Orienting a new nurse...need advice

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Specializes in Level III cardiac/telemetry.

I'm orienting a new nurse for the first time. She's been with me for 3 weeks - the first week she was only allowed to shadow (was taking her NCLEX that week) and then took 1 patient last week and this week. She's supposed to increase by 1 patient every couple of weeks. I think she's a very intelligent person and has a lot of book knowledge but we're having trouble getting her to think "real world." I recognize that when you are only responsible for 1 pt that there are a lot of things you can do that you can't do when you have 4 or 5. That being said, here's what's happening:

We make our rounds to see pt's and do assessments first thing. She does a very detailed assessment, but it usually takes 20-30 minutes. I've tried to encourage her to multi-task during her assessment (like evaluating orientation, speech, etc while also checking extremities) and that listening to each lung lobe for 1-2 minutes isn't always necessary. I can listen to all heart/lung/bowel sounds and be on to the next thing and she's still on lungs. I realize that sometimes you're hearing things in the lungs that you need to listen longer, but if the pt is in the hospital for a seizure or stroke and on initial evaluation the lungs are clear, move on. I'm trying to show her how to do a speedier assessment by example, but it hasn't worked yet. Then we get our am meds ready. She is going through every med for her pt and looking it up and checking side effects and interactions. When I've asked her about this and asked if she knows her meds, she says yes but she feels responsible about possible drug interactions. She'll get caught up about a drug that may cause constipation and then we're giving colace and thinks of that as counteractive. I try to explain that the pt needs that drug and since it is causing constipation, we are helping by giving the colace and that also as nurses we cannot know every possible drug interaction of every drug we give - we CAN know basic drug classes and interactions between classes and the general side effects. She has also been somewhat argumenative about the textbook way of doing things (like saying that auscultating to verify NG placement is wrong and the only right ways are to check pH which our hospital doesn't do or to do a chest x-ray - but we can't do a chest x-ray everytime a NG has to be replaced or even each shift.) I'm glad she knows the best way to do it, but sometimes you have to adapt and do things how you can.

I know this was long, but wanted to give some examples. Am I being too hard or picky? I'm trying to realize she's just getting started, but I want to help her get out of the "nursing school" mode and into the "real world" mode so she doesn't drown as her pt load increases. What's the best way to address this without being harsh? I'm trying to let her know that no nurse has ALL the answers or knows everything and to trust her instincts!

Advice???

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It sounds to me like you're being gentle, but it's not registering. When she gets that 2nd, 3rd and 4th patient she's going to see how right you are.

You probably just need to say flat out, that school teaches by the book, orientation teaches in reality. Good luck. Some people never do get it.

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I've been an LPN for 2 years, so I consider myself a new nurse. I remember my first nursing job and the nurse that was orientating me. I thought she was pretty "gruff". She kind of reminded me of the troll under the bridge in that story Billy Goats Gruff or something like that. I love her to death now, but I was so scared of her! Your new nurse is probably scared, nervous, excited and wanting to please you all at the same time. You sound like you would be a wonderful nurse to shadow, so she's probably just wanting to make sure she has all her bases covered. I think all the text book nursing is going to stick with her for awhile. The only way she will learn all the real world nursing is to get a heavier patient load. That way she'll learn how to cut corners (but good corners) in all her assesments and such. Hang in there!!!!:yeah:

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It sounds like both you and the new nurse are in a tough place due to the vast difference between the ideal nursing taught in school, the reality one must deal with, and the very real risks and judgement calls that are part of providing care in an less than ideal situation.

Any two experienced nurses may disagree about how thorough a certain assessment need be or the degree of pharmacological knowledge necessary to administer different drugs. A newbie has only their school experience to draw upon to make judgement calls with, and many schools will emphasize to their students to do the ideal thing, even if discouraged by colleagues. So, there you are.

I imagine that after several months, this new nurse will be familiar with a majority of the drugs, have a feel for what needs focused attention and what doesn't, and the like, and be able to understand what you're getting at right now. But right now, with the weight of the patients' safety in her inexperienced hands, she wants to make sure that she's not missing anything and that she's providing the kind of nursing care her instructors taught.

Given the way many nursing school clinicals work these days, many new nurses have a lot more ground to cover to "get up to speed" than some hospitals and colleagues acknowledge. And this puts both newbies and their preceptors in a difficult position.

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Specializes in Med Surg.

time to get one of your advanced practice nurses or a nurse educator involved. it sounds as if she has some fear/trust issues and i'm afraid that she will go to your point of view, miss something, and kick herself until next year....you need some back up and you need it now. if her facility is like mine, she will not have 30 weeks of orientation in order to get comfortable with 5 patients.

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I think your doing great so far. I feel that you just need to encourage her to be more efficient with her time management skills and let her get swamped. But before that happens a good way to get her focused on what is necessary for the pt. Have her give you like the top things to do and top things to look for. Then have her evaluate the rest of things she is looking for and doing for the pt in terms of how much it will matter. For example how dose knowing that a drug will cause constipation impact her pt care. Will she change anything she will do for the pt on that shift that you shouldn't already be doing? But basically get her thinking about the what next and dose it matter today part, rather than I need to know everything. Hope this helps!

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Specializes in oncology, trauma, home health.

Hey! You sound like a great preceptor! Good job!

At the ripe-old nursing age of just one year I can tell you from experience that she needs to have all 5 patients, STAT, then and only then will she learn how to do it in the "real" world. It'll happen..

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Specializes in Community Health, Med-Surg, Home Health.
It sounds like both you and the new nurse are in a tough place due to the vast difference between the ideal nursing taught in school, the reality one must deal with, and the very real risks and judgement calls that are part of providing care in an less than ideal situation.

Any two experienced nurses may disagree about how thorough a certain assessment need be or the degree of pharmacological knowledge necessary to administer different drugs. A newbie has only their school experience to draw upon to make judgement calls with, and many schools will emphasize to their students to do the ideal thing, even if discouraged by colleagues. So, there you are.

I imagine that after several months, this new nurse will be familiar with a majority of the drugs, have a feel for what needs focused attention and what doesn't, and the like, and be able to understand what you're getting at right now. But right now, with the weight of the patients' safety in her inexperienced hands, she wants to make sure that she's not missing anything and that she's providing the kind of nursing care her instructors taught.

Given the way many nursing school clinicals work these days, many new nurses have a lot more ground to cover to "get up to speed" than some hospitals and colleagues acknowledge. And this puts both newbies and their preceptors in a difficult position.

I so agree with you. I think that nursing education is sincerely lacking compared to the programs of the past. No reality training at all. It will take time to pick apart the lectures and gain the real world experience in order to survive.

I've been an LPN for 2 years, so I consider myself a new nurse. I remember my first nursing job and the nurse that was orientating me. I thought she was pretty "gruff". She kind of reminded me of the troll under the bridge in that story Billy Goats Gruff or something like that. I love her to death now, but I was so scared of her! Your new nurse is probably scared, nervous, excited and wanting to please you all at the same time. You sound like you would be a wonderful nurse to shadow, so she's probably just wanting to make sure she has all her bases covered. I think all the text book nursing is going to stick with her for awhile. The only way she will learn all the real world nursing is to get a heavier patient load. That way she'll learn how to cut corners (but good corners) in all her assesments and such. Hang in there!!!!:yeah:

:yeah::yeah:

Hey! You sound like a great preceptor! Good job!

At the ripe-old nursing age of just one year I can tell you from experience that she needs to have all 5 patients, STAT, then and only then will she learn how to do it in the "real" world. It'll happen..

I remember when I had two days orientation to work med-surg per diem at my hospital (I work in a clinic at my facility and we cannot get paid overtime if we work a different dept-we must sign up agency). They gave me 6 patients to medicate, but the reality is that the LPN will usually have to medicate at least 10 and on bad days about 15. I kept asking myself how I would handle dealing with that many more patients; but I did my first day working 'alone' on Saturday, and somehow, seeing the reality of it, I handled it like a champ...much better than I thought I would, and even the RNs I worked with told me that I had good time and had my basics covered. I just remember imitating each thing I saw the LPNs that trained me do and went for it. Heck, you gotta survive!

The OP sounds like a great perceptor and I believe strongly that when the new grad has to become more independent, she will learn to prioritize, or sink.

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Specializes in Developmental Disabilities, LTC.

I wish I had some advice. Just wanted to offer what I'm experiencing as a new nurse myself:

I remember being taught in school that it was unsafe to administer any medication unless all side effects were known & that once I got into practice, I was to "not be afraid" to check my drug book whenever a med came up that I wasn't familiar with. I was also taught that NG tube placement always had to be confirmed initially with CXR, then checked for placement once a shift by checking ph.

That being said, I cannot imagine interrupting the nurses I'm training with now, whom have decades of experience, to consult my drug book over every single pill that is passed, or to question their standard of practice. Nor would I question the way my new place of business checks NG tube placement - I trust that my employer has all their bases covered when it comes to stuff like that.

Hope things eventually get a little easier for you. Again, I wish I had some advice for you.

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Specializes in NICU.

It is very difficult to precept. I've only been a nurse for 1.5 years but I do precept often. I love to teach and my manager was impressed with my teaching ability I guess and now I precept. Whether or not I enjoy precepting depends on the student/orientee. Some students are easy to teach, easy going, smart, and learn quickly. Others don't do their "homework" and ask the same questions over and over. Some think they already know everything. Those types make your job stressful and difficult.

But don't worry, I think you are doing great. She'll learn. When she has 6 patients... she'll learn.

Tiger

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she's still really, really new! students have a LOT of time to kill, so doing 20 minute assessments helps to pass the time. give her a few weeks, i'm sure she'll shorten this and hone in on what's important instead of the head to toe thing.

as far as the medication goes, i suppose that's a good thing? she'll probably spend less time looking them up as she becomes more familiar? i'd just play it by ear for the next few weeks

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i am a new grad. to me you sound great, i would love to have you! My only suggestions you could give her is if she knows what pt she will have the next day, have her write down the meds and research the night before. Then she will be prepared for a day at work. Also usually there are common drugs, have her write the drug on a index card with side effects, etc. she will not have to keep looking them up, saving time. i personally take scrapbooking laminete (sp) paper and cover them so they last forever and wont tear up.

Afull load will open her eyes. good luck

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