New and Drowning

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Hi to all~

I'm new to this forum,so please be patient with me!

I recently started in the PICU unit of the hospital that I work at,technically as a "new grad" RN. I had been employed as an LPN for three years on a med/surg floor at the same hospital before this,so I came to this job familiar with the hospital's policies,methods of charting,etc. I have always wanted to be a pediatric nurse,and it is very difficult to find a job in this area if you don't have experience already,at least at my hospital,and its main competitor in the city. So when a PICU job opened up shortly after I received my degree,I applied,interviewed and shadowed on the unit.Even though it was ICU,I felt like the variety of pts and pace would be similar to the floor that I was leaving,so I figured that it would be a good move. I assumed that i would have a lot to learn in the way of pediatric procedures,ICU equipment,etc,but that I was able to meet the challenge. Boy,was I wrong!

I started on the unit a couple of weeks ago,and my first day with my primary preceptor went fairly smooth. She was patient,answered my questions,and even acknowledged that I wouldn't remember everything right away. However,she left for vacation,and I was placed with another preceptor for the next several days during the interim. This preceptor has been there for many years and is very experienced,and apparently well liked on the unit.

I have to admit,the preceptor has been nothing but polite and nice to me. The first day with this person was ok,although i didnt feel as comfortable as i did with my initial preceptor. I told this person that i wanted to get experience with lines,drips,and vents,since these were all new to me. the next day, the preceptor chose a patient that was very complex,had 7 lines and 9 drips running,was on a vent,had two chest tubes, and was post-op from a complicated surgery. I felt overwhelmed,but figured,I had asked for it,so i might as well jump in and start swimming.

Throughout the day,the preceptor would go over some things,but other questions were waved off. I asked specifics on titrating drips(something I'd never done before) and specifics about vents(ditto). The preceptor just said,"you just know what to look for." I came across a mental block when it came to calculating dosages,and maintenance fluids,and asked for help,but the preceptor was having trouble explaining,or I wasn't catching on ,I dont know. I since seeked help with these from the clinical instructor,and feel better about them.

The next few days,I felt like I was improving,but the preceptor kind of took a backseat and watched me go through the shift completing tasks,from flowsheets to hanging IV meds to speaking with doctors/family members. I'd ask questions,but the preceptor seemed to be getting impatient with me.I'd be in the middle of one task,and the preceptor would jump in and suggest doing something for our other patient.I felt like I wasnt moving fast enough,or that it wasn't prioritizing right,or SOMETHING. I havent received much feedback from this person,other than "you're doing a lot." I asked if I was on track with other orients,and was told,"it's hard to compare-the experiences are different."

Yesterday was the worst-all was going well until we had a procedure at bedside for one of the patients. The preceptor sent me for a medication,and I glanced at the MAR before I got it all,and was certain that I had the right dose. I drew it up,and the doctor stopped me,saying that it looked incorrect. Sure enough,it was. My preceptor gave me a scolding look,and I corrected the mistake,but the rest of the day I kept missing things I had done a thousand times before on my other unit.At report time,again my preceptor sat back and the oncoming nurse kept quizzing me about the exact concentrations of meds and what the vent settings were. I was so flustered,i couldnt recall the exact doses correctly,and the vent settings i had to admit I didnt know because I hadnt gone over them yet-when I asked,the preceptor told me before that I would be learning that when I oriented with respiratory. However,at report,the preceptor gave me another look. Afterwards,the preceptor asked me why I had made the medication error and told me that it was a day for me to learn.

I left work in tears,and confided in my friends who work in other units. They keep reassuring me,saying it takes time,and that Im putting too much pressure on myself. One friend told me to find resources to learn about drips,meds,and other ICU info and teach myself. This is what prompted me to look on the Internet,and I found this site.

So,my questions are these-Do I still have a chance at this unit or am I really in over my head? If not,where do I find books or info to help me learn about pediatric ICU nursing? Neither my LPN nor RN program covered this level,and my textbooks dont even review med calculations,let alone nipride drips.

I've wanted this for so long,I dont want to give up now,but I dont know what to do at this point. I hate coming home and crying every night.

Sorry for the length,but if anyone has any advice,I'd greatly appreciate it.

~Overwhelmed RN

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You are really being thrown in at the deep end. No new nurse in our PICU would have a patient with all those lines and drips without much better backup. Who is the person in charge of your orientation? I think you should speak to this person about structuring an orientation that moves in a planned manner to cover the topics you need to learn.

It doesn't sound like this preceptor is doing much to help you learn: she may be an excellent nurse but just not suited to orientation because she isn't cut out for teaching. (Like me-that's why I don't orient new nurses.) You should try to get paired with someone who is not quite so experienced. They often are better at orienting because they are closer to the experience and have a better sense of what you need to learn. Those of us who have been doing this forever do so much without consciously thinking about the details and the reasons that it can be hard for us to communicate with people who are just beginning.

You can certainly read and study, but you absdolutely should not bear the responsibility of doing it all yourself. I really think that the problem is in the situation you find yourself in, not in you. Please talk to someone about the situation before you go under.

Denise, 30 year PICU RN

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Specializes in Post Anesthesia.

Books are of very limited help in your situation. You need a preceptor that can offer you guidance and support whle you develop basic skills in this type of unit. The skill set you are using as an RN in a critical care unit is vastly different from an LPN on a med/surg floor. ( I'm sure you know this). General advise:

* Look at your patient and say " what is my most pressing need to fix, check, or adjust right now.

* Set short term goals for long term gains- What do you need to get done in the next 15-30min to keep your patient safe or improve thier status?

* Ask questions- no one knows everything and it makes experienced staff very nervous when new people try to "wing it".

* Find 1-2 staff that seem to have good outcomes and have the respect of the doctors and staff. Follow thier lead. If you can, try to get with one of them as a preceptor.

* Don't be put off by the fact that the asking the same question to 5 different staff may produce 5 different answers. The important part of care in an ICU is understanding the goals and the process you are using to achieve them, not the tasks that need to get done.

* TAKE ACLS!!! if the hospital dosen't offer it in a timely manner, look around- another hospital in the area may offer it for a reasonable cost. The ACLS text offers a lot of concise information you will find helpful- buy it for you personal library.

Good Luck!!!

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Thank you Denise,for your quick reply :)

We have a clinical instructor who oversees the orientation,and she has even said that the patient that I have had with the preceptor is not a typical one that I would get during my second week(which i just completed). The preceptor just said that he thought it would be good experience.

I'm hesitant to go to the instructor,because I know how things work from my other unit. if I say something about my preceptor,then it gets around,and I become known as either being "slow" or a "troublemaker." Do you(or anyone) have any suggestions about how to handle this conversation w/o it turning into this? It's only been a couple of weeks,is it too soon for me to be saying anything?

What is a typical orientation pattern for PICU as far as skills? I've read a few other posts on here where people have 5 or 6 months to orient!! My hospital gives us 10 weeks,and I'm going to nights(its a day/night rotation) in two weeks. I'm curious as to whats normal to have a grasp on,or what I should be proficient at first.

Thank you again for your advice!

ETA: Suanna,just saw your post as i posted this! Thank you for your tips-I will try them tomorrow when I go back!

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Hi, Sunbird...

Just saw your post and just had to send a quick reply. I am also a new grad (working in L/D X3 weeks!). I'm finding that my orientation is also a bit sink or swim and I feel for you...I can't even find my preceptor half the time! Try not to get discouraged - you are not alone! Ordinarily, I would consider myself a quick learner, but the information overload is a killer! Plus, everyone wants everything so fast (and I'm SO slow) that it's easy to make a mistake. I just suffer through the rolled eyes and heavy sighs of more experienced nurses (and docs) to make sure I understand everything - they don't seem to remember that it's just as frustrating for me not to know things as it is for them! we survived ns and this is just another challenging chapter - try to relish the good things and be proud of yourself for what you've already learned! :wink2:

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Specializes in NICU, PICU, PCVICU and peds oncology.

I would recommend PALS and not ACLS for a new PICU nurse. Children are not small adults and they don't have the same set of conditions that brings them int ICU. The most common arrhythmia in peds is bradycardia, for example, and in children respiratory arrest almost always comes before cardiac arrest, except in chldren with congenital heart defects.

I truly don't think you've been on orientation long enough for anyone, even you, to say that you're not going to succeed. A lot of "failures" in PICU are more the fault of a less-than-effective preceptor/orientation than it is the individual. Talk to your clinical educator and your immediate supervisor and see if you can be buddied with someone else. Don't give up yet, it's early days. BTW you didn't make a medication error, exactly, because it never got to the patient...

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Specializes in Post Anesthesia.
I would recommend PALS and not ACLS for a new PICU nurse. Children are not small adults and they don't have the same set of conditions that brings them int ICU....

I was thinking of PICU as "Progressive Intensive Care Unit" (ICU stepdown). Of course you are right, PALS is the best option if it can be taken soon. I still think, in a pinch ACLS isn't a bad alternative if it will be a while before the PALS class is avail. Most bigger hospitals have quarterly of bi-annual ACLS classes that a nurse could attend.

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Specializes in NICU, PICU, PCVICU and peds oncology.

ACLS would help with critical thinking, the "script" of running a code and basic crisis management, but pediatric codes are quite different, they last a lot longer and the drug doses are individualized to the patient. Also the drugs used for pediatric codes are limited to a very few... atropine, epinephrine, bicarb, calcium chloride, amiodarone, adenosine and magnesium. I can only recall a single patient we've ever used lidocaine for in our peds CVICU. So taking ACLS before PALS might just muddy the water.

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Thanks everyone,for their advice.

I actually tried to sign up for PALS prior to starting my job,but it isnt available until September,and my CI told me that my supervisor actually prefers that we go through orientation before taking it,so that we have something to compare it to.

Yesterday went ok,but again,my preceptor left me to figure out things such as a machine I hadn't used before,and stood there while I attempted to work it. Later this person continued to scold me for the almost med error the other day. I really feel like I am going nowhere with this person,that they either have already decided that Im useless,or that they would rather surf the Internet while Im running around instead of teach.

I am going to write an email to my CI and try to explain whats been going on and ask for help. I really want to succeed on this unit,pediatrics has been my dream for many years. I dont know how/where to diplomatically start. Again,I dont want to make an enemy of this person or their buddies on the unit-I just want a fair chance.

Any hints from anyone on what to say?

Thanks again:)

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Specializes in NICU, PICU, PCVICU and peds oncology.

Let's see if we can draft a script for you...

Start off by saying that you're so glad you accepted this job in PICU (and make sure you use the word "accepted") because you know it's a great place to work. Say that you've already learned some new skills and have made some new friends. Go on to say that you know you still have a steep learning curve, and are confident that you're up to the task. But... your learning style doesn't seem to be a good fit with your current preceptor's teaching style. Say that although you have experience as an LPN you really are a new RN and your new scope of practice is so different, you feel you need a more hands-on approach in preceptors, someone who doesn't expect you to know more than you do because of your background. Say that you also are someone who needs a lot of feedback, both good and bad, so that you can adjust your learning plan. Add anything else you think would be tactful but accurate in explaining your discomfort with the situation. Keep the focus on you and your learning needs and not on your preceptor's shortcomings. Ask if it would be appropriate for you, your preceptor and your nurse educator to meet and discuss your progress (something that should already be happening, but seemingly is not). Then go through with the meeting if that's what happens. At the end of the meeting you'll have an idea if this preceptor understands what you're looking for; if not, then would be the time to request someone else complete your orientation with you. If you keep it about you, and what's best for the unit, you can't miss.

(Feel free to cut and paste if you think that will help.)

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Sunbird-

I agree you need to have something change in your orientation because it does not seem like a learning environment. As a preceptor let me tell you that orientees often feel they are drowning when they are infact doing fine. A good preceptor will let you learn by doing but will not let you drown, it should be supportive and constructive. PALS is what I would take first but I also took ACLS and have used knowledge from both.

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Specializes in pediatric critical care.
let's see if we can draft a script for you...

start off by saying that you're so glad you accepted this job in picu (and make sure you use the word "accepted") because you know it's a great place to work. say that you've already learned some new skills and have made some new friends. go on to say that you know you still have a steep learning curve, and are confident that you're up to the task. but... your learning style doesn't seem to be a good fit with your current preceptor's teaching style. say that although you have experience as an lpn you really are a new rn and your new scope of practice is so different, you feel you need a more hands-on approach in preceptors, someone who doesn't expect you to know more than you do because of your background. say that you also are someone who needs a lot of feedback, both good and bad, so that you can adjust your learning plan. add anything else you think would be tactful but accurate in explaining your discomfort with the situation. keep the focus on you and your learning needs and not on your preceptor's shortcomings. ask if it would be appropriate for you, your preceptor and your nurse educator to meet and discuss your progress (something that should already be happening, but seemingly is not). then go through with the meeting if that's what happens. at the end of the meeting you'll have an idea if this preceptor understands what you're looking for; if not, then would be the time to request someone else complete your orientation with you. if you keep it about you, and what's best for the unit, you can't miss.

(feel free to cut and paste if you think that will help.)

well said, jan! this new nurse absolutely needs a new preceptor.

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