I need some advice. I started on an antepartum/mother-baby postpartum unit a couple months ago. I have previous experience with well babies at a much smaller community hospital, and coming to a much larger teaching hospital with much stricter guidelines has been quite a change. My orientation was a little haphazard--I've rotated between antepartum (which I had no previous exposure to), couplet care (which I had minimal previous exposure to) and well-baby nursery, which is quite different here than at my previous facility. For various reasons, I've had multiple preceptors, resulting in things being a little haphazard.
Things had finally calmed down recently, and I had one preceptor for most of my shifts, who suggested I request to extend my orientation by a week just to get a better handle on things and feel more comfortable--so I did. I thought things were going well and I was getting the hang of how things were done here. My two most recent preceptors both told me I had done well for my shifts with them and one (not my "main" preceptor now) even told me she was surprised I had no med-surg experience because of how well I managed a hyperemesis patient with all-IV meds.
Last week, with my main preceptor, I made a few mistakes. I hung an IV medication and forgot to label it (and when pointed out, I corrected it immediately) with time/date/initials and patient's info. I am rusty with IV's, having not dealt with them since nursing school, and simply forgot. I also had a medication to give PO that I was supposed to split in half, but when I went to give it, I dropped the whole pill in the patient's hand and she pointed out her pill splitter on the cabinet--so I quickly split it and administered the correct dosage. Finally, this facility verifies mom and baby's ID bands with shift assessments, which my old facility did not do, so I've had a hard time breaking old habits and remembering to check them with every shift. On this particular day, I remembered to check the baby's bands but not the mom's. When my preceptor pointed it out, I corrected it immediately. At the end of the day, she told me I'd done well that day overall.
The next shift I worked, I was pulled in to the office to speak with the manager, assistant manager and educator. This is the first time anyone had met with me to review my progress on orientation. I was told I was not pulling things together quickly enough, that I seemed to lack critical thinking skills, and these mistakes were cited. It seems there are also concerns about whether I am able to recognize abnormal findings in both mothers and babies. I was told they were extending my orientation by one week and if I did not show marked improvement, I will no longer be employed. The night before this meeting, I had notified the educator that I had accidentally missed a class I was supposed to be at--I was sick and completely forgot about it and felt terrible when I realized it.
I have spent some time in thought and analyzed why the cited mistakes happened. The med error and the band error both occurred when I got distracted talking to the patients, usually due to a question they had. Since I'm used to being able to go into a patient's room and do what I need while talking with them, I am going to have to make an effort to keep from being distracted (maybe asking them to hold that thought for just a moment while I finish up) until I am experienced enough with this population to not make silly mistakes like that. With the pill I forgot to split, perhaps I could have pulled her pill splitter down from the shelf first thing and had it ready before giving her the med. I have made a series of notecards outlining what I need to do in various situations to ensure I don't inadvertently leave something out.
So I guess I'm wondering where do I go from here? How do I gently ask my preceptor to step back and not automatically take charge if I'm not doing things fast enough for her? She has a very strong personality and I am very laid back so it can be hard for me to assert myself! If, at the end of the week, they decide that they do not want to keep me on, do I request the opportunity to resign? Would it be ok to request transfer to a different position/unit if one is available? Any tips or tricks I can use to keep from making mistakes like the ones cited? At my previous facility, I rarely gave anything but erythromycin ointment, vitamin K, and Hep B vaccines, so there's been a lot to learn! If they do decide to keep me on, should I start looking elsewhere? I would hate to work where I feel I'm constantly under scrutiny and I'm concerned that's how I'd feel after being blindsided by that meeting. I'm so disappointed nothing was mentioned to me at any previous point about these concerns--if I'd known I could have done something to try to change it!
Specializes in Nurse Leader specializing in Labor & Delivery.
Thanks, klone. My old facility did require bands to be matched when babies were returned to mother's room after being out for any reason but did not require verifying with each shift assessment. I take it that is unusual?
Oh, I misunderstood! I didn't realize you were referring to shift assessment. No, I've never heard of that before. Other than when they're separated, the only other time we've ever had to match them is when they're first placed on, and when they're taken off at discharge.
Oh, I misunderstood! I didn't realize you were referring to shift assessment. No, I've never heard of that before. Other than when they're separated, the only other time we've ever had to match them is when they're first placed on, and when they're taken off at discharge.
Yeah, that sounds like what my old facility did--double nurse verification at initial banding, check bands when returning baby to mom's room, and check bands before removing a band at discharge (facility I just got fired from did not remove them at discharge but did check them). I had wondered about the checking at shift assessment thing as I didn't remember it from the large-ish hospital I did my clinicals in (40ish LDRP suites).
Been brushing up my resume and wondering if the best course is to leave this job off. Doesn't seem like I can really count it as experience when I never made it off orientation!
I think that you belong at a small hospital or in a different type of specialty. People are often given an extra week on orientation but it does not sound like you were ready to safely work independently yet if you were making these small but significant errors and even worse, someone else had to catch them. Giving a patient twice the order dose of medication is a significant issue...it isn't just about splitting a pill. Do you not have access to Micromedex on your Emar because that is a fast way to look if a med can be cut, crushed, or a capsule can be opened. (I disagree with idea that they score meds that can't be cut though...but you should always know your medication before giving it...what is is, what it is used for IN THAT PATIENT, and if you are dealing with an appropriate dose - which means you will be looking up a lot of meds very quickly when you are still learning what it standard on your unit). I verbally tell my patient what I am putting in their pill cup before I even open the wrapper so they can tell me if they don't want it or don't believe it is an appropriate med or dose. I also immediately split the pill at that time and throw away the extra so I don't loose track of what it is).
The labeling of the IV bag immediately may not be as big of an issue but it is a huge concern of JACHO and accreditation issues, so that may have been an issue for them. Or it may just have been a concern that you were not noticing the multitude of small details that are involved in quality patient care.
The problem with not being fully ready when you go off orientation is that you are expected to be able to carry a full patient load independently...and give quality care plus recognize when you need to get advice. I am relatively new to the postpartum nursing side (I am shared by the gyn/med/surg unit) but I have noticed that as the newbie who doesn't have friends on the unit that I often have the most couplets before anyone else. Multiple times I have had to care for 5 couplets which is critical staffing levels on that unit ... and I have to give quality safe care anyway...my new moms and newborns are depending on it. On one of these nights I was caring for a new c-section mother with q2 hr checks for mom, a Finnigan baby with q4 hr checks (respiratory rate funny enough I had to call in the NICU resident to come assess the baby), a 1st time mother who did not speak English as her first and primary language, a baby who could not get his blood sugars stable and the mom was having building a nursing relationship with the baby, and all the mothers needed assistance and teaching with breast feeding. And the whole time doing the normal baby vital signs for babies, full assessments for both, teaching baby care, doing scheduled activities such as Algo, CCHD, weights, TcB, etc. Unfortunately, in a big hospital they don't have time to let you use training wheels when you leave orientation. I am kind of disappointed in the whole orientation process at my huge teach hospital because between the two units I am now qualified to work on, I never had the same preceptor more than twice. It was a huge teach yourself project and I spent a lot of time at home looking up what I didn't know or revisiting my personal organizational plan. I was vocal about my disappointment concerning my orientation and since I had already established myself as a good nurse on the gyn side, I think I was heard because they have since instituted multiple new policies concerning having a more planned and better precepted process.
I do not have any reason to question your ability as a nurse but it sounds like you are not a good fit for a large hospital. I think they were simply letting you know you were not a good fit for this unit the way it is run. Know that in a busy hospital you have to learn fast and perform fast. It isn't personal. And trust me, I went home in tears as many shifts as I didn't because it was hard and exhausting. I spent a lot of time at home looking up policies and things I didn't understand. Post-partum nursing is primarily about schedules and doing things on time even when multiple tasks on different babies are due at the same time, recognizing when a baby or mother is out of the range of "normal", and recognizing when a patient needs teaching and being able to give it with the attention of someone only caring for one couplet. On the gyn/med/surg floor my shift is guided by the patients who are the most sick and need the most care...on the postpartum side, it is driven by a tight schedule of tasks that are dependent of the type of delivery and the age of the babies under my care.
Good luck at your next position. Don't let this one experience steal your confidence. Learn what you can from it and find the unit or specialty that is a better fit. Sometimes life's lessons are about finding out where we don't belong.
Thanks for responding, blackribbon. I had actually done a little mother-baby at my old hospital after going to nights but the way things were done between the two hospitals was a night and day difference. You are correct that any error in medication dosage is a big deal, and after it happened and I had time to analyze it, I realized it had occurred because I had gotten distracted by talking to the patient while answering her question. I realized that I was not in a place experience-wise that I could do that and should have asked her to hold that thought, or stopped what I was doing until I was done speaking with her. It was also my first time making an error like this, period. At this hospital, most of the nurses would scan the meds and sign the eMAR before even opening them, but I was taught in school never to sign until meds were administered because then you'd have to correct your charting if they didn't take them! The eMAR at this facility did not have Micromedex but they did use a drug book that was up at the nurse's station (which is where I looked up that second medication that needed splitting, the day I got fired, and it didn't say anything about whether it was safe). For what it's worth, the pharmacist told me that the only scored medications which cannot be split are enteric-coated, which this one was not.
You mention having never had the same preceptor more than twice--that was basically my issue. I went through twelve preceptors in six weeks, partly due to the structure of orientation there, but partly because they didn't bother to try to pair me with full-time employees. I had difficulty adapting to the myriad styles of each person because when I'd learn something from one person, the next person would say that I was doing it incorrectly, which was immensely frustrating. I have realized since that part of my problem was that I struggled to adapt to so many different ways of doing things while still trying to adapt to the workflow in the new place and also shift from baby-only thinking to adult thinking as well. In retrospect, I should have spent more time studying independently and should have been more assertive in getting the information I needed (like accessing p&p from home so I could learn them--since even with some of these, different staff were telling me different things).
My biggest beef is that they waited until my orientation should have been over to tell me there were issues, rather than pointing out things along the way that I needed to improve upon. It was a waste of both my time and theirs to let me go so long thinking I was doing well (since that's what my preceptors were telling me!) when I wasn't. I asked questions of my preceptors, particularly regarding things I'd had no previous exposure to (as I was always taught that if you're unsure about something, you should ask!), but it seems that was frowned upon, at least by my "main" preceptor.
At my first hospital, I was given three weeks of orientation as a new grad and expected to carry up to eight babies as a patient load (nights with seven or eight were always bad, with assessments, weights, baths, hearing screens, helping with breastfeeding, PKU's and serum bilis--we didn't have TcB, and that was if nothing went awry!), and though it sucked, I survived and gradually figured things out. With this last job, I think having a different preceptor (one who didn't seem to think I was an idiot, preferably) might have led to a different outcome, because I am confident I could have learned to do the work and do it reasonably well. I think there was an expectation that since I was familiar with newborns, that I would be easy to orient and let loose, and when they realized I was perhaps struggling a little with re-familiarizing myself with things I hadn't done since nursing school (like hanging IVs, or PO med administration), they decided to cut their losses and let me go.
This experience has given me a lot to think about and reflect on for future positions. I'm moving back to my home state very shortly and already have a phone interview lined up (which will hopefully lead to a unit interview!) and am going to be gathering my nursing books and reviewing my old nursing notes (which are presently in storage) before going to a new position (I am tired of struggling to find work in this part of the country, and my husband, who is from here, thinks there was some regional prejudice against me as well. I couldn't tell you one way or the other). If I can find an affordable one, I may take a nursing refresher course because it's clear that I've forgotten a lot of the little things involved in adult care and need to review them (I am hoping it's like riding a bicycle, where it all comes back to you eventually). I also think I will have an easier time adapting to wherever I go in the future and have some ideas for adapting should I end up with yet another sub-par orientation. If I had to do it over, I would have moved months ago (was two weeks from moving when I got the call for this position) and listened to my gut--when HR took me to the unit for my interview, the moment we stepped through the doors, I was hit by an incredibly strong feeling of "I don't belong here!" and I should have paid attention to that--but I was desperate for work so I took the job instead.
Two questions for you, since I've never heard of them--what is a Finnegan baby, and what's Algo? Also, when you're giving your patients their meds and telling them what they are, do you also tell them the dosage? Do you find many are familiar/unfamiliar with the dosage they normally take (if it is something they have been taking)? I am always looking to learn ways to improve and am interested to hear back from you.
Algo is a type of hearing screen, and Finnegan baby is a neonatal abstinence scoring assessment.
Semper Gumby, thank you for sharing as I think it's a good reminder that we are all humans and make mistakes. There are things that I have been through and done that I am ashamed of, but more to be proud of!
LIKE DUH the other night I had an induction who I had just started on pit after her contractions weren't changing her cervix..and of course I was calling her Vertex (this is after the MD had AROM and stated that baby was vertex), and then low and behold it was a FACE presentation as told by the day nurse who I reported off to, and I mostly just felt horrible because the babies EYE was extremely swollen when it was born! and that was because I had been poking it's eye ball ! I felt absolutely, hands-down like a terrible, horrible nurse.
Algo is a type of hearing screen, and Finnegan baby is a neonatal abstinence scoring assessment.
Semper Gumby, thank you for sharing as I think it's a good reminder that we are all humans and make mistakes. There are things that I have been through and done that I am ashamed of, but more to be proud of!
LIKE DUH the other night I had an induction who I had just started on pit after her contractions weren't changing her cervix..and of course I was calling her Vertex (this is after the MD had AROM and stated that baby was vertex), and then low and behold it was a FACE presentation as told by the day nurse who I reported off to, and I mostly just felt horrible because the babies EYE was extremely swollen when it was born! and that was because I had been poking it's eye ball ! I felt absolutely, hands-down like a terrible, horrible nurse.
but i didn't get fired because of it
Thanks for explaining! I have done many a hearing screen, but we just called them hearing screens lol. We virtually never saw babies in need of abstinence scores so I was unfamiliar with that as well.
It's true, we do all make mistakes, and as bummed as I was to be terminated, I'm kind of glad to find out so early on how strictly this employer views any kind of mistake. I can only imagine what might have happened had I made one of those errors after orientation ended.
Poor baby! I'd feel pretty terrible too in that situation, fortunately babies are super-resilient! I've never done a cervical check so forgive if this is a silly question--is it generally easy to tell if you're feeling the head vs. another part of the face/body?
That's horrible! To me it seems like your "team" didn't support you in your learning curve time. I worked at a hospital that had a policy of eliminating the ZERO FAULT OR FIRED standard, which gave nurses opportunity to learn, opportunity to ask for help if they needed it, opportunity to prevent errors from guessing or from over estimating one's own skills, and allowed nurses to grow without necessarily eating their own. That you were fired is probably the universe's way of leading you to your dream job where you might be happier than EVER! Don't internalize it, for sure. And don't beat yourself up. If we were supposed to be INTUITIVE, PERFECT nurses, there would be no need for nursing school or even Preceptorship / Orientation in the first place. Hang in there!
That's horrible! To me it seems like your "team" didn't support you in your learning curve time. I worked at a hospital that had a policy of eliminating the ZERO FAULT OR FIRED standard, which gave nurses opportunity to learn, opportunity to ask for help if they needed it, opportunity to prevent errors from guessing or from over estimating one's own skills, and allowed nurses to grow without necessarily eating their own. That you were fired is probably the universe's way of leading you to your dream job where you might be happier than EVER! Don't internalize it, for sure. And don't beat yourself up. If we were supposed to be INTUITIVE, PERFECT nurses, there would be no need for nursing school or even Preceptorship / Orientation in the first place. Hang in there!
Thanks, longbow.shelly. I do agree with you. I recall the last day, another nurse asked how it was going and saw my face (I was pretty discouraged) and told her one incident from that day where doing something didn't come automatically and she said, "Don't worry, it takes time!" Guess my preceptor and management felt differently. Your hospital sounds amazing--giving nurses a chance to learn their specialty and how to do their job well without fear and intimidation.
I have chosen to look at the experience as giving me the opportunity to find something much better suited to me. I have an interview tomorrow that I hope will go well, as it's in my dream specialty!
Just wanted to post a little update--today I was offered a position in a level IV NICU, which has been my dream since I was in my early teens! I am hoping to take the lessons I learned from this experience and improve upon them for this next one so that I can be successful and become the kind of nurse I've always wanted to be!
Congrats! Your background with babies will be very helpful. No need to relearn a bunch of adult stuff.
Thanks jennylee (love the name by the way)! That's what some of the other nurses I met there felt, that coming from newborn nursery would be very helpful!
klone, MSN, RN
14,857 Posts
Oh, I misunderstood! I didn't realize you were referring to shift assessment. No, I've never heard of that before. Other than when they're separated, the only other time we've ever had to match them is when they're first placed on, and when they're taken off at discharge.