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New Grad orientation trouble


Hello Nurses- I was so very lucky to accept a position as a Float pool RN at a very busy urban hospital in North Jersey recently. I am in my 6th week (out of 10 total weeks of orientation) and I'm afraid I will not make it to the end :-(. I am not exaggerating either. The other day my educator and director called me for a meeting (on my day off) to let me know they were very concerned about my progress thus far. They started by asking me how I thought I was doing and I was honest. I told them I have definitely been overwhelmed so far but that I felt a bit more confident with my work the passed two days. Well, I certainly felt like an idiot for that because they were also honest and said they did not entirely agree. There had been some "issues" my educator had spoken to me about before this meeting....they are as follows: 1. my time management, especially with administering meds was probably her first concern. Also I was not finding time to chart in between meds and instead I would end up charting closer to the end of my shift. 2. My preceptor said my report giving was superficial. 3. And this one I agree was definitely a big mistake on my part, I didn't check bp parameters before giving hydralazine (luckily the patient's BP was indeed above the parameters set by the ordering physician). 4. I happen to prime an IV tubing with air bubbles ( keep in mind that this happened to be the one time I had a few air bubbles in my line that my preceptor "caught" before the line was actually hung- in the previous lines that I hung there were no air bubbles but of course my preceptor wasn't around to witness those). All of this was with 4-5 patients.

I admit that my orientation has been overwhelming thus far, but I have been trying to follow exactly what my preceptor has been telling me to do. They say that I have to administer meds in a timely fashion and if I do that then I will certainly rush and make mistakes. At the same time I am supposed to chart in a timely fashion...and if I do that I will fall behind with my meds. It's a catch-22! My preceptor definitely has an interesting teaching style.....she scolds me in front of patients all the time....which to some degree i understand because she is frustrated, tired and has other things to get to....but unfortunately I'm not the type of person who learns from being embarrassed in front of my patients and colleagues.

With regards to the report....by the time I'm ready to give report at the end of my shift....I'm tired, hungry and I resort to going off the top of my head because my personal "flow sheet" that I write on all day is a disorganized mess. Luckily, some other nurses have given me a run down of their report....Name of pt, under care of so and so Dr, dx, hx, pertinent negatives by system, Iv/skin, pending orders and then anything extra that needs to be added.

I have been working in the system for almost 6 years in another position and I was ready to enroll in a BSN program this March but I have since put that off til June considering that my director/educator aren't sure I'll make progress. By the end of orientation they want me to be able to handle 7-8 patients. I should add that I may have a "perfectionist" personality that may be why I take a long time to do certain things....Any advice would be greatly appreciated by all of you are or have gone through a similar ordeal! I really want to be a great nurse and I really want to keep this job as it is an excellent hospital to gain experience!

Ok, deep breath. And get yourself a tri-colored pen and a paper brain that works for you. (and one that contains SBAR as part of it)

Make sure you prioritize your patients. Write down any "odd" time meds, otherwise, you know that most meds are to be given within a time frame (8a-8p, 9a-9p).

Look at your orders, anything you need to accomplish, scan your meds, then go to patient #1--vitals, assessment, then to 2 for same, then three, then four....right down the line. Chart as you go. If you can not chart as you go, chart right after assessments are complete. Then you are going to pull meds. Pull meds for 1, go give them, (MAKE SURE OF YOUR RIGHTS OF MED ADMIN.) and briefly discuss plan of care for day. Then move on. When everyone is medicated, which should be charted as you go, then you go back to patient 1 and just do your round on them.....and down the line once again.

That your report is "superficial" be sure your paper brain has SBAR--which is SUPPOSED to be somewhat "superficial" but you need to be able to organize in such a way that you are reporting off important information. I would ask for clarification, as I am not sure what that even means, however, use a tricolored pen to your advantage to visually organize your work.

And regarding the IV...always hang the bag before you put in the tubing. I am not sure again what is meant by air bubbles. There are LOTS of tubing that has small air bubbles in them--if what they are talking about is improper priming--leaving large gaps of air, it requires you to be sure that all of the tube is filled with fluid. And that is best accomplished by not holding bag sideways or upside down and putting the tubing in, rather hanging the bag and inserting the tubing while bag is hanging, and priming to the end of the tubing. Also, not a great idea, but if your pump has "backprime" as an option, learn how to use it in case this happens again.

I am not sure I would go forward unless you have a specific plan for improvement. It is all fine well and good that they are pointing out areas of improvement for you, but part of that comes with a plan to move forward and make the changes you need to in order to be successful.

Floating is a tough thing to begin with, as every unit has their own way of doing things. To be sure that you are practicing well, you need to think about how you best organize yourself. Take it one step at a time. If your paper brain needs to be folded, each patient a different color, each item for report in red, whatever you need to do to make it work so that you are knowing who your patient is, why they are there, and what you need to do for them, and to take the few minutes to keep up on documentation (if you have a computer on wheels, even better...take it right into the room). Be sure going in you have looked at orders, meds, be sure that if someone has FBS and insulin that is your priority first thing, and do your vitals and assessment while you are there.

Because you have a couple of weeks, now is the time to refine your practice. If you need help, ask for it. Know your resources. But do what you need to do to organize yourself.

I have worked with nurses who use notebooks, clipboards, folded their brains to make columns, highlighters, different colored ink, different colored paper....you name it, it was done to stay on top of what you are doing.

Wishing you nothing but the best.

Great advice above. My biggest advice would be to cluster care. How my shift typically goes is I get report using a brain sheet I've developed to work for me. At the bottom I have empty space to write my "to do" list for each patient with check boxes so I can physically check off when I do something...this includes vitals, tele strip, fingersticks, meds, etc. I then prioritize my patients and go see each one while doing my head-to-toe assessment. This usually leaves me with about 30 minutes to chart afterwards so I get through a couple patients flow sheets. Next I make my first med pass, again prioritizing the patient. Depending on the circumstances this usually takes me an hour to get through all my patients. At this point I typically am able to finish most of my charting including education and notes. I then round back seeing if anyone needs help with their meals or to go to the bathroom, in pain or whatever. I then will go back and make sure I've completed all the orders, read old notes to try to figure out what the plan is for the patient if I haven't already and prepare myself for report off Eventually it'll be time to do another med pass. Finally I make sure my brain sheet is filled out appropriately in order to give report because I refer to mine the entire time, otherwise I would most definitely miss something.

Point is, many things such as giving report come in time and take practice! Come up with a better brain sheet that works for you and get yourself into a routine. Know that each shift is definitely not going to go as planned but do your best to go with the flow. Utilize your aides! You can do this! Good luck!

AnnieOaklyRN, BSN, RN, EMT-P

Specializes in ED, Pedi Vasc access, Paramedic serving 6 towns.

OP i would delete your location, since it is not pertinent to the discussion, just in case!

Thanks for the advice and words of encouragement! I will definitely try priming my bag/tubing that way from now on.....and I've been looking at some "brain sheets" others have provided here. Also, for the last poster re: my location....i don't know how to go back and change that :-/

I think that might've been my problem is I wasn't using a "brain sheet" that actually works for me.....mine was something I used a line with my pen to divide my patients and I would end up trying to write every little detail given to me in report about my patients on the left side. Then meds in the middle and by the end of all of it I didn't have room for anything else! I also think that having a different preceptor on a different floor will be really helpful.....I'm trying to think positive! Thanks again!!

Ok, so today was my first day back after "the meeting"....I was put on a different floor than I have been on so far which is fine since I will be a float. I had a different preceptor and one of the first things I asked her is if she has a habit of yelling at orientees in front of patients (or period) and she said Never! Which I have to say is true she had a much more "pleasant" demeanor and even though I was asking her questions quite a bit she never made me feel stupid for asking....The only downfall about today was that I was supposed to have 5 total patients and due to the type of patients we had on this particular floor (it was a mix of med-surg/tele/ rapid diagnosic) I only had 3 which is good in the sense that I was able to keep up with meds/orders/assesments/charting in a more timely fashion but unfortunately the director and educator are more concerned about me "moving forward" to take on more patients since I will eventually (and very soon) be expected to take on 7-8 patients. A 3 patient load isn't going to prove anything to them. Anyway, Wednesday I'm sure I will be back to my 5 patient load.

From what I've mentioned in my previous posts do you all think it is truly possible that I will be fired from this position? I'm still so worried....I'm sure Wednesday I will still be a little better than the other unit, but I still feel quite slow at figuring stuff out....like my preceptor would always catch my pending orders before I did....and then I somehow always forget to check pertinent labs....I've gotten better at that because I'm finding more time to look up medication info and associated lab results before I actually give a med. How do you find time to look up info on medications/orders/labs? Do you do that first thing in the morning while organizing your medication administration time table?