New RN's helping them

veegeern, BSN, RN · Sep 9, 2006

I was the new med-surg (also BSN) nurse almost 3 years ago. Where is she with her organizational skills at this point? When she receives report, does she know where to begin? Forgetting for a moment that there will be endless interruptions, can she make a "schedule" for her shift?

During my preceptorship/orientation, I did not learn how to organize and prioritize because my preceptor did that for me. It took me 6 months to 1 year to figure it out for myself. I wish that I'd had somebody to do what you're doing.

I found that before I started my day, I had to take some time to make a grid of patients and times that meds were due. I didn't list the individual meds, but I did list PO, IV, TP, etc... If the med was not in the med drawer, then I listed the actual med, route, and dose. Then, I added dressing changes and looked at care that could be grouped together. By getting this big picture of the routine care that I needed to provide during my shift I was able to handle new orders, admits, discharges, etc...more efficiently. It did take me a little more time to get my day started, but it made everything from charting to re-organizing on the fly easier for me. It also took away some of my stress and a lot of time that I spend "spinning my wheels." After about 6 months, I was able to wean myself off of this crutch (the grid).

Hope this helps. Thank you for taking the time and effort to realize that the nurse is having difficulty and caring enough to try to help.

rnmi2004 · Sep 9, 2006

How does she plan out her night? Like veegeern said, she will have interruptions, but having a schedule will help get her back on track. I have a grid listing my patients and for each hour of the night there is a box. I color code with a 4-in-one pen - red is for allergies, DNR status, bad vitals, other very pertinent info; black for general stuff like name, doc, dx; blue is for info to pass on to next shift; and I write meds/tx in green & check them off as I do them. I can just look at my sheet & know what to do next.

As far as the triage part--have her remember her "ABC's" - any pt who is having issues with this is the priority. Assuming the pt's aren't having ABC issues, the priority might be a fresh post-op or the patient who's pain has gotten out of control.

Even though I am fairly green myself, I have precepted a few new nurses, and I can see that many of them get so hung up with "I have to pass my meds and get my assessments, charting, etc. done" that they don't really pay attention to the aide coming up to them and saying "Ms. X's blood pressure is 82/49." I did this too when I was new! I kindly remind them that the consequences of passing the hs meds a little late is far less severe than the potential situation they would be dealing with if they put off addressing the more serious issues that detour nurses most shifts.

Every nurse needs to figure out a method of organizing that works with them. Maybe you could show her a few examples of how other efficient nurses on your floor go about it, let her trial them and work out what is best for her.

jjjoy, LPN · Sep 9, 2006

For myself as a new grad on a floor and prone to going "deer in the headlights" myself, I could have used more structure. I often saw several different way to approach the patient load but had no way to determine how to choose a plan of action. So I'd waver, looking for some guidance on how to prioritize and get started, only to be told "I needed to be more independent." If I sat down and made a checklist, I was too slow in getting started. If I didn't, I was too disorganized and should "keep a list". It felt like damned if I do, damned if I don't.

I needed some training wheels to get started. Some people just don't work well with a pre-set plan and for those folks, don't force it on them. But I find them very useful. Once I'm up and running I have no problem tweaking the plan, or even creating a whole new one, but when I'm getting started at anything, I like to start with structure. So I could have used a very clear plan of attack that my preceptor supported... such as 1) quick round on patients 2) check vitals 3) check in with NAs 4) a set format checklist 5) pass meds. Only life threatening emergencies and maybe a few specific other situations would warrent changing that game plan - at least until the new grad had enough experience to make the call themselves.

Also, experienced nurses know there's barely enough time to do all that needs to be done, so they're often rushing off at the beginning of shift, automatically organizing everything in their head and, me, the new grad, only sees them rushing in and out of rooms and isn't learning what exactly the experienced nurse is doing. The preceptor also knows right off what to do and what to take care off and hates to see the new grad "wasting time" fumbling along or being slow to respond to something the experienced nurse would jump on immediately. So when the preceptor steps back and sees the new grad taking 20 minutes to check in their patients and not being sure where to start after that, they "helpfully" let the new grad that they need to "be faster" and "learn to proritize better."

To me, it's useless to say "You need to work smarter and faster" or "you need to learn to prioritize better" or "you need to be more organized." I realize that. The question is HOW? And you can't seriously expect me to get it all together in a few weeks when experienced nurses are still struggling with some of the same issues.

I also suspect many nurses run more on gut than on conscious deliberation, and can't always give concrete, clearly articulated reasons. That doesn't mean they don't know why they do what they do, but it's so second nature at that point it's hard to explain. Even if they could, they don't have the time to do so because the way it's set up, nurses don't have a minute to spare to review a specific case and go over it with the new grad to review how decisions were made.

The sink or swim philosophy of nursing would be fine if there were tons of qualified people to compete for the positions. But we need LOTS of nurses so it makes sense to provide some swimming lessons for those who don't immediately take to nursing like a duck to water. And while maybe nursing schools should better prepare students for the "real world," we have to work with things the way they are.

bradleau · Sep 9, 2006

Thanks for your input. I will use this to at least let this new nurse know that she is NOT ALONE. We have another new nurse that is TOO CONFIDENT, her only experience in a hospital was as a unit secretary. Knows a little about everything. She scares me. When I first started working at my current job, I made out my own personal work sheet. Now we have nurse kardex's printed off for each shift. Mostly up to date, but of course the information is not as easy to use/ or see quickly. But it is a start. Also our charting is on the computer...we chart by exception....with what we should be evaluating located on the same page in a blue side bar. Meds are accu dose and bar coded, as well as the patient being barcoded. The E-MAR shows the times of your medication. If you are past that 10 o'clock med, it comes up red. So most all of the stuff I used to have to write down is there for me with a click of the mouse. We are responsible to view the prior 24 hrs of orders and sign that we did this. Later, if there is time, we try to view the whole chart. Also if you see something listed for the patient such as meds, you may have to go back further into the chart. Yes, now I run more on gut than conscious deliberation. Precepting a new nurse is something that I love to do. Precepting with a nurse just a couple of years out of school is even better at times. They are closer to the problem than our more experienced nurses. We have more than one working with new nurse, so they can get an idea of different ways to approach a problem. Thanks

Jules A, MSN · Sep 9, 2006

I don't have any sage advice but wanted to pat you on the back for being so kind and willing to help a new nurse. It is my belief that sometimes the "slow starters" end up better than the "immediate super stars" once they get their bearings because they keep finding ways to learn and improve.