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New ICU Nurse- Preceptor Problems

Hello everyone, I just wanted to get some general feedback and get some opinions on my current issue. I recently graduated from a nursing program in March with my RN license. I was offered a job at a local ICU in a large facility and accepted the position. The original position offered was for a nights, but I would orient on days for a month to see the physician's faces and what not. Anyhow, the other stipulation was that I would have one main preceptor and one backup preceptor. Well, my main preceptor got sick (really sick) and was out for the rest of my dayshift orientation. However, I really didn't have a backup preceptor. Instead, I was passed between 6 other nurses. The problem with that was I never really got the hang of one style of any procedure or route of documentation. I tried to pick up on a little something from everyone, but it was hard. (The last time I even took a class that had more than 2 alternate professors, I had to drop because I wasn't learning anything.) By the end of my dayshift orientation I had not even taken one patient by myself. So, I was already behind when it came to night shift.

When I started nights I had one preceptor. It was much better than days. Slowly, my preceptor started just hanging around the desk and waiting for me to come ask questions. When I would ask questions, I would get a question with a question "well, what do you think is going on?" I put a lot of thought into my questions and tried to figure out the answer before I even asked, but always got the same response. Over the course of the next couple of weeks my preceptor was asked to step up to charge nurse often. Three would be nights at the end of the shift where she would literally tell me I had to evaluate myself because she didn't see me all night. This was becoming an issue for me and management because they said I was not progressing like I needed to be. I agreed with that statement because I felt like I wasn't learning anything from her either. After the first encounter with management, they ended up letting my preceptor take three days of vacation to orient at a different facility for a PRN job. So I ended up switching to a less critical unit for those three days (Where I didn't get any negative feedback from my step-in preceptor). Now I'm in a position where, I am going to either have to transfer units all together, or sign a corrective action plan stating that if I am not able to come off orientation within the next 30 days, then I will be asked to resign. The only problem with transferring units is that there are really no positions within my network of hospitals that are of interest. You go from titrating vasopressors and dealing with vented patients to passing out pain medication before rehab. I am not harping on any rehab nurse because I know they are masters of time management and have a difficult job as well, but I never really had much interest in rehab, and I still don't. I already told management that if I were to try to extend my orientation then I would request a different preceptor. They told me they didn't know if they could do that for me or not because the preceptor pool is so thin.

As of now, I've been off work for a week and supposed to have a sit down meeting with my clinical director, my current preceptor, and my team manager. At this point, if I tell the truth, my preceptor is going to feel like I am throwing her under the bus, and so will my TM because I get criticism from them (which is fine because I'm a new nurse and constructive criticism is how I get better), but I don't get many concrete examples of how to fix the issues they see I have. This is how it feels "Your time management needs work, fix it. cluster care." "You need to think critically." I think that last statement is a bit of a cop out because you need a firm foundation on a particular subject before you can "critically think"

Lastly, my TM's are still using examples of things that affected my nearly a month ago, that have not been an issue since. Example, I had a PICC line that would flush and draw at the beginning and middle of shift. Well, come time for lab draws it won't flush or draw. I try to troubleshoot it by patient positioning etc., but no success. I get an order for cath-flo to see if that would work. No success... So the only alternative would be to stick them. I got the stuff. I gather my stuff and try to stick this person multiple times, but they have poor veins and I couldn't get the stick. I asked my TM to help and 45 minutes later they come in to help. They ended up getting the stick and we got the lab work. My TM told me that they felt that lab draw "threw me off track and derailed me and I couldn't recover from it, and that I should have anticipated that PICC would not draw." (I'm still confused on that one) That was nearly a month ago and hasn't really happened since, but they they still use it as a way to evaluate me.

My question is, so far, I don't feel like I have gotten the support I needed in the ICU (I don't expect to be spoon fed material, but I didn't expect this either), and from everyone's previous experience, is it worth trying to stick it out another 30 days to try to make it work, or just work on transferring units? I ask this because I feel like someone has already made up their mind about me it won't matter how ready I am to come off orientation in 30 days, it won't happen. I just don't understand how upper management can take any information from my preceptor as valid considering she hasn't worked with me in 2 weeks. A patient's condition can change day by day, so does my abilities, and evaluations from 2 weeks ago don't seem like a fair way to assess my ability and progression.

dexm

Specializes in ICU, ED.

If they can't guarantee that you will have a preceptor who will be able to give you their full attention, I might think about switching units. There's no way you are going to be able to progress like you need to if your preceptor isn't available to help you and is not able to accurately evaluate you. If your preceptor isn't with you at the bedside there is no way they can give you adequate feedback about your performance. How are you going to get better if you aren't receiving adequate feedback?! That's ridiculous.

It's also ridiculous that they would allow your preceptor to charge while they are orienting someone. I realize the preceptor pool is pretty thin, but how can they expect you to learn if no one is there to teach you? IMO, it's managements responsibility to make sure that preceptors aren't put in charge positions while they are orienting someone, and for them to blame you for not progressing like you should is outrageous. They should make sure that nurses who are orienting someone are not charging, and if there is no one else that can charge they need to assign another nurse to precept you for that shift.

It doesn't sound like you are getting the support you need from this unit, and that's really unfortunate. I definitely wouldn't worry about throwing your preceptor under the bus during that meeting. Tell the truth. It seems like this is more managements fault than your preceptors.

I remember once I came in to orient and just ended up taking over another nurses two patient's so she could go orient to the Rotoprone bed. My preceptor was also busy that night orienting other people to CRRT. So, I ended up doing my thing alone and didn't really see her. So yeah, it has been ongoing... I don't feel supported there at all. I mean, I've gotten more help from other nurses on the unit then I have my own preceptor. Toward the middle of our orientation my preceptor would try teaching me stuff that was way outside the scope of my practice.. I mean, the inner workings of the ventilator. I know I have to understand the vent to an extend, but the crap we were going over was not necessary info because we have Respiratory therapists for that. We would waste tons of time doing stuff like that and at the end of my shift she would tell me I have time management issues, and I wasn't learning jack about my actual job. I made a comment to my TM about that once and said that I felt like we were wasting time with her sending me on wild goose chases for information and that maybe it would be better if she would back off that and start teaching me pertinent material. I guess she might have taken that to heart and just became detached... I think that is when it all started to get worse.... Now I'm behind on orientation, and I'm at risk of being terminated. I mean, I'll take some responsibility in this. I could have been studying more at home and asking other nurses more questions and getting feedback from them. My preceptor can't do everything for me.

Edited by lordizzy626

I can totally relate to what you're going through. It was so tough for me to get through icu orientation. But, now looking back, I should have been open to new opportunities and left the icu. Instead-though I have learned a lot-I realize I was unhappy most of the time. I guess my advice is to have an open mind to whats out there. You already have an open and compassionate heart. It's ok if icu isn't for you. You deserve to feel fulfilled and satisfied in this incredible profession of ours!!! Go soar and make difference where you're best suited.

icuRNmaggie, BSN, RN

Specializes in MICU, SICU, CICU. Has 24 years experience.

It sounds like this unit has staffing issues and a very disorganized orientation program for graduate nurses. Have you been to Critical Care Consortium classes, ACLS and do they offer ECCO? These are opportunities that you should complete and you can put them on your resume. You are a novice, and I would expect that you would be able to complete your tasks efficiently at this point. Time management is a reasonable goal after six months. They may want to get you up and running because they are so short staffed.

Critical thinking is learned. There are a limited number of scenarios in the MICU (sepsis DKA ARF Resp. Failure, CVA etc) that you are going to see over and over again until it becomes second nature. Look up each admitting diagnosis in your downtime. Know them inside out.

We have all at some point received some negative or even false evaluation of our abilities and yes it stings. Just shake it off. And flush your capped lines as part of your initial assessment.

You are on orientation and it may not be the most supportive unit in the world but is up to you to make it work with your assigned preceptor. We all want our orientees to be successful. You are on probation, so try to foster good relationships with everyone. It has been my experience that nurses who hate questions do not know the answer. Find another resource person. Help out your coworkers, and for heavens sake don't gossip or use a cell phone anywhere except the break room. It won't be forever.

If you have a specific clinical question post it here. There are many experienced ICU nurses here who can help you master the pathophysiology. Best wishes, Maggie

Edited by icuRNmaggie

Well I don't mind ICU, I just mind the precepting and how things have went down so far. I''m open to other types of nursing, but not rehab... I did clinical rotations in rehab and I KNOW I would not be a good fit for that type of unit. We'll see.... If nothing good comes of this meeting (and I really don't have high hopes) I'll be back on the job market. Unfortunately, I'll still have 6 months of experience and looking for a new job already.... :/ I know that doesn't look good..

Wow, this is so different from my experience. I was hired as part of a critical care internship with a small number of other new grads. We had six months of orientation, which included class time and a structured preceptor-supervised clinical practice period. We had ONE preceptor in each ICU unit we worked (we spent time in each unit at my hospital). After the six months, we were assigned to a home unit with ONE preceptor in that unit. We worked with only one patient for a period of time, then began with two patients (still supervised). After another period of time, we were kicked out of the nest to go solo, but with only ONE patient. Finally, after we had been cleared by the preceptor and our unit manager, we were considered a bona fide ICU nurse with two patients and no longer supervised any differently than any other nurse. However, our more experienced nurses were ALWAYS available to help at any time and seemed to enjoy teaching the new nurses.

I'm sorry for what you have been going through. :(

My advice to you, especially as a new grad in the icu is have faith in yourself, try and instill some confidence in yourself and take the leap off of orientation. The ICU takes a great deal of time to orient to, if not years. If you have other supportive seasoned nurses to go to while you're working but are able to manage the basic nursing on your own, you will be okay. All you need is some support for the critical care part when you are unsure, and keep building on what you know. The lack of confidence in yourself is what probably is throwing management off.

icuRNmaggie, BSN, RN

Specializes in MICU, SICU, CICU. Has 24 years experience.

Toward the middle of our orientation my preceptor would try teaching me stuff that was way outside the scope of my practice.. I mean, the inner workings of the ventilator. I know I have to understand the vent to an extend, but the crap we were going over was not necessary info because we have Respiratory therapists for that. We would waste tons of time doing stuff like that and at the end of my shift she would tell me I have time management issues, and I wasn't learning jack about my actual job. I made a comment to my TM about that once and said that I felt like we were wasting time with her sending me on wild goose chases for information and that maybe it would be better if she would back off that and start teaching me pertinent material. I guess she might have taken that to heart and just became detached... I think that is when it all started to get worse.

You, as the nurse in charge of the patient, are responsible for understanding the vent modes, settings, waveforms and pressures.

You preceptor was making an effort to teach you something about mechanical ventilation and you felt the need to belittle her efforts to your manager?

How many preceptors have you had?

Edited by icuRNmaggie

It is hard to really pinpoint. I mean, I graduated nursing school with a friend of mine and he started in the same ICU at the same time as me. The only difference between his orientation and mine was that he had the same preceptor all through his day orientation, and had the same preceptor all through the night orientation. He just got off orientation. My clinical manager just enrolled a group of us into some Critical Care Consortium classes. The are supposed to happen sometime this month.

From what I understand, time management is always an issue. Even for experienced nurses. I am able to handle two patients by myself pretty confidently. This past week is the first time they tripled me and I still managed to get everything done, I just didn't sit down. One of the critiques I got from that shift was that my task list was not caught up. The patient's were getting all their care (Fingersticks, turning, tube feeding checks, temps) and by the looks of their vitals they were remaining as stable as possible. The "task list" is pretty much an excel spread sheet that you check off as you go. So, the work was getting done, but the task list wasn't being checked off. Something that I told him I would work on, but I didn't feel like it was as big of a deal as he was making it. I never have a negative attitude towards anyone there. I'm always respectful and I take criticism without taking it personally. Maybe it is just a scenario where that particular unit is not a good fit... :/. I will take accountability and say that i could have been studying about disease processes and protocols on my own time at home more. Aside from that, I have tried to soak up all the knowledge I can when I go into a shift. I get paid 100% of my check, so I put in 100%.

I did have a lack of confidence at first, but then I slowly started getting more sure of my actions. I mean, I think there is a difference between being confident and being cautious. So far, I can recall one account where being cautious interfered with me making the best decision for my patient. Overall, I feel like it will all come in good time, but not in the time frame they expect it.

I understand that I am expected to know the vent modes, settings, waveforms and pressures. I can look at vent settings and tell you if a patient is riding the vent and needs to be taken down on sedation (if that is the case) or if the PEEP is still appropriate, if the FI02 is still appropriate depending on ABG results, tidal volumes etc... I can take that information and paint a picture of my patient's situation now. These things I learned from other nurses. It's like me teaching you the inner workings of your shifter and your steering wheel on your car when you first start driving. That information MAY be helpful in the future, but for me to make you a successful driver, I need to teach you how to drive and not teach you the internal workings of interacting mechanical parts. It is hard to build anything on a foundation that you do not have.

Horseshoe,

I really don't know what to think. Part of me believes I belong in critical care, but after my orientation in critical care, I am not so sure. I have to really consider my own personality and traits, and see if it meshes well with the type of care and detail associated with CCU's in general. I am leaning towards this orientation time being a fluke, but then again, there is that doubt in me that wonders if I belong there. I didn't know anything going in, I know a little bit now, (still not near as much as these seasoned pro nurses), but my only expectation is to try and avoid making the same mistakes twice and learn something new every day.

icuRNmaggie,

I forgot to answer your questions about the amount of preceptors that I have had. By my count so far, I have had a total of 10 preceptors. Not because of personality issues, but because of scheduling and my original preceptor being ill.

4boysmama

Specializes in Hospice + Palliative. Has 4 years experience.

The "task list" is pretty much an excel spread sheet that you check off as you go. So, the work was getting done, but the task list wasn't being checked off. Something that I told him I would work on, but I didn't feel like it was as big of a deal as he was making it

Is this task list an official part of the charting? Or is it a throw-away shift to shift/for personal reminder use only type thing? If it's a part of charting, I can see why i would be problematic that it wasn't being hecked off...if it's not charted, it didn't happen yk?

It is more or less a throw away shift to shift for personal reminder. It will have things like, "turn patient", "check vitals" "glucose check". Your charting will cover all these things, it is just a basic reminder. That night I had 3 patients. Being pretty new, 3 patient's is a lot of work. It is really hard to stay caught up on checking off that "task list". I mean, I have had experienced nurses tell me that with 3 patients it is hard to keep up on that task list. I can keep up with it when I have two patient's, but being tripled doesn't make it as easy to keep up on. I agree with him that it needs to be done, but it seemed like a very minor ordeal to be caught up on in the grand scheme of things. Minor to me.. Then again, I'm a new nurse and I don't know what is major and what is minor. lol. Some stuff I have done in the past they critique me and say, "you could have or should have done it this way instead." You know what, I agree with them and I try to improve.

Here.I.Stand, BSN, RN

Specializes in SICU, trauma, neuro. Has 16 years experience.

You, as the nurse in charge of the patient, are responsible for understanding the vent modes, settings, waveforms and pressures.

You preceptor was making an effort to teach you something about mechanical ventilation and you felt the need to belittle her efforts to your manager?

How many preceptors have you had?

Toward the middle of our orientation my preceptor would try teaching me stuff that was way outside the scope of my practice.. I mean, the inner workings of the ventilator. I know I have to understand the vent to an extend, but the crap we were going over was not necessary info because we have Respiratory therapists for that. We would waste tons of time doing stuff like that and at the end of my shift she would tell me I have time management issues, and I wasn't learning jack about my actual job. I made a comment to my TM about that once and said that I felt like we were wasting time with her sending me on wild goose chases for information and that maybe it would be better if she would back off that and start teaching me pertinent material. I guess she might have taken that to heart and just became detached... I think that is when it all started to get worse.

Right...this is very important not outside the scope of your practice at all. Some places don't even have RTs; actually a while back on one of the Critical fora, I remember an Australian ICU nurse was saying the RN completely manages the vent. True, the RT may be the expert, but they are a resource. I ask our RTs tons of questions even after some experience with vents (3.5 yrs total in ICUs, plus 1.5 in LTAC), and they are invaluable for their very specialized knowledge. But ultimately you are the nurse. The RT might be assigned to your ICU for the night; YOU are assigned to your pt. If someone is offering to help you understand this extremely complex stuff, you need to soak up that information.

As for asking "Well, what do you think?" I would be willing to bet that this is the preceptor's way of discerning your own thought pattern and to know where exactly your knowledge deficit is...not to mention a great way to help you learn to think critically. :yes: It's kind of like when students post here with their homework questions C&P'd; among the first replies, you will read something like: "We're happy to help, but we won't do your homework for you. What has your research revealed?"

If they're offering you another month of orientation, personally I would take that opportunity and throw everything I had into it. Actually for my current ICU position (a very high acuity unit--level 1 trauma center, stroke center, PCI center...although most of the cath lab pts go to cardiac stepdown vs. SICU, but I digress) I got 32 shifts of floor orientation. And I was treated as a new ICU nurse, although I had previous ICU experience, because I had been out for some years. It can be done.

But if in the end it doesn't work out, at least you know you've tried everything. And there's no shame in needing to gain some experience in med-surg before moving to the ICU. Actually a big school of thought is that it's a good idea to work in med-surg for a yr or two right out of school. It doesn't mean that you're just not cut out for the ICU; it means you're a new nurse and have a huge learning curve.

Here.I.Stand, BSN, RN

Specializes in SICU, trauma, neuro. Has 16 years experience.

Wait, 3 patients in the ICU???!? That explains some difficulty. :nailbiting:

You know, 3 patient's seems to be the norm for a lot of units I have heard of. Only a few local units I hear normally keep a 2:1 ratio. It doesn't change the fact that I was getting my arse kicked that night. haha. I started off on nights barely being able to keep up with one, then barely keeping up with two, then taking two comfortably..... After taking the two comfortably, they decided to throw 3 on me,and that was where my latest evaluation came from. Unfortunately for me, 3 patient's seems to be the norm in that unit as of late.

icuRNmaggie, BSN, RN

Specializes in MICU, SICU, CICU. Has 24 years experience.

You have not worked with your preceptor in two weeks. Are you off of orientation?

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