New BSN Nurse with Minimal Guidance in LTAC: I want to do things right

[Nurse Beth, MSN]

Dear Nurse Beth,

I am an RN with a BSN and live in a part of the country where there is a glut of new grads. I was grateful to get hired at an LTAC several months ago. My job is chaotic, low-paying, and the training and guidance are minimal. I spend most of my shift hanging IVs, pushing pain meds, trying to get the LVNs and CNAs to work together, plus a lot of ridiculous lawyer-driven charting. I have not learned anything new in the past few months. I continue to apply for other jobs and look forward to my 1 year anniversary, which hopefully will open up other opportunities.

I worry that I am not being exposed to the skills and techniques of first class nursing. I was recently orienting a registry RN and learned several things from her. For example, the best way to draw blood from a PICC and the rationale behind it. All of my colleagues have their own techniques for everything, which are usually based upon the minimal amount of effort they can get away with doing. I have looked for an official manual but it is giant, dusty, and not user friendly.

I am not going to go to the Dir. of Education. It would be an insult to her, plus there is an understanding that there is a big difference between how things are done and the official procedure. Her job is to make sure boxes on forms get checked. When I was a student, I could observe the RNs and learn from them. That does not apply here.

Also, my BSN was from an accelerated for-profit school. We were taught to the test so I am insecure about some of my fundamental knowledge.

I really want to be the best nurse I can be. I want to be professional and clinically sound. Are there any resources I should be.

Dear Wants to do Things Right,

You're awesome.

Your environment is not conducive to professional development or evidence-based nursing practice, which you already know. So much is going to change for you as soon as you land a job in a reputable, functional healthcare facility with well-written policies and procedures.

At the same time, sacred cows of nursing practice exist everywhere, and I have learned to research my own questions, rather than follow the opinions of others.

Here's an example of just a few things I've discovered during my own research recently because I want to follow best practice:

• When performing a Therapeutic Phlebotomy, do not use a vacutainer, it can lead to an air embolus.
• Sandbags are of no value when pulling a femoral arterial sheath
• Chemotherapy precautions for healthcare workers should be in place for 3 days post last chemo administration
• Reverse isolation is not an official isolation (per CDC) except in bone marrow transplants
• Data does not support the use of Trendelenburg for hypotension

Join

Join a nursing organization(s) for the latest in evidence-based practice.

I have a passion for both professional development and evidence-based practice, and I belong to: American Association for Critical-Care Nurses (AACN), Academy of Medical-Surgical Nurses (AMSN), Infusion Nurses' Society (INS), Oncology Nurses Society (ONS), Association of Nurses in Professional Development (ANPD), American Nurses Association (ANA) . As a member, I have access to their entire backlog of journal articles.

For example, I just received the latest standards and guidelines on flushing of central line catheters from INS, which is very helpful.

Abstracts from recent journal articles can be found on Google but often the full article is available by purchase only. Full articles can be pricey, but are free if you belong to the associated organization.

Learn to use Google Scholar. You'll love it, and you can view and cite references right from the page.

Subscribe

Subscribe to one or two nursing journals, such as the American Journal of Nursing, or Nursing Made Easy. Invest in Lippincott's Nursing Procedures for the latest and referenced in procedures.

Join Twitter to meet like minded nurses. Follow me at @bhawkesrn and check out some of the nurses I follow. Are you on LinkedIn, and have you joined any nursing groups there?

Do continuing nursing education (CEs) on topics that interest you. Online CEs are easy to find.

Once you get started looking things up for yourself, you'll discover other resources. Lippincott Nursing Center is an excellent online resource.

[amoLucia]

To Nurse Beth - I too support membership in professional organizations. But I counted your membership at SIX organizations. I think that's a bit unrealistic for a new grad like your letter writer (even for me with all my years!). I would venture that her true interest in whichever field of nsg has not even jelled yet so even a single membership could still be a questionable selection. And subscriptions to professional journals also rank up there as a tad costly for a neophyte nurse who has non-specific interests but specific needs. But a few good ones are out there if she locates them.

Unless your nurse has a distinct preference at this time, like ortho or pulmonary (or money is NO object), both approaches might be of limited benefit to her at this time.

You've gleaned what works best for you AFTER years of experience. Your newbie has less than a year of practice. I really don't know how helpful reading a technical publication will help her fundamentals. New nurses gravitate to learning skills, a more hands-on approach than just reading.

Internet usage may be helpful. I'm a dinosaur so that route would be slow for me, also because I'm a show-me first type of learner. And with all the cautions re the dangers of social media and sharing too much info/HIPAA makes me nervous.

The Staff Development Dept REALLY needs to be involved with her educational needs, even though your OP is hesitant to go that route. That is that dept's job. But it seems a more direct route for providing the timely assist that your OP specifically needs.

Your recommendations do sound most appropriate for the more seasoned nsg veteran like myself.

[IVRUS, BSN, RN]

"The Staff Development Dept REALLY needs to be involved with her educational needs, even though your OP is hesitant to go that route. That is that dept's job. But it seems a more direct route for providing the timely assist that your OP specifically needs."

I totally agree with this statement by amoLucia... One must hold their education director accountable for providing you, the worker, with the needed information on best practices and updated P&P manual. An infusion manual MUST be made available to each clinician so that he/she can access it anytime so patient outcomes will be optimal. I understand the OP need to reach out to the WWW, but then again find it very sad that she/he has too. Each institution should provide their employee with the tools to do the job correctly. It is a sad, sad commentary that the manual is old, outdated and obviously never used if dust has made its home on it.

[RNrhythm, BSN, RN]

I am in a very similar situation and I bet the information you want is more basic than what you will find in a professional journal. At my work, on the in-house home page, after much searching for policies and procedures, I found a link to Lippincott's generic procedures and guidelines for a unit like mine. Your facility needs to subscribe. I can only access it from work. It is called Lippincott Procedures. You can ask whomever is in charge of Staff Development if you have access without ruffling any feathers, or search your in-house home page.

Also, I go to manufacturer's web sites. They usually have important clinical info pertaining to their products.

There is also Youtube. Obviously Youtube is not a clinical reference, but you will get other people's opinions, rationales, and practices, as you would from a random colleague

[RNrhythm, BSN, RN]

"One must hold their education director accountable for providing you, the worker, with the needed information on best practices and updated P&P manual."

That's really funny. Tell me another. Clearly my work environment is more like the OP's than yours. The last thing I want is the attention of anyone in management. I get what the OP is saying, that to suggest that there may be something lacking in staff development would simply antagonize those people.

Like myself, I bet what you are experiencing is the perfectly normal anxiety that comes with being a conscientious first year RN. You are a better nurse than you think you are, and your commitment to ongoing educations speaks well of you.

[IVRUS, BSN, RN]

That's really funny. Tell me another. Clearly my work environment is more like the OP's than yours. The last thing I want is the attention of anyone in management. I get what the OP is saying, that to suggest that there may be something lacking in staff development would simply antagonize those people.

Like myself, I bet what you are experiencing is the perfectly normal anxiety that comes with being a conscientious first year RN. You are a better nurse than you think you are, and your commitment to ongoing educations speaks well of you.

So, you are saying that you can't rely on the EDUCATION/STAFF DEVELOPMENT person to give you the needed information to do your job right??? Or that you're afraid to ask, even though patient outcomes depend on it?? Hmm.

[djjohnnie]

So, you are saying that you can't rely on the EDUCATION/STAFF DEVELOPMENT person to give you the needed information to do your job right??? Or that you're afraid to ask, even though patient outcomes depend on it?? Hmm.

I found myself in a similar environment as OPP. I asked my supervisor for the facility's procedural manual who then went to the person who handled Staff Development. I watched the head of Staff Development get unreasonably upset at this question, her voice raising several octaves, angry that she was being confronted with this. Basically, we had a manual at some point, she had never bothered to update it like she was supposed to and the random (outdated) sheets we had shoved in the front of the MAR should be good enough. Figured this was just an example of the "real world."

LTAC environments provide minimal training and minimal supervision. When our facility accepted our first patient with a wound vac it was the patient's spouse who taught me how to change the dressing. We're constantly thrown into situation with little or no training. Sadly, this is par for the course. I just got hired at a hospital and I pray that I didn't pick up too many bad habits.

The only advice I have is to make your own educational moments.

[RNrhythm, BSN, RN]

So, you are saying that you can't rely on the EDUCATION/STAFF DEVELOPMENT person to give you the needed information to do your job right??? Or that you're afraid to ask, even though patient outcomes depend on it?? Hmm.

Yes, exactly.

Go ahead and shame/scold me all you want, but this is the environment I work in, and apparently others do, too, include the OP.

[RNrhythm, BSN, RN]

After several months, I just learned that I was applying wound vac film incorrectly. So much easier now!

[Axgrinder]

The first year of Nursing in the clinical setting can be stressful. For me it only pointed out everything I wasn't able to learn while safely a student, paying exorbitant semester fees.

There is so much to learn in regard to nursing, that even after a long fruitful career one will still not have had the opportunity to learn everything of value there is to know - great and small. It's only natural to feel intimidated in this circumstance. In nursing school there is only enough time to learn that we don't really know anything yet. The real learning comes from the day to day experience in our first job … then every day thereafter until we retire. Our whole nursing career is pretty much one giant learning curve.

I bet you have much more refined clinical skills then you give yourself credit for. With your fiercely burning desire to continue to expand your clinical skills, to keep growing, and keep learning, I feel confident you will make sure you gain every opportunity available to you to do just that. I bet you are one heck of a nurse right now.

Good luck with your career. The world is your oyster - now go out there and get it! :)