Orientation Woes

[Andrew, RN]

Hey, everyone. This is lengthy, but I have a lot to say.

I'm a new nurse working in a CVICU (open heart recovery). I've been a nurse for three weeks now, but I've worked in the hospital in a different department for four years.

My preceptor left to do payroll the other day instead of staying with me to do orientation stuff. While gone, the charge nurse decided I was ready to start taking patients and gave me a thoracotomy. I stuck it out until the nightshift came in. I would have rather had my preceptor with me to double check things but I handled everything great, didn't miss any meds, and no one died. =)

The nurses proceded to not listen to my report and instead criticized my paperwork for about 10 minutes. I left the department and a few minutes later, they called my house, cell, and another department trying to find me to ask if I gave an antibiotic, which I did and charted. I hadn't even left the hospital yet!

I go home, sleep about 5 hours and get up 5 am the next day to work 12 hours. Here's where things start to get interesting. My preceptor is not there, she has the day off. I was supposed to just "help out". I end up getting the thoracotomy, the same guy I took care of last night. No big deal, I'm familiar with him. I end up with an additional patient because another RN had to take a fresh admission.

So, here I am. Three weeks after just getting my license and I have two patients. They're stable and just waiting for a room on the floors to open up so they can be transfered. They're both sleeping. I go to get some food and the charge nurse says "You picked the wrong place to work if you're expecting to get breaks".

I get both my patients transfered to the floor. Remember the thoractomy patient? Here's a little background. He had an airleak the first time I had him, which the surgeon was informed about. For the first 24 hours after surgery, his tubes were to suction. He was stable the whole time, oxygenation was great, ABGs were great, he had no pain and no complaints.

The first morning post-op, the surgeon personally discontinues the wall suction. There is no bubbling in the waterseal chamber my entire shift, thus no airleak, so I sent him to the floor that afternoon. The floor nurse PAGES the surgeon saying there is an airleak.

The surgeon then proceeds to call my department and yell at my ad-hoc preceptor for the day (who is a traveler with a Master's Degree and works as a NP and educator) about how she is an idiot and not teaching me right. She has a fresh post-op CABG and didn't have time for that.

The surgeon does not ask to talk to me, he just yells at everyone else over the phone over nothing.

The floor nurse calls me to talk to me and says there's an airleak and she paged the doctor. The first thing I say is "Is the patient okay?" She says yes.

I'm thinking his airleak came back after he got to the floor. I was looking at those chest tubes every hour recording the output and checking for an airleak. Another nurse saw them at 11 am and didn't see an airleak.

Nothing bad happened. No patient was harmed. I did not miss a med or treatment. My patients were stable and did great.

My director is on vacation so I left a voicemail for the executive director of surgical services and I'm going to talk to her tomorrow in person.

I feel like I'm being treated like crap because I'm the new guy, people are not helpful or receptive. The department is short staffed and busy. My assigned preceptor is ill and might be gone for a few weeks if she has surgery. I'm being screwed out of a proper orientation and am thinking about changing departments.

I'd like some input on this. What are your thoughts?

[TRINI_RN]

Whoa! How long have you been on orientation? It seems to me that your preceptors aren't precepting at all!!! Where is your support? If you're being precepted that person should be there all the time backing you up, checking your work, and supporting you, especially in the CVICU for God sake! Run, run far away from this place, they'll cost you your license before the ink even dries. Good luck.

[Andrew, RN]

I've been on orientation for almost the same amount of time that I've had my license. Less than a month.

I had a patient last week with my preceptor. He bled out over a liter, I transfused 10 units of blood, some cryo, plasma, and platelets. He had a tamponade and went back to surgery.

My preceptor is great when she's there. She has the most experience and is great to talk with. She's been there for me up until now. She's been sick and may need surgery.

I should look for a different department that will give me an actual orientation.

[suanna]

I've worked CVSICU for 20+ years. What you describe wouldn't happen in my unit. For one, we do not hire nurses without at least 1 year experience to work in CVSICU. It's not so much that the knowledge base is lacking, it's just the ability to handle to pressure is a learned skill. Your skin gets a little thicker with a year or two under your belt. CV surgeons are notorious for being a bit high strung and demanding. Being able to hold your own against a raving lunitic who happens to be the doctor in charge is something that comes easier with time. New nurses make everyone nervous. It is almost universal that the least experienced nurse is going to undergo a lot of scrutiny. It's just to easy to miss a little something that could send a patient down the drain in a post open heart unit. Our orientation is 8-12 weeks depending on the skill level of the nurse. Even off orientation the newer staff are usualy assigned the least complex patients for 3-4 mos whenever possible. All that being said I think you did a fine job of managing the patients. Stick it out a few mos. and the heat will come down quite a bit. Once your peers realize they can trust your judgement working CVSICU gets a lot easier. Want to speed up the process? - READ, ASK, OBSERVE, HELP OUT- If a patient is complex and your patient(s) are caught up pitch in as much as you can. As far as break time is concerned- I can't remember the last time I ate lunch off the unit. If you get 10-15 min 2-3 times in a 12 hr shift you are lucky. Some days are better than others, but even if you aren't busy doing you are busy monitoring - patients condition change very fast. That is the fun of CVSICU! Even the least experienced nurse will be given a lot more respect when they are seen going the extra mile to learn the skills.

[Sterren, BSN, RN]

I'm also in an ICU setting and while I've been taking two patients, my preceptor is there every step of the way to help me out and back me up. I would suggest trying to synchronize your schedule with your preceptor's, ASAP. If she's great when she's there then you need to make sure you are there together. I'm glad you are managing things so well but as a new grad my fear would be that the one day I couldn't keep everything going well, would be the one day that my patient coded or had a mistake made that caused them serious harm. You and I just don't have the experience to be flying solo like that yet. Try to make sure you are working the same shifts as your preceptor, or demand more backup when she's not there. It's just not safe, yet, for you to be working so independently (nor would it be for me to be completely independent yet, I'm learning and I'm capable, but I'm inexperienced and just plain not ready.)

[glamgalRN]

First off, I want to congratulate you, it sounds like you did a great job under a lot of stress. I give you a lot of credit, one month after starting as a new RN on an ICU unit I would simply refuse to care for any patient without my preceptor by my side. Regardless of how comfortable you feel after a month, your main priority is patient safety and protecting yourself!

Before you try to switch units, I would talk to your manager and try to work something out, esp if the CVICU is something you're really interested in. Ask if you can have the same schedule as your new preceptor. You sound like you work hard and don't deserve to be treated this way! I hope it all works out for you.

[NsgChica]

Andrew, RN,

The situation you described seemed all too familiar. I also work in a CVICU and let's just say I had a crash course, not an orientation. I had seven preceptors and have taken patients by myself because of staffing issues. It's sink or swim. I have contemplated leaving numerous times but now have decided to stick it out. Plus, I believe that the experience gained from working with hearts is invaluable. I talked with my nsg manager and eventually things got better. If you believe that talking to the director will solve orientation issues than do it. If things don't get better, there are other places to work. Anyhoo, sorry that you had to go throw what you went through. It is very scary when you are operating out of your comfort zone. However, it seems as though you handled everything competently...or at your level of competence.

[lcbradley]

Wow. This must be contagious. I now have a year of experience in ICU and just recently changed hospitals. I have had 7 preceptors all who tell you how you should be doing things. This has been so frustrating. Although I am finally on my own, I feel so detached. It's really hard to find team players. I find myself helping out all the time and favors are not returned. When experiences start out on a bad note, it makes it really hard to feel as though you belong. We are able to transfer after 6 months so I will play it by ear.

[Andrew, RN]

Ok. I have a plan.

My manager is back from vacation. She talked with ICU. I am joining ICU's orientation while my preceptor is away. They have a planned out orientation that goes through "modules" where a different body system/disease/etc is covered every week or so.

This is great. I have support and things are working out. I'll keep you guys up to date.

[cubbynurse]

Just another tip- if you are ever on your unit and your preceptor is out, you might be able to be assigned a secondary preceptor. I start orientation in 2 weeks and my preceptor is only part time....so when she is not there I will be with another experienced nurse. Congrats on handling it so well but I hope you are never again in a situation like the one you described! Good luck with the ICU orientation :)

[Andrew, RN]

Update:

The unit director in ICU decided based on a 10 minute meeting with me that I am not "ICU material" because I am a new grad. I found this out from my manager, not her. She didn't have the guts to tell me that to my face, apparently.

Yes, that's right. I had someone who was not my boss at the time making employment decisions for me.

She has about 5 new grads working for her, at least.

She has taken over CVICU in September.

I left CVICU before she took over. The hospital stuck me in an ambulatory surgery unit getting patients ready for surgery and taking care of them post op if it is an outpatient procedure. It's easy and the staff have been very helpful. It's like the difference between night and day from where I was before. It is just a temporary thing and they will make me Per Diem starting October 22nd.

I have become ACLS certified and I am looking at a job at another hospital.

I plan on meeting with the Vice President of Nursing and give her my 2 cents on the hospital, where it's priorities are, and my disaster orientation.

Needless to say, I'm pretty ****** off.

Also: The hospital has fired IV team and most of the educators in order to save money.

[love-d-OR]

Hi Andrew,

Its always nice to hear updates on this forum! Although you are quite angry about the outcome, I believe it was a blessing for you. The situation you described months ago was very unsafe and unsupportive. If you still want to be a CVICU nurse, then I recommend you look into other hospitals with an established preceptorship program (although I think you will not be trained as extensively as a new grad). Anyhow, I wish you the best.