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

LindseyGearllach · Dec 12, 2015

It was a poor choice to put you with a novice preceptor. It's like the blind leading the blind. However, I think your mentor put you in a bad situation by telling you to report every little thing. By doing this, all you were telling your new employer and coworkers is that you thought you were above them. Pointing out practice issues is a fine balance of what is a critical issue and what is not critical. And as a new nurse you think you know...but you really don't. Until you are on your own, your preceptor is your mom and dad, and you need to follow their lead. Consider this issue a lesson learned and change your thought process until you are on your own...then it's all yours.

CarpeDiem'15 · Dec 12, 2015

If you haven't charted, you haven't done it. I get that. But I personally think it's a two way street: if you haven't done it, don't chart it! I totally agree with the OP that if you aren't going to give meds at that point in time, then don't prescan them and sign off that you have. And OP had a totally valid concern with the patient's reduced urine output, it's clear she was suspecting patient may be having contrast-induced nephropathy (and it didn't help patient was on vancomycin which also has potential for nephrotoxicity) based off increasing SCr, BUN levels and decreasing GFR + patient's self-reported assessments of urine frequency 24-hours post IV contrast.

OP, only thing I can say is that there was nothing wrong with the contents of your thought processes or complaints with your preceptor's shortcuts. Maybe there was a different way you could have gone about getting those heard (soft-skills like rephrasing questions another way, etc), but honestly I don't see anything you've done that merits you being fired!

FunnyPants · Dec 12, 2015

I a new grad from an excellent, small hospital based program...Not because your school prepared their students well, and your preceptor stated that she didn't learn anything in school means that it's the end of it. Nursing school is preparatory. You continually learn in your nursing practice and build your skills as your progress. So your school may have given you a good foundation, but your preceptor has much more critical thinking and real world experience that should be taken into consideration rather than denouncing her ability to do her job. However you do have some good observations.

Dressing change: Unless otherwise stated, dressing changes don't need to follow sterile procedures. However, I would have changed gloves after removing the dressing. On the other hand, what was the quality of the dressing? Was it very soiled? bloody? was the wound infested with maggots or poop? etc

Multiple IVs ordered at the same time: Err, no. I personally wouldn't scan a medication and hold off on administering it to the patient. One might forget. Can the med be retimed? Are they compatible, perhaps they can be y-sited? Can you start a new IV for meds that are not compatible for IV ABX that will be given frequently?

Insulin: errrrr, why was the fsbs(finger stick blood sugar) done at 0630 for an 1100 order??? Did you ask your preceptor this? This suspicious. Ideally, the fsbs should be checked about 30 minutes before meal trays arrive.

vaccination: assume nothing.

Blood pressure and meds: Also, how have the patient's BP been trending? Do they consistently have a high or low BP? Were you going to give all of these meds for a charted BP of 100/75 HR55 or was the BP 185/101? If you're concerned , you can also tell your preceptor that you are checking because you'd feel more comfortable rechecking the BP since the aids began to check vitals 2hrs prior. I check the blood pressure before giving meds, unless I have a BP that's within the past hour.

Report: Hmmmm, why was she in the hall and not in the room? Discussing as in gossiping the Hx of drug abuse or passing on the pt. Hx.

One should consider your patient's dignity and not speak about them so candidly with others. However, as you progress in this profession you see that it happens quite often. Keep it to yourself and when you are giving report, you won't do what she's doing. This will be your standard. Move along.

Charting: When does your shift begin?? "The charting can wait in my opinion, as long as everything is done on time.", said no nurse ever!! Well I am certainly excited that you have the time for am care, and feed your patients (not being a smarty pants here). What's your patient ratio? the acuity? are you reviewing your labs? charts for new or change in orders? reviewing physican's notes? How much/how many tasks do you suppose that you preceptor is noticing not being addressed and she is completing because you are not making a priority to check? I don't know about your hospital, but at my facility we have computer charting. Docs have modified orders based on assessments, notes, and current vitals. You have an aide so that you may focus on your RN job. Utilize them.

Feedback: "continued to receive negative feedback from my preceptor and will discuss it with 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?" At some point you have to ask yourself "what about me? Am I missing something?" have you spoken to other new grads about their precepting experience? Do you talk to your preceptor about why she is doing x,y, z?(i,e,; the dressing change without glove change in between?). I'd like to get your preceptor's perspective. Do you bring to the attention of your manage every little thing that you don't agree with. I support that there are behaviours that you may not agree with, but how much of what she does warrants a complaint?

eieiyo · Dec 12, 2015

I noted that most of the responses to this thread were demeaning to this nurse. I applaud her for wanting to maintain her standards. One thing that bothered me was wanting to pass off morning cares because she is the RN. This is a good time to talk with our patients, maybe complete an assessment. When I was in med surg years ago on evening shift, I took the time every shift to change everybody's draw sheet and give a back rub. I wouldn't have passed on that task to anybody else. It didn't sound like she had time management issues. When someone is a preceptor, they should be at the top of their game. And be able to explain rationales. Starting out by pre scanning meds and cutting corners is not a good idea. While the dressing change may not have been a sterile technique, gloves should have been changed between Taking off the old dressing and putting on a clEan dressing Belittling new nurses for their standards is why many nurses leave nursing or get burned out. Rather than doing that, we should be encouraging this nurse. Props to you new nurse! Yes real life nursing is different than school but don't give up your standards.

susskykatherine · Dec 12, 2015

No need for sterile dsg on chronic wound, ok to scan all meds,check recent creatinine and fluid intake on oliguric pt before calling provider,pts will not be checking their own bp prior to meds at home,more important to check 1 hr after esp if new med, ok to remind preceptor of hippa rules in a nice way like what if that was your family member etc, transitioning to the real work is hard, all nurses practice differently to some degree.its a balance between taking reasonable shortcuts so you can get done what needs to be done and following best practice based on evidence.

Heartnurse24 · Dec 12, 2015

I am actually shocked at the responses to this new nurse. It sounds to me like she is being set up to fail. Nursing school vs work nursing is a whole different reality, however, it is OUR job as experienced nurses/preceptors to guide her and give FULL explanations as to why a corner may need to be cut. She has a right to question why IV meds are all being scanned in at once, or fingersticks/insulin coverages don't match. At the end of the day, it is HER license that they will come for, because we all know the preceptor will CYHA and not admit to any wrongdoing. I also fault her employer's orientation program. The nurse manager and educator should be giving her weekly meetings to assess what she may/may not be doing right and have discussions with her and her preceptor together to open up communication and find out if there are any personality clashes. There continues to be a lot of intimidation, incivility and workplace bullying in nursing and it sounds to me that this is what is occurring. Shame on you for thinking she's "nitpicking". She needs help and GUIDANCE as a brand new nurse so that she can better her skills and her practice. We have all been brand new nurses before. Dont act like we haven't. (sorry for the tone, but this post really upset me).

brewski09 · Dec 12, 2015

There are serious issues here as well as some thug a that aren't an issue. First of all, scanning mess and then not giving them until later can be viewed as a reportable medication error as well as falsifying documentation to the hospital and the BON. I think that is a very big issue and absolutely do not practice this way nor do I find it okay. The vitals not being charged by the techs u till that far after can also be coo soldered falsifying documentation and is also unsafe when giving cardiac meds. I also agree with the insulin issue, meds within an hour of the finger stick is pretty standard practice.

the dressing change I've seen go both ways. I prefer the sterile gloves because they are so much better protecting me for dressing changes that are involved like that. However, look up your hospital policy on the dressing change. Look it up for everything for that matter and print it out so you can tell your manager the policies you were following. If leave that unit if I were you because the managers and your preceptor don't seem very open.

FYI, if you are a union hospital have your union rep there even though you aren't off probation yet, they may still be able to help.

debdouc · Dec 12, 2015

I can really appreciate your position here but would like to point out some possibilities for you. My comments come from my experience with Preceptor A , who was a 20 year fabulous nurse from a diploma program. She was also a horrible preceptor, going about her business and not giving me much attention unless she didn't like what I was doing. I was stressed because I wasn't getting what I needed and didn't know how to change that. When my externship was over and I had my license, I requested a change in preceptor, had had enough experience with all the nurses by that time to know who would provide me with the best learning experience, and requested the change, got it, and had a remarkable experience with Preceptor B. I learned, was able to question and interact with Preceptor B in a fulfilling way, and ended up doing well.

1. Morning care is part of nursing school clinical process and is an important part of the learning process. Once you're a licensed nurse, though, it's important to think about your job and realize that, while providing basic care falls within your scope, so does timely charting. The CNA also has the scope of providing basic care but not timely nursing charting. Ultimately, if you are busy doing basic care rather than getting your charting done and something goes south with the patient, the clinical picture, represented by timely and accurate charting, is incomplete and you, your patient and the entire clinical team are disadvantaged by not having adequate information available on which to evaluate the patient's change in status.

2. Many, if not most or all, hospitals and physicians set parameters for blood pressures and heart rates when giving blood pressure medications, indicating that these need to be done just prior to giving the medication. If you are not comfortable with the time lapse between v.s. and medication, get your own set to make sure it is safe to give the medication. Many charting systems request these be entered along with the medication administration. You haven't hurt anyone by getting a second set and are following the provider's orders in doing so. Patient safety is the ultimate goal.

3. Many facilities require that premeal blood sugars and insulin be done when the meal trays are delivered to the floor so that the patient is less likely to experience a dangerous drop in blood sugar. You might want to check your facility's standard of care and act accordingly.

4. When questioning your preceptor's practice, it's a good idea to ask in learning mode rather than in challenging mode. Just because your preceptor does things a certain way doesn't mean that that should be your model for practice. Ask and do the best you can, understanding that everyone is a teacher, whether by fair means or foul.

5. Reread your dressing change orders to determine whether it is to be sterile or clean. In my experience, hospital dressing changes are sterile because we have the means to do so and it is about patient safety and wound care. If the order says clean rather than sterile, act accordingly.

6. I've never heard that scanning medications in advance of hanging them or giving them was appropriate nursing practice. It gives an inaccurate picture of patient care and medication administration. It makes no sense on any level, especially when considering the opportunity for medication error. It doesn't even make sense from a time management perspective. Scan the medications when you are giving them and do your best to prevent medication errors that will ultimately be traced to you if you do otherwise. It's your practice and your license, no matter what your preceptor says. You don't have to challenge or argue about it. Just do the right thing.

I've read many of the responses to your post and can really appreciate the wealth of experience represented. Ultimately, we each, individually, are responsible for our own practice and the consequences thereof. We are also responsible for our patients and their care in which we participate, and to the facilities for which we work. Sometimes it's a juggling act to keep all the plates in the air. Best wishes to you as you continue your journey.

Dranger · Dec 12, 2015

Some of your concerns are valid some are nitpicky.

The insulin, BP med, pressure ulcer dressing and urine output situations come to mind.

GFR is used often for CKD staging an the fact they gave contrast must have meant they REALLY needed to see something in that CT. Obviously it is an acute exacerbation of a chronic problem which has resulted in an acute kidney injury. This is something a doctor is going to see in I/Os and lab work. Is it something I am going to call about? Probably not. Docs aren't idiots, he/she is going to see it during rounding.

If you ever work nights and only have a doc on call you are going to need to use critical thinking to determine what is worth calling about. Would I mention it in passing if the doc was there? Sure. Would I drop everything to call him/her? No.

eieiyo · Dec 12, 2015

I agree that nursing can be a popularity contest. Two identical nurses, one brown nosed one not: the big shots will choose the brown noser. I tend to not be a brown noser, and although I am a very good nurse, the other is chosen. I fight this every day

eieiyo · Dec 12, 2015

I agree that nursing can be a popularity contest. Two identical nurses, one brown nosed one not: the big shots will choose the brown noser. I tend to not be a brown noser, and although I am a very good nurse, the other is chosen. I fight this every day

joanna73, BSN, RN · Dec 12, 2015

Playing the game is not unique to nursing. Is it fair? No. However, workplace politics exists everywhere, in every profession.

There is a certain art to knowing how to filter your comments and how to stay under the radar, without sucking up. Some people never realize this, and they are the ones who are labeled the "problem employee". Again, is it fair? No. It is what it is.

Unfortunately, during a probationary period you have to be vigilant about the filter. Once people know your work ethic, that filter becomes less important.

If there were many options for employment, that filter may not be as important. However, finding new employment often takes months.