I am in a new situation. Looking for some advice. I am orienting an RN with 8-9 years of experience in small community hospitals to our larger-teaching hospital. Never mind our behemoth of a computer charting system which can trip up just about any nurse with any level of experience... it is her assessment and critical thinking skills which are sadly undeveloped.
She seems to act like a nurse who is babysitting for the night. I am really starting to see how the environment in which you work can shape your practice as a nurse. We are a unit where patients diagnoses are not yet set. Tests are still being run. Good physical assessments need to be done. I almost feel like I need to have her do a full assessment on me like we did in nursing school to see if she even knows what to do. I am worried that this would insult her, but at the same time I don't want to sign her off if I don't think she is doing things appropriately. How much is just differing nursing judgement?
I am an RN/BSN with 22 months experience plus 2.5y as an LVN. All my experience has been hospital based. I consider myself good at assessments, critical thinking, and asking questions. This RN had rarely called a doctor for anything at night in all her time. And I have to question some of the things I have seen her do in assessments. Her response typically does not satisfy me.
I can't even count the number of times she has asked me about calling the doctor for something when she hasn't even asked the patient enough questions... she never asks is this pain different? does anything make it better? what makes it worse? do you think a warm pack or cold pack might help? As well as lacking the ability to sort of communicate a full picture of what is happening with the patient? Did she doze off while she was talking to you or what she up talking on the phone and eating while she was saying she was in pain? Is she getting all of her normal home meds that might help her with this pain? When you palpated her abdomen at your second assessment was it any different than the first (since pt in for abd pain)? I have to prompt all of this. Then she tells me she never palpated the abdomen because she didn't want to cause unnecessary pain and that the doctors always did this at her last job. When I asked her how she would know if something changed during her shift... got a little firmer or a little more tender, how would she know? She just stared at me expressionless.
She has three more shifts on orientation. I am certain I cannot request more orientation time. She gets a little defensive when I question her assessments. I don't think this is abnormal. I was thinking about recommending that she be required to do some of the free computer education units having to do with assessment and treatments for what we see the most of on our unit. Even when she gives report she just tells what she did all night not why the patient is here, etc. Even after me providing examples of reporting additional diagnostics and lab tests, she doesn't add it to her own reporting practice.
I know I can't teach critical thinking skills in a week... her previous 9 years of experience have not served her as far as professional development. What else can I do? There will be nights when she is the only other nurse working with another RN. Sometimes me, and she just isn't catching on. I am willing to do every computer education assignment I recommend for her so I can discuss it with her, but it is like she needs a nursing refresher course even though she has been in practice the whole time.
I don't feel I'm all that boiling over to be told by a 28 yrold to "simmer down". If the older nurse discussed in the original post who is the new orientee only shrugs yes or no to a preceptor of 22months out of the starting gate, maybe it's more of the way the younger nurse is coming off to her- that not geling. I'm thinking that older RN is not all that boiled over with the younger nurses she has to work with- perhaps that's why she is so quite. Maybe she is biting her tongue so as not to offend. When there is a whole lot she'/he is not saying. I find that many times in the younger nurses this is not the case. I have also worked at this age in my life with afew RN's who are older than I, who were OR nurses back in their day, quit working for years and years, took a refresher course, came to the stepdown unit, are what 'seems' very slow moving, soft spoken, don't say much, but can tell you in report every wrinkle in an elderly patients body. One old nurse I worked with as a younger nurse, counted how many floor tiles the patient soiled in a diahrrea explosion. One smart assed young doctor learned very quickly not to argue with another old RN, when she was able to tell him the exact time to the second when his drug seeking patient opened her bag and began to self medicate-- Looks are deceiving. Some how I don't think that older RN is going to stick around on that unit- and not because she can't do the job.
I don't feel I'm all that boiling over to be told by a 28 yrold to "simmer down". If the older nurse discussed in the original post who is the new orientee only shrugs yes or no to a preceptor of 22months out of the starting gate, maybe it's more of the way the younger nurse is coming off to her- that not geling. I'm thinking that older RN is not all that boiled over with the younger nurses she has to work with- perhaps that's why she is so quite. Maybe she is biting her tongue so as not to offend. When there is a whole lot she'/he is not saying. I find that many times in the younger nurses this is not the case. I have also worked at this age in my life with afew RN's who are older than I, who were OR nurses back in their day, quit working for years and years, took a refresher course, came to the stepdown unit, are what 'seems' very slow moving, soft spoken, don't say much, but can tell you in report every wrinkle in an elderly patients body. One old nurse I worked with as a younger nurse, counted how many floor tiles the patient soiled in a diahrrea explosion. One smart assed young doctor learned very quickly not to argue with another old RN, when she was able to tell him the exact time to the second when his drug seeking patient opened her bag and began to self medicate-- Looks are deceiving. Some how I don't think that older RN is going to stick around on that unit- and not because she can't do the job.
So being able to "tell you in report about every wrinkle in a patient's body" and "counting how many floor tiles the patient soiled in a diahrrea explosion" is pretty well pointless if you can't critically think through and perform the needed interventions to properly care for the patient.
I'm not sure why your taking this so personally, perhaps you need to step back and look objectively at this and how your own situation affects you perception. Just because someone has been homeostasing with an RN license in their pocket for 8 years means nothing. I've worked with some darn good older providers that I may disagree with on some things here or there, but could take care of my family anytime. I've also worked with some 20+ year folks (and some brand new ones as well) that I wouldn't let care for my worst enemies pet. Don't blindly defend people just because they are "experienced". Some experienced providers have no business having a license.
I can't help but think that had this post been written by an "old" nurse orienting a "new" nurse the responses would have been very different. I also don't doubt that somewhere is an orientee thinking their preceptor is awful.
It's all about perspective. I suspect the new hire is just fine other than she doesn't do well with someone breathing down their neck, critiquing everything they do.
Specializes in Oncology, Rehab, Public Health, Med Surg.
as an older rn returning to the hospital setting after a 16 year lapse of hospital care, i feel like i might have some input about this situation.
obviously, i'm not in your there so i don't know all the details. but have you tried being more direct with her?
why didn't you palpate the abdomen? we consider that part of our routine assessment esp for abd pain--then does she do it next time? if not, why?
when you shrug your shoulders when i ask you*abc*, i get confused. does that mean you agree with me or you don't understand or you'd rather hear anyone but me talking right now or.....?sounds like asking open questions like how do you think you're doing may not be focused enough. if it doesn't work, at least you've got material to document to cya
depending on where she's coming from, she can be having a steep learning curve just acclimating to computer charting and such. remember, computer charting hasn't been around forever--just since you younger nurses have been around. maybe it might help if someone her age that she might be able to relate more to helped with orientation?
i read a lot about how new young rns get scared and overwhelmed and self-doubting. i'm here to say that it also happens to older nurses in new learning situations too.
i know you're helping her with orientation not actually precepting her as in an internship. but it sounds like a direct talk might be in order--with her and/or the nurse manager.
Wowsa... thanks to all those who read my posts carefully and with an open mind. Your statements in my defense have been right on the money.
Would it matter to those who thought this was an ageism issue to know that I, the 22 month RN, is actually the one in her mid-40's and that the 9 years of RN experience on orientation is just under 30? Seems like it shouldn't.
I have tried to ask direct questions. I get blank stares and shrugs. I try humor. I think I am sort of funny... she did laugh a couple of times. I am from another totally unrelated, licensed profession where we gave respect to others who had bigger or older licenses when they came into help with our unique situation. I get it. Really. I am as straight forward as one can be without being a total idiot.
A few other bits... I was never breathing down her neck. She was allowed her own pace the first 4 of 6 weeks. I picked up the extra patient load. She wanted 2 patients... she had 2 patients. I took the rest. I quickly sensed she would be too nervous to form effective relationships with patients with me in the room, so I stood outside the door and eaves dropped. She sat at a separate charting station of her choice, and I asked her to notify me when she was at a good place to stop so we could chat. Hours would go by and she wouldn't approach me, so I had to interrupt her sometimes. My biggest short coming in orienting her was probably NOT riding her more, NOT ensuring she was doing complete assessments. She considered herself computer savvy and took pride in besting me on computer shortcuts.
I communicated my concerns this morning to a supervisor. Seems everyone is aware by what they have seen and heard and just waiting for me to make it official. The details will drive the process on some level. I don't quite know what this means for her or me. I'll keep you posted. Please feel free to continue the debate.
You can take a break from nursing, eveN for years. If, however, you have many years of strong experience and are bright and vigilant, it all comes back pretty quickly.
I agree w the original poster. The high-level centers do make a huge difference quite often...at least this has been my experience. Sometimes you even take a pay cut to work in some of these centers, which often are in the city, so tha means high $$$ for parking. I have found that the solid experiences are well worth the cut . Really, it can make a big difference.
My biggest short coming in orienting her was probably NOT riding her more, NOT ensuring she was doing complete assessments.
I agree with this statement. I realize this is your first time precepting, and you are working your way up a learning curve too -- this is something you will likely do differently next time.
Also, you say you asked your preceptee a lot of direct questions, but did you make direct STATEMENTS to her? As in, "I'm concerned that your assessments are not thorough enough, here are several examples of things you didn't assess that I think you should have, let's work on this"?
I'm concerned about the fact that she is 3 shifts away from being off orientation and you only just this morning finally spoke with a supervisor about your concerns. You should have had this conversation, both with your preceptee and your supervisor, 2 to 3 weeks into the orientation -- this would have given you and your preceptee more time to work together to address these concerns. You seem to have been overly-concerned about not offending her -- better to upset or offend her but at least let her know where she stands, then to act like everything is ok until 3 days before her orientation ends. You're still learning how to precept -- this is something that I believe you should handle differently next time.
As for what you should do this time, talking to your supervisor was the right first step. If you feel that this nurse is falling so far short that she would be a danger to patients if working on her own, then you need to be clear about that. I would argue for more time for her orientation if at all possible, and then, instead of asking her at the end of the shift how she thought she did, TELL HER how you thought she did, including very specific examples of what she still needs to improve.
Your concerns were well thought out and reasoned for a very real problem where a final decision could have significant consequences for the orientee, the patients and the facility.
My intuition tells me your supervisors chose you as the preceptor for your good temper, patience and attention to detail and that they already had their own reservations.
Now you know experience does not equal competence.
When I have found myself in similar situations: a) assessed nurse's skill - has limitations, b) now what to I do? The elements that make a difference in which decision to make about the nurse assessed became: willingness and ability to learn. Your orientee did not appear to be involved in the process by her lack of responsiveness and/or else s/he recognized she was in a situation beyond her ability. If someone is found lacking in present time [sloppy habits, grumpy attitude, narrow scope] can they, will they learn and learn in the timeframe allowed?
Thank you for giving accurate feedback to your supervisors so that they can make the decision they need to make.
Some times accurate yet unfavorable feedback delivered with tact prevents a smaller problem from being a bigger one.
Ultimately the orientee needed to be reassigned or retrained to meet the standards of the environment s/he found herself in.
working at a facility that precepts new grads for 10-12 shifts not weeks, I think she had plenty of time to ease in. If you have taught her the hospitals way of doing assessments and she still isn't doing them correctly then maybe a nurse educator at your job could help her out. After a few demonstrations of assessments a nurse of 9 years usually would pick up quickly. Maybe coming from someone else/ another perspective might work
Specializes in Med-Surg/Peds/O.R./Legal/cardiology.
SunDazed, you are an excellent preceptor in the making and a very valuable person for your unit. I am concerned that this "experienced" nurse is very insecure in her abilities and is cautious to admit it. Ask her about 2 or 3 previous high acuity patients she had at her former facility, diagnoses, and how she handled those situations, as well as outcomes. Her confidence is lacking (in my opinion) and she needs a boost. Many factors come into play here...clinical skills, emotional stability, respect, time management, and confidence building. Precepting is difficult but rewarding. You will both get there. :redpinkhe
maybe it might help if someone her age that she might be able to relate more to helped with orientation?
:yeah:
kcmylorn
991 Posts
I don't feel I'm all that boiling over to be told by a 28 yrold to "simmer down". If the older nurse discussed in the original post who is the new orientee only shrugs yes or no to a preceptor of 22months out of the starting gate, maybe it's more of the way the younger nurse is coming off to her- that not geling. I'm thinking that older RN is not all that boiled over with the younger nurses she has to work with- perhaps that's why she is so quite. Maybe she is biting her tongue so as not to offend. When there is a whole lot she'/he is not saying. I find that many times in the younger nurses this is not the case. I have also worked at this age in my life with afew RN's who are older than I, who were OR nurses back in their day, quit working for years and years, took a refresher course, came to the stepdown unit, are what 'seems' very slow moving, soft spoken, don't say much, but can tell you in report every wrinkle in an elderly patients body. One old nurse I worked with as a younger nurse, counted how many floor tiles the patient soiled in a diahrrea explosion. One smart assed young doctor learned very quickly not to argue with another old RN, when she was able to tell him the exact time to the second when his drug seeking patient opened her bag and began to self medicate-- Looks are deceiving. Some how I don't think that older RN is going to stick around on that unit- and not because she can't do the job.