Orientee with untreated ADHD

BeachsideRN, ASN · Jul 11, 2015

Yikes. Untreated ADHD can be scary and even dangerous. Not saying that she needs to necessarily take medications (which may be her isssue) but there are non-pharmacological ways of managing this disorder. I think maybe you need to have a "come to Jesus" talk with her and tell her exactly what you said here. Your opinions on her performance, how she can improve it (writing stuff down, giving you time to explain etc).

canigraduate · Jul 11, 2015

Hello all! I've been working as an RN on an ortho/neuro/trauma med/surg floor and I've had one orientee that was AMAZING!! She worked on our floor as an aide so she was knowledgeable on our floor. My current orientee told me that she knows she has ADHD and isn't taking anything for it. I'm having a hard time with her because she doesn't focus, she forgets what I tell her, and she tells me she's not scared or nervous of anything. I feel like I need to stand next to her with everything that she does and she doesn't give me a chance to explain since she's going a million miles a minute. She's already on shift 11 out of 30 and I would love some advice on how to change my preceptor skills to accommodate her.

This is a little confusing. Is it your current orientee that is amazing and knowledgable, or the one orientee that you had before this one? If you are talking about two different people, you should probably stop comparing them.

I am an RN with unmedicated ADHD. And a darn good one. I had to quit meds because of my job and because of heart problems. I am reasonably well adjusted on my own. Most ADHDers are, they just need more time to complete tasks and chart. ADHD is NOT particularly dangerous. Sleep deprivation is more dangerous than ADHD.

Don't focus on the ADHD, focus on the orientee. What are her specific problems?

You say she doesn't focus. This is a very vague statement that needs clarification. Is this a constant or is it just sometimes? Is it because you're telling her something for the umpteenth time? Is it because you're demanding a lot of things from her at once? She may just need an organization tool such as a brain sheet. Also, don't overwhelm her.

I had a preceptor once who would rattle off a bunch of stuff she wanted me to do, chart, and fetch all at the same time. She would get mad that I wrote it down. "Why can't you remember these things? I can." Well, that's good to know. Out of the ten thousand things running through my brain, it's easy for these ten to slip through the cracks if I don't write them down.

You say she forgets what you tell her. There is a common nursing education method that you can use that will help, called the "teachback" method. If you are not familiar with it, it is basically having her repeat her understanding of things back to you or demonstrating what you've just said.

Ask her how she learns best. Most ADHDers are kinetic and audio learners. Having her look something up is... not pointless, but not optimal. It is better if you tell her and demonstrate to her.

ADHDers are often high in intelligence, so she may not need a deep explanation. Sometimes just a quick comment is enough to remind her of information she is already aware of.

You say she's not scared or nervous of anything - trust me, she is. She's just learned not to show that in front of neurotypical people because it's like blood in the water to a shark. She may not be scared or nervous of the things you think she should be, but she is definitely not going to show you or tell you that she's nervous until she is near the breaking point.

Also, hovering over an ADHDer is guaranteed to cause them to make mistakes. Don't do that.

What you can do is make your information short and sweet, and repeat it to her IN DIFFERENT WAYS. Notice the "in different ways." If you tell me something three times in a row, I only heard the first one. My brain has already assimilated that info and determined that listening to it again is a waste of time. I literally can't process it. If I didn't get what you wanted me to get out of what you said, you need to show it to me or demonstrate for me, or at the very least tell me using different words.

Also, you will have to teach your orientee time management, something that you do and take for granted. By that I mean you will have to teach her how to approach a room, how to get back out of it in a reasonable amount of time, and how to chart quickly.

Most ADHDers have no linear time sense. Everything is now, the other day, a little while ago, or soon. There is no "in ten minutes," "half an hour ago," or anything clock-based. Teach her to check the clock EVERY TIME she does something, so she won't get behind. She may be one of the few who have taught themselves this to fit into the mainstream, so just see where she is on the time spectrum.

One of the best preceptors I had taught me time limits. I learned that assessments on a Med-Surg unit should take less than five minutes and to do them on my first hourly round. I learned that giving PO meds should take two minutes or less, and that hanging an IV med should take less than a minute. She taught me that chit-chat can wait until after med pass and to chart everything as soon as I left the room.

I had to be taught to make sure to get all of the materials I needed BEFORE I went in to the room. I still forget stuff and have to run out and get it. Also, make sure she knows to take care of any meds due if she is going into the room for something else. I still forget sometimes and have to run out and get them and come back. Patients look at you like you're stupid when you run out to get the cardiac monitor, then the batteries, then the IV pole, then the fluids, then the PO meds.

Also, don't tell her anything about ADHD. Don't suggest meds or therapies or anything. It's none of anybody's business, including yours, unless she invites you to talk about it.

Finally, show her some trust. It sounds like you are prepared for her to fail. She is most likely picking up on that, which may be why she is not as responsive as you would like. Focus on her strengths and try to work with those.

Make sure you don't come across as critical. Many ADHDers experience severe dysphoria if they perceive criticism. So, while you may think you are explaining, she may think you are ripping her a new one.

Good luck. You will find that once you are not looking for flaws, you will enjoy the creativity, the empathy, and the problem-solving abilities that ADHDers bring to the table. I hope.

ICU.RN23, BSN · Jul 11, 2015

This is extremely helpful and thank you so much for giving my your insight. I'm a very passive person and I just didn't know how to approach her about this. I have ADD and we talked about it one on one, but I've never suggested medications for her. I don't want her to fail because that would reflect badly on me and I know she's going to be great, I just need to change my style of teaching to help her more.

What I mean by her not focusing is when I try to explain something to her, she interrupts me like she's always in a hurry, but we have plenty of time. The other night she called me into a patient room about a medication order and that she swears the Pyxis told her to take out two rather than one. I went to look at the order in the MAR and she kept going on about it in front of the patient, after I told her a few times that we would go look after we were done in the patient room. Then the count was off for the med and I told her that we would act like we would take out another dose, put the extra one back, and press cancel all meds so that the Pyxis count would be normal, but she seemed like in such a rush that she closed the pocket and the count was definitely off.

IV starts have been a little nerve-wracking because I know she knows how to start an IV, but she's not familiar with the new product. She'll just stop and say she doesn't know what she's doing with the needle in the patient's arm. I think for IVs I'll have her watch me first and she could do the next.

I think that instead of walking things through step by step, I'll just pull her aside, explain what we're going to do, and let her fly on her own. I'm working her this evening so I'll definitely utilize this information to help her grow. Thank you :)

canigraduate · Jul 11, 2015

This is extremely helpful and thank you so much for giving my your insight. I'm a very passive person and I just didn't know how to approach her about this. I have ADD and we talked about it one on one, but I've never suggested medications for her. I don't want her to fail because that would reflect badly on me and I know she's going to be great, I just need to change my style of teaching to help her more.
What I mean by her not focusing is when I try to explain something to her, she interrupts me like she's always in a hurry, but we have plenty of time. The other night she called me into a patient room about a medication order and that she swears the Pyxis told her to take out two rather than one. I went to look at the order in the MAR and she kept going on about it in front of the patient, after I told her a few times that we would go look after we were done in the patient room. Then the count was off for the med and I told her that we would act like we would take out another dose, put the extra one back, and press cancel all meds so that the Pyxis count would be normal, but she seemed like in such a rush that she closed the pocket and the count was definitely off.
IV starts have been a little nerve-wracking because I know she knows how to start an IV, but she's not familiar with the new product. She'll just stop and say she doesn't know what she's doing with the needle in the patient's arm. I think for IVs I'll have her watch me first and she could do the next.
I think that instead of walking things through step by step, I'll just pull her aside, explain what we're going to do, and let her fly on her own. I'm working her this evening so I'll definitely utilize this information to help her grow. Thank you :)

You're welcome! It's hard to precept when you're ADD, so cut yourself some slack.

A few suggestions for when she's on full speed ahead:

Instead of giving her verbal cues, ask her to step outside or help you fetch something. Then tell her that it is inappropriate to show incompetence in front of the patient as it causes them to lose trust. Or indecision, incompetence might be too harsh. An ADHDer sometimes has to be hit over the head because we don't pick up cues well.

Remind her to take deep breaths and slow down, she has plenty of time. It sounds like she is so frazzled by her mistakes that she is compounding them. Remind her that you are there to help and teach her, and that no new grad is perfect. She probably wants to impress you and is freaking herself out when she makes mistakes.

For the IV starts, definitely have her watch you do one. If you have the time, you can set up a dummy IV stick to get her comfortable with the equipment. I had someone teach me how to use a new cannula by placing some prune juice in empty 250cc bag connected to IV tubing, covering the tubing with a paper chuck, and then having me stick that. It worked pretty well.

It sounds like your preceptee is suffering more from immaturity than ADHD, honestly. There is no cure for that except time. Just try to be as patient as you can be, I know it's hard.

allnurses Guide · Jul 11, 2015

Yikes. Untreated ADHD can be scary and even dangerous. Not saying that she needs to necessarily take medications (which may be her isssue) but there are non-pharmacological ways of managing this disorder. I think maybe you need to have a "come to Jesus" talk with her and tell her exactly what you said here. Your opinions on her performance, how she can improve it (writing stuff down, giving you time to explain etc).

I agree, but you should have a discussion with a supervisor first and have this talk with a third party party present lest you be accused of bullying. ADHD is recognized under ADA and people who have it are protected - still if she can't do the job without "Reasonable Accomodation" it's time to have a heart to heart.

Hppy

BeachsideRN, ASN · Jul 12, 2015

I agree, but you should have a discussion with a supervisor first and have this talk with a third party party present lest you be accused of bullying. ADHD is recognized under ADA and people who have it are protected - still if she can't do the job without "Reasonable Accomodation" it's time to have a heart to heart.
Hppy

Absolutely. I meant to edit this and add that I was posting this as a person with non-pharmacologically controlled ADHD. It's what I would want from a preceptor. Though I am currently in school and am very forthcoming with my instructors that I accept and appreciate this type of interaction.

TriciaJ, RN · Jul 12, 2015

When you say that she seems to be too rushed to listen, I wonder if that is how she is responding to not having time-management skills. It's like she knows she needs to be faster at things, so she tries to function in warp mode. Hopefully once she develops strategies for organizing herself (and learns that her brain sheet is her best friend) she can take some breaths and settle a bit.

You sound like a really caring preceptor. I wish you both the very best.

TLBNurse · Jul 12, 2015

This is a little confusing. Is it your current orientee that is amazing and knowledgable, or the one orientee that you had before this one? If you are talking about two different people, you should probably stop comparing them.
I am an RN with unmedicated ADHD. And a darn good one. I had to quit meds because of my job and because of heart problems. I am reasonably well adjusted on my own. Most ADHDers are, they just need more time to complete tasks and chart. ADHD is NOT particularly dangerous. Sleep deprivation is more dangerous than ADHD.
Don't focus on the ADHD, focus on the orientee. What are her specific problems?
You say she doesn't focus. This is a very vague statement that needs clarification. Is this a constant or is it just sometimes? Is it because you're telling her something for the umpteenth time? Is it because you're demanding a lot of things from her at once? She may just need an organization tool such as a brain sheet. Also, don't overwhelm her.
I had a preceptor once who would rattle off a bunch of stuff she wanted me to do, chart, and fetch all at the same time. She would get mad that I wrote it down. "Why can't you remember these things? I can." Well, that's good to know. Out of the ten thousand things running through my brain, it's easy for these ten to slip through the cracks if I don't write them down.
You say she forgets what you tell her. There is a common nursing education method that you can use that will help, called the "teachback" method. If you are not familiar with it, it is basically having her repeat her understanding of things back to you or demonstrating what you've just said.
Ask her how she learns best. Most ADHDers are kinetic and audio learners. Having her look something up is... not pointless, but not optimal. It is better if you tell her and demonstrate to her.
ADHDers are often high in intelligence, so she may not need a deep explanation. Sometimes just a quick comment is enough to remind her of information she is already aware of.
You say she's not scared or nervous of anything - trust me, she is. She's just learned not to show that in front of neurotypical people because it's like blood in the water to a shark. She may not be scared or nervous of the things you think she should be, but she is definitely not going to show you or tell you that she's nervous until she is near the breaking point.
Also, hovering over an ADHDer is guaranteed to cause them to make mistakes. Don't do that.
What you can do is make your information short and sweet, and repeat it to her IN DIFFERENT WAYS. Notice the "in different ways." If you tell me something three times in a row, I only heard the first one. My brain has already assimilated that info and determined that listening to it again is a waste of time. I literally can't process it. If I didn't get what you wanted me to get out of what you said, you need to show it to me or demonstrate for me, or at the very least tell me using different words.
Also, you will have to teach your orientee time management, something that you do and take for granted. By that I mean you will have to teach her how to approach a room, how to get back out of it in a reasonable amount of time, and how to chart quickly.
Most ADHDers have no linear time sense. Everything is now, the other day, a little while ago, or soon. There is no "in ten minutes," "half an hour ago," or anything clock-based. Teach her to check the clock EVERY TIME she does something, so she won't get behind. She may be one of the few who have taught themselves this to fit into the mainstream, so just see where she is on the time spectrum.
One of the best preceptors I had taught me time limits. I learned that assessments on a Med-Surg unit should take less than five minutes and to do them on my first hourly round. I learned that giving PO meds should take two minutes or less, and that hanging an IV med should take less than a minute. She taught me that chit-chat can wait until after med pass and to chart everything as soon as I left the room.
I had to be taught to make sure to get all of the materials I needed BEFORE I went in to the room. I still forget stuff and have to run out and get it. Also, make sure she knows to take care of any meds due if she is going into the room for something else. I still forget sometimes and have to run out and get them and come back. Patients look at you like you're stupid when you run out to get the cardiac monitor, then the batteries, then the IV pole, then the fluids, then the PO meds.
Also, don't tell her anything about ADHD. Don't suggest meds or therapies or anything. It's none of anybody's business, including yours, unless she invites you to talk about it.
Finally, show her some trust. It sounds like you are prepared for her to fail. She is most likely picking up on that, which may be why she is not as responsive as you would like. Focus on her strengths and try to work with those.
Make sure you don't come across as critical. Many ADHDers experience severe dysphoria if they perceive criticism. So, while you may think you are explaining, she may think you are ripping her a new one.
Good luck. You will find that once you are not looking for flaws, you will enjoy the creativity, the empathy, and the problem-solving abilities that ADHDers bring to the table. I hope.

WOW, I am 53, and only recently found my footing with my ADHD. I am blessed beyond words to have a loving husband who works with me, instead of against me, in managing my daily life - which can be very chaotic, and I AM medicated.

Thanks for pointing out so many salient features and misconceptions of ADHD adults; the dysphoria caused by criticism, the overwhelming aspect of learning new information and the fact that hovering makes it worse. My biggest issue is becoming overwhelmed by the chorus of sounds and noises on a tele floor. Once I am overwhelmed, I must remove myself from the situation, calm down, and refocus as to the task at hand. Many misinterpret this as my inability to do the work. Maybe your orientee will benefit from a few time-outs in her day?

Lastly, too often I find ADHDers are just waiting for their next fail, and next person to say something like, "You could accomplish/do/or be so much more/better if only you would . . . " - this is a sure-fire path to self-destruction. Please, support what she is doing well, encourage what she seems to miss, encourage her to write down your requests/actions/tasks, and, provide time for her to calm down and refocus so she can do what she darn-well knows. Heck, she has already graduated and passed a grueling examination - I know she can do this too.

Been there,done that, ASN, RN · Jul 14, 2015

You need to treat her as any other orientee. Perform your weekly evaluations, noting any areas that need improvement.

When she is on her own, the docs, patients, and admins... will not be accomodating.

canigraduate · Jul 14, 2015

You need to treat her as any other orientee. Perform your weekly evaluations, noting any areas that need improvement.
When she is on her own, the docs, patients, and admins... will not be accomodating.

Yeah.... No.

Cerryrnbsn · Jul 16, 2015

Thank you for that. You explained ADHD perfectly. It is not that we can't be great nurses, we just need different ways of doing things. We know our faults; and as a preceptor, she's probably scared that you think she can't make it.