We have several new grads in our ER. I'm starting to think that most nurses should have at least a year on a more general ward before learning a specialty.
I'm seeing some clueless mistakes, and lack of basic skill in pt care. That includes things like how to clean a pt and roll and change bedding. Basics about IV med administration, dose calculations, prioritizing, and realities of inpatient care. They have no idea how the rest of the hospital functions.
On top of that, some of them seem to harbor elitist attitudes, as if they are already big hotshots. Yet, they themselves seem to lack the above mentioned skills.
so pretty much every floor requires the best, right? And how do you get there? By learning, by watching, by doing, etc...
Start in a less fast paced unit with patients that are not generally as unstable. Watch and do there, ideally with a good orientation/preceptor. When you have developed some experience and proficiency, then consider moving to a faster paced unit with more critically ill patients, where you can again watch and do, ideally again with a good orientation/preceptor.
One of the new grads in our unit just made an almost fatal mistake the other day, I heard. The risk with new nurses in higher acuity units are that the pts are more unstable, and a newbie error with a more critical med can more easily kill a pt. Yes, things can go south on a medical unit, but generally the pts are more stable, and the pt is not on high risk meds.
Emergent, I have to ask - is the new grad still on orientation? If so ... where was the preceptor?
A good orientation/precepting program is not as simple as it seems on the surface. It requires the unit as a whole to adhere to certain commitments:
1. The patient assignment of the preceptor/preceptee is not a higher number of patients "because there are two of you".
2. Patient assignments are selected carefully, and ideally chosen as a progression. We start new nurses day 1 in the "med surg" type area of our ED -- not the treat-'em-and-street-'em-as-fast-as-you-can fast track area, but also not the critical or trauma rooms either.
3. Is the new nurse being oriented by one primary preceptor, so that progression is evident? Is progress / feedback documented and monitored?
4. In the final few weeks of orientation, is thought given to, New Nurse has not get had a patient being given High Risk Med X -- let's find her a patient that fits that scenario before she's done with orientation?
I'm not saying that your ED maybe just didn't hire good new grad candidates ... or that that nurse didn't perhaps make an inexcusable error. But if there's that much chaos going on -- it's time to re-examine the orientation program.
The new grad was off orientation, Altra. She just failed to question an order, was obviously unfamiliar with the med. I don't want to share too many details, but it causes resp depression and is always given in very controlled situations,, and it was given immediately prior to someone else transporting the pt upstairs. Pt almost required intubation I heard.
She was oriented with one nurse, I don't know the structure of our orientation program because haven't taken the course to become a preceptor, nor do I plan to, it's not my thing.
I think if you're having a new grad just off orientation taking high acuity ED patients, that's the problem, not that they are a new nurse working the ED. In terms of acuity the median ED acuity is actually less than that of a medical floor, there are ICU level patients but there are also "reat 'em and street'em" patients. I've never worked in an ED where any and every nurse was expected to take critical patients, that's always been a specialty within the ED in my experience and your example is a good reason why.
As far as a gaining new experience, an ED is actually a great place to start; it helps build assessment skills and there are few places where you'll get to hone your clinical skills (IV starts, Foley starts, etc) as often as you will in the ED. As long as their is a system for making patient assignments that is somewhat responsible in terms of matching acuity and abilities, I don't think the ED is a horrible place to start out.
At dinner tonight with a NP at a correctional facility. An experienced nurse gave 1.25 mg of digoxin to a patient instead on 0.125 mg. Should no experienced nurses be able to work in corrections?
How did she do that? It would require 3 ampoules!! Digitizing a patient takes only one!
Nursing students in most cases do slow down the flow of the day and that can be a problem when you're trying to get things done on time. There are also many nursing students that don't try to quicken their pace or aren't focusing on their patient or doing their charting when they should be. Last week I had a student, very polite and stuff, but she wasn't checking her patient enough and didn't do a lick of charting. She also wasn't walking fast enough. If she wants to follow along she has to walk faster. I think this might have been the fault of the nursing program she was in because I've had stellar students before. And to give her the benefit of the doubt, this was her first clinical experience.
I also had a orientee who seemed like she didn't care much when I asked her to do an accucheck she just shrugged her shoulders and said, "Oh I already know how to do that." She also seemed very unmotivated. She is on her own now and to my surprise she has actually picked up the pace and is doing great.Still stumped by her earlier behavior though.
Unfortunately, it's not always feasible for only the experienced nurses to take the critically ill patients. Our ED has a grand total of 7 nurses on night shift that have been there longer than a year (admittedly most were RNs in other places first). I can count 5 nurses that have been a nurse for 5 years (only 2 of these have been in the ED, this long). I've been in the ED for not quite 2 years and I'm #4 in seniority for night shift nurses, I think for the whole department I'm around #12.
Couple of weeks ago I was doing charge and our house supervisor wanted us to hold an ICU patient. I told them that we'd either have to get an ICU bed or transfer the patient because after my 1300-0100 staff left I didn't have anyone that would be appropriate to hold the patient other than myself. The five night shift nurses with me that night had been in the ED for a combined 15 months if recall correctly. The one that had been there for 6 months was in triage.
The above post #139 by Bobjohnny illustrates all of the comments I have made on this thread.
Also, it is not always obvious from patient presentation which patients are seriously ill. Without very good assessment abilities, which are developed over time and experience, one can miss many abnormalities, to the detriment of the patient. An inexperienced nurse is more likely to fail to observe assessment abnormalities, or to interpret them incorrectly. For seriously ill/unstable patients, this can matter a great deal. The ideal of giving the sicker patients to the more experienced nurses is not as easy to do as it might appear.
Lots of great, and varied, responses. A new grad should be able to TRY and work in a specialty area. As previously noted, med/surg is a specialty. During my clinicals, there have been plenty of times on med/surg where the nurses have had to deal with crises, etc. My point is that is was chaotic, but not as bad as an ED can get. Hospitals have the specialty fellowships (ICU, CCU, ED)for new grads and I'm applying for an ED fellowship. You don't need "experience on a floor" before you can work in an ED. I would be bored out of my skull working med/surg when I graduate.
Start in a less fast paced unit with patients that are not generally as unstable. Watch and do there, ideally with a good orientation/preceptor. When you have developed some experience and proficiency, then consider moving to a faster paced unit with more critically ill patients, where you can again watch and do, ideally again with a good orientation/preceptor.
But you know, there are certain habits you pick up from certain units that make it harder on others. We've got a nurse on my unit who everyone hates staffing in pretty much any area, because he is slow and is overwhelmed by juggling multiple patients. He came from an ICU. And when things go south, he's amazing. And I heard he was a great ICU nurse. But when it comes to fast turnovers and managing multiple patients, he's less than desirable. He stares at lab values for long periods of times and fusses over mostly healthy patients, because in his head, he considers them as he would his ICU patients.
Never thought you could complain about someone being too thorough, did you?
stolik19
7 Posts
@susie2310
so pretty much every floor requires the best, right? And how do you get there? By learning, by watching, by doing, etc...