My preceptor is everything they taught us NOT to be...

VANurse2010 · Dec 10, 2015

I don't have time to give a full reply now, but... there are a couple practice issues with your preceptor, however, *you* were in the wrong on several of those examples above and you really need to let the small stuff slide or you are going to drive your self crazy and more importantly not be successful as a nurse. I have multiple issues with some of your examples, but the biggest one - that dressing change did not need to be sterile unless the facility policy required it. I have never done a truly sterile dressing change in 5 years - nor have I been required to. You're not in a BICU.

nutella, MSN, RN · Dec 10, 2015

It is not a good development that you are facing termination. If you are truly in danger if getting fired perhaps you want to look around for something different. Once you are fired it will not look good on your resume. I am not suggesting you should do anything that is unsafe or not right - you need to work in a way that you can actually manage an assignment of several patients.

I wonder if you could ask for a different preceptor, it sounds that the relationship is already strained a lot.

joanna73, BSN, RN · Dec 11, 2015

Have you discussed your progress with your preceptor and manager? They should hopefully be able to provide constructive feedback.

Sounds like you are definitely on their radar. Perhaps apologizing to your preceptor and attempting to smooth things over might help.

Even if your preceptor has unsafe practice, pointing it out will not help you succeed.

Lev, MSN, RN, NP · Dec 11, 2015

Pt has a stage 4 pressure ulcer on her coccyx, wet to dry dsg changes ordered q day. I observed while she changed the dressing. No sterile field, no sterile gloves, out clean gloves on, removed the dsg and packing, never changed the gloves, soaked the packing with her gloves hands, repacked and dressed the wound.

Unless sterile dressing changes are ordered, there is no reason for sterile technique. Clean technique is adequate. There is nothing wrong with this scenario.

If my pt has multiple IV meds ordered for the same time she told me to scan them all, hang one, and leave the rest to be hung when it finishes. I don't sign for meds that haven't been given.

I see people doing this frequently. I generally do not personally do this. However, you should do it her way while you are on orientation.

Non verbal pt has orders for blood glucose monitoring and insulin sliding scale. 0630 fingersick done, pt does not score for coverage. 0800 the tech who came on did another finger stick and pt needs 2 units. At 1000 preceptor says that pt needs coverage, I never signed off on the task (he didn't score when it was ordered). 1030 administering meds, recheck fingerstick and pt needs 2 units. I signed off on the 0700 order (outside of parameters), charted the new reading, gave the insulin at 1030 for the 1100 order. That's wrong, I should have covered him for 0700 and rechecked at 1100. I told her I don't think I should give insulin 2.5 hours after a fingerstick without a recheck. Or cannot even tell us if he's feeling off, and is npo with tube feeds.

What was the fingerstick? I can't decide if this was right or wrong unless I know the fingerstick. Your preceptor knew what the fingerstick was and made a decision. Stop fighting with her.

New admission two days post discharge. Dementia, not a good historian of her medical hx. Form asks "has pt had a flu shot". Preceptor states "I don't know for sure, but they must have given it on d/c. Charts that she had it and pneumonia vax on date of last d/c.

I don't know what the hospital's policy is. However, generally if you are unsure if a patient had a flu/pneumonia shot then its ok to go ahead and give it.

We were told that no blood pressure meds are to be given without a. BP within 30 minutes. She was not there that day. It is 0920, pt has a bp charted for 0811, but the techs do vs at 0700, it was charted at 0811. "Give it, it's fine". Next pt is on a beta blocker, calcium channel blocker, and 80mg lasix. I rechecked the BP and she seemed quite annoyed.

What was the BP before and when you rechecked it? Again, I can't judge this situation without knowing the numbers. If her BP was 178/92 at 700 and you work on a M/S floor you can probably go ahead and give it. I usually do check BPs before administration, but not always. Go along with your preceptor and when you get off orientation you can do what you want.

I heard her giving report in the hall outside a pt room. Openly discussing hx of drug abuse, etc. Another pt is a registered sex offender, I overheard her telling a tech from another dept. His reason for being a sex offender.

Ok nurses talk about their patients. Just don't talk about it, ok.

I had a pt who was on two iv and, including vancomyicin. The day before she had IV contrast. Her BUN and Creatinine were elevated, GFR was around 40 the day before. She told me in the am that she is usually up four times a night to void but hasn't been up once. I report this to preceptor. After a little bit, I got her up to the commode where she voids 40mls. At lunch I got her up again and she voids 60. I went to preceptor who tells me that she went for her. I asked if I should call the doc just to be safe, she says she will take care of it. End of shift I asked, she said pt is fine, no need. RN I am reporting to ask about output, I explained it to him and he called provider.

So the patient voided 3x for you and how many times did she void for the CNAs? Was the patient getting IVF besides for those mixed with medications? Was the patient on a fluid restriction? Had she gotten fluids before or after the IV contrast?

I could keep going, but I feel like a vindictive crazy person. I know these are bad habits, and refuse to adopt them into my own practice.

If and when you get off orientation, you can choose the way you perform tasks. However, now that you are on orientation, the way your preceptor does things is the way you do things unless direct harm is coming to the patient.

She wants all of my tasks and charting to be done by 10am. I often do not reach that because I choose to assist pts with am care, breakfast, ect. The charting can wait in my opinion, as long as everything is done on time.

No it cannot. You are hired as an RN, so your RN job requirements which include documentation, comes before the tasks the CNAs can carry out, such as toileting and feeding patients.

I have one foot out the door anyway, and will likely be fired today. I can deal with that, I definitely can, but I was advices by a mentor to approach her, I tried, and yo go to the manager, I asked him to meet with me, and he told me that he has continued to receive negative feedback from my preceptor and will discuss it with me. I know I'm being fired, and there's not much to do to change that, unfortunately being fired means I will not be eligible for 're-hire at the one hospital near me. But, what do I do about this preceptor? Let it go so the next new nurse can learn these poor habits, or try to bring it to someone else's attention?

You need to shut your mouth and apologize for being so nitpicky and throw in some complements for your preceptor, manager, and unit if you want to keep this job. There is no nicer way to put it. It takes a year to get comfortable and start solidifying habits. Doing something in a less by the books way during orientation does not mean you are set up for a career as a terrible nurse. You build your own habits.

emmy27 · Dec 11, 2015

She wants all of my tasks and charting to be done by 10am. I often do not reach that because I choose to assist pts with am care, breakfast, ect. The charting can wait in my opinion, as long as everything is done on time.

I would bet good money that this is the crux of the problem. A new grad who is late on documentation because of refusal to relinquish tasks that can be safely delegated is not successfully transitioning to the RN role.

Yes, your tone in this post suggests that there might be some personality conflict or that you two may have gotten off on the wrong foot or have communication difficulties. But what you tossed in to the last paragraph about your task prioritization and documentation is a very legitimate, concrete concern for a preceptor to have about an orientee. If this is something she's addressed with you and you're resisting her feedback, that may very well be what your manager is concerned about, with good reason.

The complaints you have about her are for the most part either unwarranted (like the clean dressing change) or subjective and difficult to assess without having been there to see the full clinical picture. The single complaint you admit she has about you indicates a failure to progress in your role transition towards being an independently practicing RN.

Success as a new grad is about much more than performing each individual task precisely according to textbook, it's about learning to embrace a complex set of competing demands and responsibilities with limited resources in a way that's very different from even the best nursing school setting. Which is tough, and nobody does it instantly, but it's nearly impossible to do at all without willingness to learn from others- not everything, perhaps, you will meet many nurses over the years whose practice you may not want to precisely adopt- but you also can't reject everything a more experienced nurse assigned to your orientation has to say about your own practice because you think her dressing change wouldn't have passed your clinical instructor's muster. Well, at least you can't and hope to progress in your orientation.

You may well be highly competent in all your clinical tasks, but that is a relatively small part of the job. I'd head in to this meeting with your manager with an open mind and a willingness to consider the content of this negative feedback, or you may find yourself not only fired, but facing the same problems in a new setting.

mountainclimber · Dec 11, 2015

It's important to hold back with initial assumptions of wrongdoing in a new workplace. As others have said, observe and hold your tongue a little longer. Eventually you may have trusted confidants that you can consult with when you have concerns.

LPNtoRNin2016OH, LPN · Dec 11, 2015

Your giving off bad vibes. I do a gazillion dressing changes, all kinds, all stages, a day in LTC and they are never ordered sterile. I realize this is LTC and the hospital but the only time I do have a sterile field dressing is on a PICC line in the SNF part.

It's important to realize while you have life experience, you do not have experience in this area. You most likely came off to her as edgy and unwilling to learn. Nursing is so different from nursing school - you do not just have one patient anymore, you have upwards of 10. You have to be open to constructive feedback. I used to be totally closed off to it, would get defensive. Once I got knocked down a notch, I learned just how block headed I was really being. Make sure when you get into this meeting, your all ears, and when you get a chance to talk, apologize and state your willing to change your attitude.

The only major problem I see with this is that they stuck a one year old nurse as a preceptor. It's most likely stressing her to all get out and then to have her work constantly questioned is flaming her annoyance at you.

Anna Flaxis, BSN, RN · Dec 11, 2015

It sounds to me like your preceptor does take a lot of shortcuts (except the dressing change-as others have mentioned, dressing changes on chronic wounds do not need to be sterile), but while you are on orientation, you should do things her way. Once you are off orientation, you can do things your way.

NOADLS · Dec 11, 2015

OP, you seem to be picking at things which are standard practice. Some of the things your preceptor did are questionable, but not really out of the norm.

The lesson you should be taking away from this is that best practice is taught in school, but in reality, best practice is a pipe dream because of human nature (management won't give you the time to implement best practice, and as an employee, it is second nature to seek shortcuts to make your job easier)

It would help if you only addressed serious issues and made no mention of small technicalities (ie. "OMG YOU GAVE THAT BLOOD PRESSURE MED 29 SECONDS TOO LATE!!!!").

thenightnurse456 · Dec 11, 2015

Nursing school and working as a nurse are two very different realities.

Maybe try to mend the broken preceptor/new grad relationship. Or talk to your manager regarding what can be done on your behalf to improve.

jadelpn, LPN, EMT-B · Dec 11, 2015

The big red flag in all of this is the insulin/dosing and you signed off outside of the parameters. And if I am reading correctly, gave 2 doses of insulin? One to cover 7am at 10 and the other then right after another FBS and more coverage pre- "lunch"?

Tube feeds can and do cause some weirdness with blood sugar, hence why it is important to stick to the schedule. Be mindful of what you were "allowed" to do and not do in this scenario.

Otherwise, technique, how a nurse practices may not be 100% like you would do it, however, when you are on your own, it may be different due to your own practice to facility standard.

I agree with you on pulling multiple meds at the same time (even IV fluid). There are nurses who will not use bags that have been sitting out--as they want to pull their own meds. But something rectified when you are caring for a patient.

The patient who was in kidney distress--make sure that you actually tell your director that you did in fact question the viability of giving vancomycin with what appeared to be a change in condition. A very throw you under the bus issue.

The wound---I dunno but wet to dry on a pressure ulcer is not something I think I have done in literally 10 years, as there's many, many other current wound procedures that could be more effective. It is a clean, not sterile procedure. I would perhaps advocate for a wound consult. But the procedure itself...yes a new pair of gloves could have been donned after unpacking the old wound, prior to redoing the new dressing. Especially since the mechanism of action is that the now dried "wet" part can cause bleeding. And the evidence based practice on keeping a pressure ulcer wet....bottom line is that it is not how you would do it, but your input could be that you would have done x,y,z

You are in a position where you were unable to be independent on a few things that had the potential to cause patient harm. Perhaps if you discuss those things with the manager, and how you realized and what you would have done, you may not find yourself "fired". It is a frustrating place to be in, but don't let them throw "unsafe practice" around without you explaining.

I can't help but think of what you said about report and talking down about patients. "I now know that the patient in room 457 is a sex offender, who ____________. As does half the floor and the visitors. And housekeeping. And the lab. And x-ray. Not because I cared for the patient, rather that I heard my preceptor reporting off. In the hall. And I was at the nurse's station..." I wouldn't probs be that sarcastic, but if you find yourself under the bus and a termination over the limits placed on your practice by the preceptor, and your nursing judgement (which a preceptor is trying to foster) was over-rode and then blamed on you, I would say it.

Overall, sometimes things just don't mix. And being precepted by a newer nurse is not always ideal.

Let us know how it goes.

Been there,done that, ASN, RN · Dec 11, 2015

Have you discussed your progress with your preceptor and manager? They should hopefully be able to provide constructive feedback.
Sounds like you are definitely on their radar. Perhaps apologizing to your preceptor and attempting to smooth things over might help.
Even if your preceptor has unsafe practice, pointing it out will not help you succeed.

So.. what I hear you saying is... while one is orientation... one has no say in the delivery of care?