Orientation. Advice on precepting

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Specializes in Med surg/tele.

Hi experienced nurses. I’m a 5 year med/surg tele nurse at a community hospital. It’s A large unit. I just started precepting a new hire/rehire about three weeks ago. She’s at week six already. I’m told she’s been working at an office as a health coach, but was in hospital several years ago.

shes been out of the hospital 8 years. Any tips on getting her better up to speed? She doesn’t seem to be getting it!

She’s very good with the routine head to toe assessment and charting the routine daily required documentation, but that’s about it.

It gets as basic as making sure she pulls two pills instead of one...always has to run back. Minimal critical thinking, time management skills, Where to find meds not just stocked in pixie, and some other everyday skills (discharge education, secondary bags often antibiotics, especially when not with current fluids and programming flush bag is needed)

Responses to attempts at guidance is usually me repeating five times for her to still not get after multiple times with skill.... next day, five times explanation of same common skill. And “oh!” Like she’s heard it for the first time.

I’m frustrated. Prior preceptors of hers experience same frustrations.

I’m starting to keep a log of these to turn into educators and manager.

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Specializes in Outpatient Cardiology, CVRU, Intermediate.

That does sound frustrating. Have you talked to her directly about it? Are these specifically things that could put the patient in danger, or just that she manages her time poorly? If it's poor time management, she may just take longer than others to get her rhythm and routine down.

If she isn't grabbing enough pills from the Pyxis, take her step by step through. (For ex: I make a med list in the morning for my patient and jot down Metoprolol, 50mg. Then when I pull meds from our machine, I see it on my list and as I pull each individual pill package. That helps me make sure I take enough pills. We also have to scan our meds at the bedside, and I make a point to scan each pill package, not the same Metoprolol package when there are 2 pills needed. (Does that make sense? If there are 2 pills needed, and I only scan one, then that is a double-check that I need to stop and re-check.)

Maybe take a minute and use a specific example of something that has been repeated over and over. Kindly ask her, "I noticed we went through this process a few times already this week. What part of the process do you feel like you get stuck on? How can I help you remember that antibiotics need a flush bag and the additional tubing?" And then if that particular situation comes up, stop her, and talk it through.

"Patient has Zosyn ordered. Let's think this through. Any maintenance IVF running? No. So we need something to prime the line. Let's get a flush bag and tubing, and then Zosyn and tubing. Stop at the counter where the line labels are and fill them out. Then let's take the whole thing to the room." For me, I do better practicing the "same" routine over a few times, before it sticks. And I still forget/things happen!

And if you've done the above a few times, and it still isn't sticking, let her safely fail. (Don't endanger the patient, of course!) If she is allowed to safely make those mistakes, even again and again, she might recognize where she is running into these situations and be able to "fix" them. Discharge teaching may just take time to get into her rhythm or spiel. That might be an easy one to do a couple run-through's for practice with you, like practicing giving report back and forth to each other. This may just take time and practice on her part, and a lot of running back and forth to get things she forgot. Hang in there; stay patient!

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I would request that for the next week, you two are assigned three patients. Then I would do nothing but observe and answer questions. If she is forced to organize her care and perform tasks on her own, it may click better.

How long is her orientation?

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Specializes in PICU.

Just one thing about your log. Please share it with her first before turning it into the manager or educator. Not showing her this will definitely blindside her.

Please share it with her and then give tips on how to improve. She may feel things are going okay.

take some time and talk with her, ask her what was going on and how she could have improved the events. In essence coach her through the events you are logging. Just because she has worked in a hospital, doesn't mean things will come easy for her.

Again, please share the log you are keeping with her first before going above her. It looks like you are secretly trying to have her fail with out helping her first.

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I prefer regular, pre-planned meetings between preceptor, orientee and whomever oversees them (educator, ANM, manager, etc.). Without discussing how things are going and having a routine/neutral meeting that is not a surprise attack, everything just has a random feel to it. Meetings allow everyone to speak from their perspective. They can also include discussions of strengths/what's going great, what needs more work (or some kind of tweak) and what seems to be problematic areas that must improve. They also involve an opportunity for the orientee to safely discuss things that might not be working for them.

Basically I feel that progress should be addressed in a professional manner instead of being some random thing where the preceptor notices and tries to correct random problems as they arise.

And....if, eventually, someone is actually going to fail to meet expectations and not complete the orientation, I don't want that to be because they were not given fair opportunities and timely, honest yet useful feedback.

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Specializes in ER, Pre-Op, PACU.
12 hours ago, Sweetheart2005 said:

Hi experienced nurses. I’m a 5 year med/surg tele nurse at a community hospital. It’s A large unit. I just started precepting a new hire/rehire about three weeks ago. She’s at week six already. I’m told she’s been working at an office as a health coach, but was in hospital several years ago.

shes been out of the hospital 8 years. Any tips on getting her better up to speed? She doesn’t seem to be getting it!

She’s very good with the routine head to toe assessment and charting the routine daily required documentation, but that’s about it.

It gets as basic as making sure she pulls two pills instead of one...always has to run back. Minimal critical thinking, time management skills, Where to find meds not just stocked in pixie, and some other everyday skills (discharge education, secondary bags often antibiotics, especially when not with current fluids and programming flush bag is needed)

Responses to attempts at guidance is usually me repeating five times for her to still not get after multiple times with skill.... next day, five times explanation of same common skill. And “oh!” Like she’s heard it for the first time.

I’m frustrated. Prior preceptors of hers experience same frustrations.

I’m starting to keep a log of these to turn into educators and manager.

I would imagine being out of the hospital environment for that long is very intimidating for her to start back again. Precepting can be very challenging and every nurse needs a different approach. One thing I would work on is giving her weekly constructive feedback - what is going well, what needs improvement, what her thoughts or concerns are, etc. I would also suggest sharing the log with her and seeing if she can improve before escalation. I have seen nurses absolutely crushed when their preceptors are not honest with them and instead pull them into a meeting with educators and a manager - and they feel like the rug has been basically pulled out from under them. It makes them lose trust and faith in their team.

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Specializes in Med surg/tele.
3 hours ago, Been there,done that said:

I would request that for the next week, you two are assigned three patients. Then I would do nothing but observe and answer questions. If she is forced to organize her care and perform tasks on her own, it may click better.

How long is her orientation?

Being an experienced nurse it was supposed to be 6-8 weeks, but it’s likely going to be 12 weeks.
We will not be able to be assigned less patients. (General culture of how it works) and there are days half of the nurses have an orientee. Most new grads. Best I can do is take anything above what she takes on my own and watch with the others.

Shes been taking the assignment for several weeks. When there is a very stable group with minimal need to call the doctor, communicate changes with the care team, she can do most of it. Anything that interferes with the plannned schedule and routine seems to be where the problem happens.

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Specializes in Med surg/tele.
3 hours ago, SarHat17 said:

That does sound frustrating. Have you talked to her directly about it? Are these specifically things that could put the patient in danger, or just that she manages her time poorly?

I address my concerns as soon as possible in real time. One example of safety, she was giving lopressor to a patient, there were no ordered parameters and the heart rate was low. She planned to just give it rather than review history of heart rate and possibly question if it should be given. Thank you for your suggestions. Staying patient is becoming very difficult but I will try.

3 hours ago, SarHat17 said:

Hang in there; stay patient

1
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Specializes in Med surg/tele.
3 hours ago, RNNPICU said:

Just one thing about your log. Please share it with her first before turning it into the manager or educator. Not showing her this will definitely blindside her.

Please share it with her and then give tips on how to improve. She may feel things are going okay.

take some time and talk with her, ask her what was going on and how she could have improved the events. In essence coach her through the events you are logging. Just because she has worked in a hospital, doesn't mean things will come easy for her.

Again, please share the log you are keeping with her first before going above her. It looks like you are secretly trying to have her fail with out helping her first.

I do coaching as I go. The intent is absolutely not to ty and have her fail without helping her out. Thank you for sharing that it may come across that way.

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Specializes in Community Health, Med/Surg, ICU Stepdown.

The thing with the lopressor makes me nervous. I'm glad you prevented a potential med error. But then I would feel like I would need to supervise her giving meds, or at least higher risk ones. Multivitamin probably OK LOL. That is stressful though, because then you feel like you can't split up the patients and have her take some on her own. I agree setting up a non confrontational meeting with manager, educator, etc would be good to go over progress and concerns. I think if you approach is calm and from the angle of wanting to help her and protect patients it will be OK. I hope she can improve and you sound very patient ?

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1 hour ago, Sweetheart2005 said:

Being an experienced nurse it was supposed to be 6-8 weeks, but it’s likely going to be 12 weeks.

Another thing that sets everyone up for failure is hospitals' failure to have a reasonable plan...or to decide that they don't want to invest the resources likely required for success and decline to hire the person.

8 years is a long time to be out of the hospital setting. I would have assumed that this was going to require something much more like a new grad orientation than an experienced nurse orientation. There's always room to be pleasantly surprised if things go very smooth and all of the orientation time that was budgeted is not needed, but if the opposite mistake is made it's just a disaster from start to finish.

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Specializes in Med surg/tele.
6 minutes ago, JKL33 said:

Another thing that sets everyone up for failure is hospitals' failure to have a reasonable plan...or to decide that they don't want to invest the resources likely required for success and decline to hire the person.

8 years is a long time to be out of the hospital setting. I would have assumed that this was going to require something much more like a new grad orientation than an experienced nurse orientation. There's always room to be pleasantly surprised if things go very smooth and all of the orientation time that was budgeted is not needed, but if the opposite mistake is made it's just a disaster from start to finish.

Yes, and several of us have voiced the need for additional orientation that have precepted her. We have a new grad program where for the first two weeks that one of our best floor preceptors has a couple new grads and essentially floats. A couple med passes, assessments, requests the floor nurses to check availability to hang secondary IV meds, just the hands on pop up skills to transition into the orientation. She also takes time in the skills lab and focuses on educating different topics: stroke, cardiac stuff, respiratory etc. and how to care for them. They are confident in several skills.
I mentioned a day to float might help. Do admissions, secondary lines that pop up. It won’t help with managing g a day, but she needs to know how to do these skills to work them into her day. Hopefully we can do some.

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