Pediatric ICUs Need to Really Want Their Nurse Orientees to Succeed

Pediatric Critical Care Columnist · Mar 26, 2009

This is a really important issue and I don't have the time right this second to reply the way I'd like, so I'll be back as soon as I can...

Guest343211 · Mar 26, 2009

OK! Looking forward to your reply!

Pediatric Critical Care Columnist · Mar 27, 2009

--please expound upon what precepting skills you have obtained.

I have no formal training in precepting new staff members, but I've been told by those I've worked with that they learn a lot from me. I'm the parent of an adult with a learning disability that wasn't identified until her second year of university. The techniques that work with her work for anyone. I ask a lot of questions and let the orientee think the problem through rather than just giving them the answers. When I correct them I give them the reason for it, ie where their train of thought derailed. I always start the first shift with them by asking about what they already know and what skills they have. When teaching new skills I make sure they know that the way I'm teaching them to do something is the way it works best for me but that as long as critical elements are performed, they can find their own way. I don't step in and take over unless the patient is being put at risk (no matter how antsy I get at how slowly and deliberately they're moving because I know I can do it much faster :wink2:). Critical care isn't instinctual until you've been doing it for a long time. Novices have to think through everything they do and why they're doing it is possibly more important than how. I try to organize care so that the orientee moves from basic to complex, building on what they've learned as we've gone along. I encourage them to use their resources to their best advantage, and to remember that the parents are GREAT resources. (Who else knows the child better?) I model communicating with families and other disciplines and encourage them to take on more responsibility for that as time goes on. I work with a lot of people who do not know how to stand back and let people learn, so for me these things are really important!

Have you be well-educated in how to teach adults? How one teaches an adult nurse is different than how one would teach children.

As I said, I have no formal education on preceptorship. I've read some excellent resources on teaching adult learners and use the tips that seem to work for me best. The university our hospital is affiliated with offers preceptor workshops (mainly aimed at precepting nursing students, not new staff members) but they're invariably scheduled on days that I'm scheduled to work and getting time off to attend something like this is just NOT going to happen.

How patient are you?

I've got the patience of Job, I think. My coworkers think they know when I'm irritated, but I try not to let it show. Last night we were chatting about an incident that had happened to a patient and how angry and upset the nurse was. "H" said she had never seen "M"'s face that red and she said she was sure she could see smoke coming out of "M"'s ears. I remarked something to the effect of, "If you ever see me looking like that" and "H" replied that she'd want a front row seat. Now having said all that, our CNE has placed certain orientees, who have been really struggling, with me so that I can assess their suitability for working on our unit. And she has done this because she's seen my style of precepting and knows that I will be fair and objective. Sadly, two of these nurses were let go after their shifts with me, but in the end it was what was best for all concerned. I was really afraid that one of these nurses would have lost her license had she been allowed to continue.

Do you really want to see people come in and succeed?

Absolutely. I've been the new kid on the block a lot of times in my life (grew up in a military family then created a military family of my own) and know how it feels to want to be accepted and included. I also know that our working conditions are much better when we're fully staffed, and the best way to improve working conditions is to have a healthy workplace where people feel valued, respected and supported.

Are you, your unit, and the hospital truly invested in seeing to consistent and effective orientations for nurses entering your units?

I personally am, but the organization I work for is not. When I look at the choices of preceptors that have been made and the fact that some orientees have four or more, all of whom have very different styles and levels of experience, I have to shake my head. Pairing a nurse with generous non-critical care experience with a nurse who graduated last year, was preceptored by someone just like herself and who is still learning the essentials is a recipe for failure, but they do it over and over and over. Assignments are never based on the learning needs of the orientee but on the needs of the unit. If the acuity is high and the preceptor is senior staff, they'll get an assignment appropriate for the preceptor and the orientee learns little or nothing while the patient is possibly at risk. Last year I provided my manager with information on AACN's Essentials of Critical Care Orientation and was blown off like I was in a tornado. Using ECCO would cost the hospital money so of course it was rejected.

You know. . .you've really succeeded when you invest in a fellow nurse and help them to succeed. I wish nursing would get this. In general, physicians are much better with this than nurses. And there is really no reason that nurses can't be more collegial like physicians.

The nurses who are still working on our unit who have precepted with me still come to me with questions and concerns. They feel comfortable coming to me because of my philosophy that the only stupid question is the one you don't ask. The younger nurses see me as a mentor. (Wow, I'm so full of myself!! Time for a reality check... I'm not having such a wonderful time learning our electronic charting package, so I hope I don't have anyone buddied with me until I figure it out!! And I suck at 12-lead ECG analysis. And I'm a squeaky wheel. SO not a paragon...)

Guest343211 · Aug 6, 2009

Jan that was a great reply. You sound like a wonderful preceptor and nurse.

I especially appreciate how you honed in on the fact that ECCO was dismissed out of hand. This is HUGE. Now, dare I ask you this question? Is your hospital a Magnet Hospital. I ask this b/c I think the Magnet people should come down really strong on this.

Nurses need to be more objective and have better balance in precepting. They need courses that are not just a week or so many days. And they need to be evaluated themselves, b/c not everyone that really knows what they are doing--and that do what they are doing exceptionally well--make good preceptors. Some people are more gifted and geared to teaching--and teaching adults in a respectful and not condescending way. Others just are not. So, OK. Don't invest a lot of training dollars in those that don't have a proclivity for teaching or those that don't have the EQ traits needed for the role. But there again, people would need to be objective in evaluating who does and who does not meet the requirements of proclivity, talent, strong EQ, etc.

Some great nurses are, well, simply put, very intolerant and impatient. For example, I remember working with a very good nurse in a PICU. She really was on top of her game; but she was not precepting or teaching material. She was too coorifice, too impatient and intolerant, and had very little understanding for those she precepted or oriented. She wigged over things that did not and should not have been "wigged out" over.

When people make mistakes, listen, the "punishment" or "harranging" should meet the crime. Some unit nurses flip out over issues that really are NOT that huge of a deal. People can manage to make things huge if they want to, but they need to evaluate this in the grand scheme of things--not by way of Monk's standars, if you know what I mean. They waste energy and stress the already stressed out preceptee (novice or experienced or expert) over issues that they really aren't viewing in balance. There is so little objective analysis in these areas with nursing it seems. Nursing needs to change this, and these accrediting agencies could do a lot to move this along.

Pediatric Critical Care Columnist · Aug 6, 2009

Jan that was a great reply. You sound like a wonderful preceptor and nurse.

:omy: :tku:

I especially appreciate how you honed in on the fact that ECCO was dismissed out of hand. This is HUGE. Now, dare I ask you this question? Is your hospital a Magnet Hospital. I ask this b/c I think the Magnet people should come down really strong on this.

Canada doesn't have a Magnet program (and we don't have anything like JCAHO either). In terms of the depth, breadth and outcomes of our clinical programs, we jockey for first place every year with that other notable Canadian children's hospital. But when we look at human resources management there's a huge disconnect. We have a management "team" but very little is ever accomplished on that front. (I haven't had an evaluation in nearly 4 years, for example.) The administration cares more about credentials than abilities. Last year I had a meeting with our management team in my role as unit representative to our union local and my self-appointed designation as a team builder. I was told then that the team was planning a major overhaul of our standards and practices and the basis for it was the Magnet program's framework. Nearly a year later there has literally been zero progress. They chose to enforce the hospital's dress code as their first step... something that should have been ongoing... rather than address things like staffing, safety, engagement, education and so on. I also introduced the AACN's Healthy Work Environments principles to them about 2 years ago; it was well-received, but there's been no improvements there either. But back to ECCO... now AACN has a pediatric orientation package that might be even more useful, but the site license is far too costly for it to be considered. We have a new CNE, someone who seems to have some vertebrae, and I've given her all the information I brought back from NTI about it. No doubt it'll gather dust somewhere.

Nurses need to be more objective and have better balance in precepting. They need courses, to be evaluated themselves, b/c not everyone that really knows what they are doing--and that do what they are doing exceptionally well--make good preceptors. Some people are more gifted and geared to teaching--and teaching adults in a respectful and not condescending way. Others just are not. But there again, people would need to be objective in evaluating who does and who does not meet the requirements of proclivity, talent, strong EQ, etc.

Ain't that the truth! There is NO consideration of any of that when preceptors are assigned, only whose schedule might work. I think that might be changing though. I stopped to chat with our new CNE one morning as I was on my way home after a night shift. She asked me if I'd be willing to take on the orientation of a new nurse who is coming to us with lots of adult ICU experience and "needs someone who can talk to her on her own level, someone who actually has something to teach her". Whoa!! So I brought up a number of issues that have been festering with me for a long time and she said she recognized all of them and was working to change things. (Of course, she's 15 weeks pregnant and will be going on a 50 week mat leave in January...) It was a heavy conversation of a sleep-deprived person!

Some great nurses are, well, simply put, very intolerant and impatient. For example, I remember working with a very good nurse in a PICU. She really was on top of her game; but she was not precepting or teaching material. She was too coorifice, too impatient and intolerant, and had very little understanding for those she precepted or oriented. She wigged over things that did not and should not have been "wigged out" over.

I know more than a few people who fit that description.

When people make mistakes, listen, the "punishment" or "harranging" should meet the crime. Some unit nurses flip out over issues that really are NOT that huge of a deal. People can manage to make things huge if they want to, but they need to evaluate this in the grand scheme of things--not by way of Monk's standars, if you know what I mean. They waste energy and stress the already stressed out preceptee (novice or experienced or expert) over issues that they really aren't viewing in balance. There is so little objective analysis in these areas with nursing it seems. Nursing needs to change this, and these accrediting agencies could do a lot to move this along.

Sometimes it's those very mistakes that teach someone the most. IF it's handled the correct way. I have no problem watching a new staff nurse turn the art line stopcock the wrong way... once... because once is usually enough. One nurse asked me why I didn't stop her so I asked her if she'd ever do it again, seeing how much blood was on her gauze. She laughed and said, "Probably. But you can bet I won't today!" If a mistake is going to harm a patient I'll step in and suggest a better approach, but there's very little harranguing that goes on. And I take some time at the end of the shift to ask what went well, what didn't and how it could be done differently next time. Seems effective.

Did I mention that I heard a rumor that our administration wants to shorten our orientation to 2 classroom days (from 5) and 8 weeks' clinical for new grads (down from 16)? We're a quaternary PICU for Heaven's sake!