia, not a good historian of her medical hx. Form asks "has pt had a flu shot". Preceptor states "I don't know for sure, but they must have given it on d/c. Charts that she had it and pneumonia vax on date of last d/c.

We were told that no blood pressure meds are to be given without a. BP within 30 minutes. She was not there that day. It is 0920, pt has a bp charted for 0811, but the techs do vs at 0700, it was charted at 0811. "Give it, it's fine". Next pt is on a beta blocker, calcium channel blocker, and 80mg lasix. I rechecked the BP and she seemed quite annoyed.

I heard her giving report in the hall outside a pt room. Openly discussing hx of drug abuse, etc. Another pt is a registered sex offender, I overheard her telling a tech from another dept. His reason for being a sex offender.

I had a pt who was on two iv and, including vancomyicin. The day before she had IV contrast. Her BUN and Creatinine were elevated, GFR was around 40 the day before. She told me in the am that she is usually up four times a night to void but hasn't been up once. I report this to preceptor. After a little bit, I got her up to the commode where she voids 40mls. At lunch I got her up again and she voids 60. I went to preceptor who tells me that she went for her. I asked if I should call the doc just to be safe, she says she will take care of it. End of shift I asked, she said pt is fine, no need. RN I am reporting to ask about output, I explained it to him and he called provider.

I could keep going, but I feel like a vindictive crazy person. I know these are bad habits, and refuse to adopt them into my own practice. She wants all of my tasks and charting to be done by 10am. I often do not reach that because I choose to assist pts with am care, breakfast, ect. The charting can wait in my opinion, as long as everything is done on time. I have one foot out the door anyway, and will likely be fired today. I can deal with that, I definitely can, but I was advices by a mentor to approach her, I tried, and yo go to the manager, I asked him to meet with me, and he told me that he has continued to receive negative feedback from my preceptor and will discuss it with me. I know I'm being fired, and there's not much to do to change that, unfortunately being fired means I will not be eligible for 're-hire at the one hospital near me. But, what do I do about this preceptor? Let it go so the next new nurse can learn these poor habits, or try to bring it to someone else's attention?

Thanks for listening, sorry about the extremely long post...I refuse to adapt bad habits just yet, or sit back while patient safety is compromised, unless of course I'm being an over reactive cry baby.

[VioletaRockos]

Alright. I have to say something. Because I was a preceptor a year in to my first job as a new nurse. I hope you see this comment out of the hundred or so you probably already have here, but you probably won't, so here it goes anyway.

You sound like a very good nurse. Yes, patient care always without a doubt comes first. There have been days (I'm almost 4 years in now) where I don't start charting until my shift has ended. On a med-surg floor especially, the first things you should be doing are assessing your patient and getting the patient up and out of bed/walking/into the bathroom so they can have breakfast and you can pass your AM meds. This is priority number 1. For your 5-7 patients on dayshift.

What you have to realize is that if you try to practice to the perfection that you are trying to aspire to, you will get fired or burn out within the first year. Because whether you like it or not (and trust me, no good nurse does like it), charts matter. The time you chart matters. If you don't give your meds in a timely fashion, that's a write up. If you don't have your charts at least started by a certain time, that's another write up. When that one patient gets sue happy about something that happened during their hospital stay and you're brought to court, charting times matter.

Hospitals don't like when their employees are a liability. So they expect the impossible. They expect you to be the perfect nurse, the perfect customer service robot, and an asset to their company. Nurses take shortcuts. Like many comments before me have said, there is real world and nursing school world. That ideal vision needs to be removed from your head, and instead planted with the smart nurse who has the skills but knows how to get **** done.

Dressing changes are never sterile on the floor, unless they are ordered as such. Change your gloves in between removing the old and applying the new. Make sure the patient isn't soiled.

Go by your CNAs vitals. That's what they're there for. Unless you know that they did them purposely at a wrong time to better suit their needs.

It's okay to scan 2 IVs at the same time. If something happens, you back chart and say not administered and this is why.

Stop striving for perfect. Go for ideal. Nobody wants the perfect nurse when you're taking too much time doing something that doesn't need to be done, and your 4 other patients are ringing their buzzers.

If you see something against policy or something unsafe that your preceptor is doing, you can report them. Otherwise, learn to adapt, but be comfortable and safe doing so, for your sake and your patients' sake.

[VioletaRockos]

Weekly reports are a standard thing?

Yeah, I need to get out of my hospital.

[hali_parker]

Okay, I'm going to approach this from a different angle here to start.

As a new nurse with about 1.5 years of experience with the 1st year being on a med/surg floor, I can relate to the big picture of what you are saying here.

Based on the information I've been given here, I believe you have your heart in the right place, and you have a lot of passion for your patients and the drive to be a good nurse, and that is wonderful. That is something you should cherish and hold on to, and never let anyone change. Also, you are critically thinking. You have potential to be a wonderful nurse.

With that being said, another huge aspect of nursing is learning and growing. As a brand new nurse all the way until the day you retire you will be learning. Learning is not always receiving advice and wisdom. Just as often you are going to be learning based on making the decision that what you see is not something you want to be doing in your own practice.

I have now moved to a critical care, which is a better fit for me. Med/surg is not for everybody, but those who do it have a brave heart and handle very difficult patients and assignments in their own way. If med/surg is not for you, take the opportunity to still be learning and work on making a short term goal for yourself and go for it. During my time on my previous unit, I saw things daily I did not agree with, but only if I thought a patient's safety was being jeopardized did I decide I needed to intervene; I really can only think of this happening a couple times. You have to respect your fellow coworkers and learn from them, even if it is not the type of learning you were to expect. You are just a baby nurse (I am just a toddler nurse :)) we have SO much to learn!

Trust your gut, critically think, ALWAYS be open for criticism, learn how to interpret that criticism (ex.- charting supposed to be done by 10- I need to focus on time management and work my way to charting being done by 10! Do NOT automatically assume this is not an issue and that your preceptor is at fault. Her approach at telling you may be poor, but find in yourself what you can learn from that!!), and finally find a place where you feel valued and happy.

Good luck. You are not in this alone (use your resources), but you ARE solely responsible for the kind of nurse and coworker you will be.

[Agmommy]

I agree with the other posters. There is such a thing as real life nursing. You are comparing things to the way you learned it in school and it's just not realistic all of the time. The dressing change for sure is not done sterile. There is no way to keep it sterile after. The I.V's get signed out together, you can always chart they weren't given. The reason for this is time management. This is a corner that is ok to cut. If you did things by nursing school standard, you would literally never finish a days work. In order to have time for other things you cut these corners. You really need to have time to look up labs, test results, talk to other team members, etc. The BP med situation, I wouldn't not go with the earlier BP unless it was lower and cutting it close. If the patient trended a higher BP, I would use it. It doesn't hurt to retake it tho. Part of your preceptors job is to determine if you will fit into the team they have. If you are constantly challenging her practice, you may not be a team player. You are going to see things you disagree with. You will see what really poor nursing care is someday. This isn't it. Sometimes you have to just say to yourself, "self, make note to not do this when I am off Orientation". Them you move on.

You most certainly wouldn't be the reason that patient ended up on dialysis bc of the decrease voiding. That doesn't happen overnight bc of a decrease in voiding. You have to trust in your preceptor that they have been doing this longer, have seen more and have a lot to teach you. I wouldn't take what your mentor friend said to heart. They may be just trying to sound good to a new grad. If you want to keep your job and reputation than just go with the flow and know that you can do what you want when you are on your own.

Lastly, the charting needs to be done asap. The doctors come in and look for your assessments. There are reasons for that to be done by a certain time. In fact, it is mandatory at most hospitals. Your cna or tech will do am care. You have to delegate some stuff. If the patient starts going south and you haven't even charted your baseline assessment, that could be a problem.

Good luck to you

[CardiacDork, MSN, RN]

You should have bladder scanned the patient with the voiding issues, this way you know if it is an issue with urine production or expelling the urine. Just a thought. You do not need a doctors order or instruction to bladder scan.

[qestout, ASN, RN]

Resign before you get fired. You'll feel so much better after you remove yourself from that stress. You will get another RN position soon.

[Lad345]

A little bit of both, honestly. She sounds like she needs to improve her practice, but what you need to learn about nursing is that everyone has their OWN license and their OWN accountability.

Sorry but you have to get through preceptorship, and unfortunately it won't be the last time you have to pacify and put up with bull. Was the BP 110s/60s? What's their trend? You'll learn to base your practice on life, not books and 30-min rules. If something you're asked to do is truly unsafe and reasoning isn't given, then: yes, absolutely refuse, collect your objective evidence, chart asap, and demand they do the task themselves if they insist.

You need to, for lack of a kinder what to state it, hop down from your high horse. You sound as though you have yet to understand the big picture of nursing. You can't improve something you don't understand. You'll learn the value of getting your charting in when you get 2 discharges with 2 readmits, and suddenly that person you've been watching codes and you have no head-to-toe BC you were doing ADL care.

[kyrasouth]

I am a new RN but not a new nurse. I have worked in LTC for 10 years and am not transitioning to hospital care. It has been difficult for me to change the way I was used to nursing in LTC to acute care. All nursing is not the same. Every nurse does things differently. Book nursing is based on a perfect world and is not realistic. I understand that you just finished school and have learned to do everything perfectly but nursing is not perfect, it is realistic. Reading your post, you seem to know book nursing very well but clinical nursing is different. If someone has chronic HTN, they need their meds, they need to keep that medication in their system to maintain their bp at an acceptable level, even if its 110/70 right now, chronic HTN patients will jump up if not given their medication. Its not just about the numbers, its about the patient. You have to treat the patient not the machines. Maybe your preceptor knows this and maybe not, but trust me, they have chosen to allow her to precept you so they think she is competent even if you don't. Now you have the option to refuse to administer any medication if you have a medically based reason not to, but you will have to have a good reason not to give it and be ready to show how it would be a detriment to the patient to give it. I am not bashing you or calling you whiny, just being honest about nursing. The manager does not know your skills and does not trust you, they are relying on your preceptor to tell them how you are doing, you need to fix your relationship with her, never act like you are better or more knowledgeable than her, even if you think you are.

Nursing is not fair and you are new so you are not the one managers will listen to because to them you have no skills (even if you do), you have to prove yourself over time. Many thing will confuse you and frustrate you. You will be expected to be in ten places at once, do ten things at once, pass meds, assess, give care and chart all at the same time. You have to learn how to prioritize and delegate so you can get the more important things done within a reasonable amount of time, and you will still get those awesome notes about how you did something wrong or not on time.

Things to remember, take care of your patients, don't piss the doctor off, chart well enough to cover your own ass. Real nursing is nothing like nursing school, it is chaotic and never perfect scenarios. If you are not comfortable where you are, maybe you should look at a different kind of nursing, there are thousands of areas to work in.

[Zombiologist]

I am a newish nurse, and I had the opportunity to precept a new grad this fall. I was not shy about admitting my shortcomings in front of my precectee and we both learn lots.

Op, your preceptor is not perfect. Nursing is tough. And if you are coming on to a floor saying you came from a good program instead of being willing to learn, I am imagining that you are a tad defensive when taking feedback.

Your preceptor was chosen because she is a good nurse and they thought you could learn from her. And you did not.

My preceptee is now flying own her own and I hope that she never forgets to ask questions.

[Kssable]

I think you're in the right. Don't listen to these other posters. Practice what they taught you in school and patient safety comes first, not short cuts. Lots of nurses nowadays do shortcuts and risk patient lives, be a smart, responsible nurse but realize there are a lot of bad nurses out there that do not follow safe good guidelines

[CardiacDork, MSN, RN]

I think you're in the right. Don't listen to these other posters. Practice what they taught you in school and patient safety comes first, not short cuts. Lots of nurses nowadays do shortcuts and risk patient lives, be a smart, responsible nurse but realize there are a lot of bad nurses out there that do not follow safe good guidelines

Honestly, most nurses do try to practice as close as possible to nursing as it was taught by the books, but sometimes shortcuts happen, or you actually can delay care. Sometimes following the nursing school mindset is totally contradictory to the real world mindset. The blood pressure medication is a great example. I have patients whose blood pressure is 108/62 BECAUSE of their antihypertensives. Stop them? And they'll rebound.

Another example is perhaps you have a patient with regular insulin odered at 0730AM, but perhaps the patient doesn't eat until about 0900, if you're in by the books thinking would you hesitate to put the insulin off an hour or two to accommodate the preprandial times?

I mean, there are so many examples.

Sometimes you have to use that noggin and not rely exclusively on what a book says, because let me tell you...patients are all individuals with individual physiology and pathophysiology.

If you're a nurse, you ought to know better.

If you're a pre-nursing student - realize this now and don't you forget it! = )

[allyl]

I definitely agree with the majority. While you are definitely knowledgeable about best practice, the world is not "best". If you were working with one patient at a time of course you could do everything right but you're not, multiple people will be needing multiple things at once and patients are humans who have their own quirks.

I think everyone else has covered the clinical aspect so I'll just echo about time management. I am still horrible about this but documentation should be done AS SOON AS POSSIBLE. As for feeding patients and AM care, why are you doing AM care?! The only time that is acceptable is if you are down a CNA or a patient asks for something you can do quickly while you are in the room doing YOUR job. Ex.- Pt just finished urinating in urinal and your there to give meds, of course you'll empty it for them and give them hand sanitizer! Wound care scheduled for the day but wants a shower first, they can wait for the CNA to give a shower who can then notify you when they're back in bed. Just have supplies ready to go so they don't have to wait around with a wet dressing. Also fully brief your CNAs, they are a super help if they know what you want and explain why. She can't have food today vs. She can't have food until after her scan at 10am but clear liquids are fine, I've ordered her an alternative tray if. This saves time as you don't have to discuss with the Pt why the tray is different and if the tray is normal they can alert you.

Last thing, personally I love to orientate new people. Teaching is fun for me and I get to learn what they would do in certain situations while perfecting my own practice. While we all development tricks of the trade and shortcuts, having someone around watching what I do and questioning makes me aware of my own complacency at times. I always pretend that they are a State auditor so I try to do the 'right' techniques. That can make me realize, "Hey, I've been taking a shortcut and it really doesn't waste that much time to do it the correct way" or "This is a really useful trick I need to teach this person." Sometimes it's just newer practice that I've learned since the school way isn't always up to date (especially in wound care) or things that certain doctors like. One doctor who I didn't like personally was great to work with as he knew I would do the dressing change his way and I knew what supplies he would want for chest tube removals.