Please help me...

WillyNilly · Oct 6, 2008

You can always go to the supervisor about what you have seen and know when you begin on your own to do things the right/safe way. I would say something like "I love being on the unit but I have seen a few things that I have concerns about. Some nurses are doing XYZ and I dont feel it is in the patients best interest or safe practicing. Could XYZ be done or a refresher teaching course?"

I was always taught to voice a concern but always have a solution no matter how silly it is so it shows you are trying to fix it-KWIM?

ewilson3 · Oct 6, 2008

i agree with the reply above, these issues definitely need to be discussed with your nurse manager or educator that is following you. the situations you have described are jeopardizing the lives of patients. it a very unsafe work enivronement for the nurse following and for the patients. i definitelly suggest you speak to one of your suPervisors!!

locolorenzo22, BSN, RN · Oct 7, 2008

Ok, if they are taking VS without actually measuring them...then that is a problem. If the breath sounds are different, then there is a issue. After all, if the next shift catches that, there's a problem that things are resolving quickly.

5 vs 4 staples? Could have just missed one.

You KNOW what you should practice like. And, as sad as it is, either you should report your concerns to your manager...and if no results, I would go to the next level. Realize that this may make you a "target" on the floor....so be prepared. OR...it may take patient harm for these nurses to be caught. You practice as professionally as YOU know you can....and don't become one of these nurses. Always treat your patients as humans, and know that they will recognize that.

Your license is not on the line if you do NOT practice in this way. Give the safe, effective, quality care that you know you can. Good luck to you.

PICURN74, ASN, RN · Oct 9, 2008

I would talk to the supervisor about the things you have seen and then either promise yourself to do what you know is right not what your preceptors are doing or start looking for a new job. An expierenced nurse can be an awful nurse and a new grad on first day off orientation could be the best nurse on the unit. It is evident that you know the most important things about nursing, keeping patients safe.

UM Review RN, ASN, RN · Oct 9, 2008

So far I've had three days on the floor with a preceptor, and every time it's a different preceptor. I am having a hard time with how all of the three are practicing as nurses. I try extremely hard not to be judgmental, after all I am a new nurse, but not new to nursing.
I've observed pulse being counted by just looking at a patient, respirations being entered in a chart at the nurses station after not being counted, lung sounds being charted for without checking (she didn't even have her stethescope with her). These are just the top of my list... bare with me.
We received in report that a patient had 4 staples posterior occipital, thats what my preceptor also charted. However when I went in for vitals, I wanted to observe them and noticed there were 5 not 4 staples. This leads me to question if they were ever even looked at, at all.
All three of the nurses walked into patients rooms unannounced, didn't address patients before getting vitals and as one did, throw the sheets off of a patients lower extremities to assess edema without even looking at the patient.
I found two pills in two separate patients beds, gave them to the nurse and she shrugged and threw them into the sharps container.
Pneumothorax patient with a chest tube had nothing at the bedside incase the tube came out, not so much as even a 4x4. Oh, and lungs were not assessed after removal of said tube.
Hearing in the med room, "we're not supposed to do this... but I'm going to anyway" when mixing medications, and charting meds are given before they are. I happened to question a paticular medication that was being pulled from the pyxis, she was pulling the incorrect dosage... I just asked if I read the MAR correctly and she said to shhh I was confusing her, she finally realized it was wrong when she looked up at the screen and said, "oh, I've never noticed that before, hmmm."
Not counting pulse before administering dig.
Stating to a patient, "I'm gonna put you in a vest if you keep trying to get up!"
Sitting at the nurses station talking, gossiping about each other and their patients... how so and so's a pain, telling personal information.. etc.
This is just a short list, sadly I could go on.
What do I do? I'm supposed to learn the ropes, but I don't want to be this kind of nurse. These nurses (3) have been at the facility for 6-12 years. I'm at a loss and all I get is, "welcome to the reality of nursing". Please tell me this is not it.
How do I stay professional and practice safely in this type of situation? How do I not become jaded?
Am I being too judgmental? Am I looking at this wrong? Please help me. I want to be a good nurse.
How do I continue? I refuse to put my licence in jeopardy, I refuse to not provide the level of care I know I'm capable of. But how do I learn in this type of situation?

Just do the best that you can for your patients. Your assessments, your charting, your interventions all have to be able to stand alone legally. That's the best way to protect your patient and cover your butt.

Learn from these nurses by not doing what they do. Count resps. Listen to lungs. Always assess completely. Make sure the patient takes the pills, not just pockets them and spits them out.

If you find pills in a patient's bed, you cannot give them to the patient at that time, because who knows what they are, how they got there, or when. I would've tossed them too. In fact, I would've searched the bed for more, because who knows if they were given that day or if the patient helped herself to her own home meds. Had a patient who had a stash of various home meds in a baggie in her bed that way.

Experience will come and you will find yourself assessing instantly and automatically every time you come into contact with another human being. (It's how I pass the time in line at the supermarket. I can't help myself. :banghead: )

New nurses make me nervous sometimes because they may also be misinterpreting what they are seeing. For instance, I might be checking someone's pulse by viewing the pulse in the patient's neck, for instance. If I'm really pressed for time, I'll do a very rapid partial assessment and then go back later to finish up. I can take someone's hand and sneak over to the radial side and within a couple of beats, pretty much tell whether the patient is above or below normal. I can tell if someone's respirations are normal within 10 seconds of seeing the patient. I can talk to a patient and determine shortness of breath. The patient thinks that all I'm doing is making conversation and paying some attention to them, but my assessment switch is completely on.

Then there's the new nurse who wants such a detailed report that she makes me wonder if she's doing her assessments at all or just copying mine. I confess, a couple of times I've told her I didn't assess things that I actually did assess, because I wanted to get out of there and because the information was totally irrelevant.

Of course, I have to echo the other posters who suggest discussing your concerns with your supervisor. I just think you should keep an open mind as there might be more than one explanation for what you are seeing in a couple of these examples you gave.

litlamp · Oct 9, 2008

Just do the best that you can for your patients. Your assessments, your charting, your interventions all have to be able to stand alone legally. That's the best way to protect your patient and cover your butt.
Learn from these nurses by not doing what they do. Count resps. Listen to lungs. Always assess completely. Make sure the patient takes the pills, not just pockets them and spits them out.
If you find pills in a patient's bed, you cannot give them to the patient at that time, because who knows what they are, how they got there, or when. I would've tossed them too. In fact, I would've searched the bed for more, because who knows if they were given that day or if the patient helped herself to her own home meds. Had a patient who had a stash of various home meds in a baggie in her bed that way.
Experience will come and you will find yourself assessing instantly and automatically every time you come into contact with another human being. (It's how I pass the time in line at the supermarket. I can't help myself. )
New nurses make me nervous sometimes because they may also be misinterpreting what they are seeing. For instance, I might be checking someone's pulse by viewing the pulse in the patient's neck, for instance. If I'm really pressed for time, I'll do a very rapid partial assessment and then go back later to finish up. I can take someone's hand and sneak over to the radial side and within a couple of beats, pretty much tell whether the patient is above or below normal. I can tell if someone's respirations are normal within 10 seconds of seeing the patient. I can talk to a patient and determine shortness of breath. The patient thinks that all I'm doing is making conversation and paying some attention to them, but my assessment switch is completely on.
Then there's the new nurse who wants such a detailed report that she makes me wonder if she's doing her assessments at all or just copying mine. I confess, a couple of times I've told her I didn't assess things that I actually did assess, because I wanted to get out of there and because the information was totally irrelevant.
Of course, I have to echo the other posters who suggest discussing your concerns with your supervisor. I just think you should keep an open mind as there might be more than one explanation for what you are seeing in a couple of these examples you gave.

That is a valid point, thank you for making me look at it a bit differently. I don't want to jump to conclusions or misinterpret anything and I know being a new nurse I may be over critical which will change as I learn. I guess I just want to learn the book way (facility policy way) first then the shortcuts just in case that person with normal respirations for 10 seconds doesnt have apnea until 15 seconds. I know my instincts will pick up with time and experience. I see now how much I need to work on time management and prioritizing skills and how important they are.

I do understand how you would handle the pills in bed situation, I wouldn't think of giving them at that time I guess my main concern was what if it was a critical medicine? But, not knowing the details I guess just assess the patient from there on for any changes. Would you include something like this in report?

I can understand what you are saying about the one new nurse wanting a very detailed report. Being new, I'm not exactly sure what to give in report. I asked my preceptor last night and she said to tell the on coming nurse "everything".... eek well, that really narrows it down for me. I noticed when I started telling her the critical lab values that her eyes started to roll.... but I thought it was important? In a few instances I received report and the off going nurse knew the patient had an IV but couldn't tell me where or what was running.

I just want to be the best nurse I can possible be, I want to be good with all aspects of care and keeping my patients comfortable and safe. I'm giving it more time before I say anything to my supervisor, and if I continue to see something I'm questionable about I'll bring it up as unjudgmental as possible.

Thank you for responding, I don't know what I'd do without this forum.

UM Review RN, ASN, RN · Oct 10, 2008

I guess I just want to learn the book way (facility policy way) first then the shortcuts just in case that person with normal respirations for 10 seconds doesnt have apnea until 15 seconds.

Why am I sensing that this statement infers that shortcuts are against facility policy? I did not say that a quick check was done in place of a full assessment, only that sometimes a quick check is sufficient until a complete assessment can be done.

Also, even a quick check will take a few minutes. If your patient has apnea after 10 seconds, you'll probably know right from the doorway, because you'll hear no sound vs. a regular breathing pattern.

I do understand how you would handle the pills in bed situation, I wouldn't think of giving them at that time I guess my main concern was what if it was a critical medicine? But, not knowing the details I guess just assess the patient from there on for any changes. Would you include something like this in report?

I would.

Actually, come to think of it, I did find a xanax in bed with a new transfer the other night and what I did was to look up the pill on our Pharmnet, and just in case I didn't figure it out, I sent it over to Pharmacy to ID it. I then included the information in the patient's chart as well as informing the Charge nurse, leaving a note for the doc, and then giving the info in Report. Some might call it overkill, I call it covering your butt.

I can understand what you are saying about the one new nurse wanting a very detailed report. Being new, I'm not exactly sure what to give in report. I asked my preceptor last night and she said to tell the on coming nurse "everything".... eek well, that really narrows it down for me. I noticed when I started telling her the critical lab values that her eyes started to roll.... but I thought it was important? In a few instances I received report and the off going nurse knew the patient had an IV but couldn't tell me where or what was running.

At least you got that much. There have been times when I've been so busy I've nearly forgotten my own name, so to me, that would be forgiveable. I would find it on the MAR before I ever checked the IV because I always check the MAR and orders before I assess the patient.

One piece of wisdom I would like to pass on to you and any other new nurse: Never completely trust the report you get. Check everything. I know, that nurse who gave you report, she's a great nurse, she gets all her work done, blah, blah, blah, but believe me, don't let the fact that you've worked together for years or that you respect her work lull you into a false sense of security. She's going to make a mistake because she is human, and you're the one who has to find the mess and clean it up.

I confess, I probably should not have used that particular newbie nurse for an example because she is really not the norm. I give a very detailed report normally, in a narrative fashion, but this nurse wanted factoids, not a story, and I tend to tell the whole story, not just disjointed bits and pieces, because I can recall it better that way. What cooked me was when I was giving some very important information about one patient's social situation that would have a huge bearing on how/when/where the patient would be discharged, and she looked at me like I was completely stupid and said, "Look, I don't need all that social crap, so spare me." It was a good thing I was in complete shock; otherwise I would've slapped her silly. Whereupon I informed her that I was giving her essential information that she herself might not need, but that the next shift most certainly would, and that she needed to pass it on, if nothing else. Sure enough, next day, everything is in a complete uproar over this patient's discharge, because the newbie didn't pass on "all that social crap." :banghead:

But I digress. :wink2:

I just want to be the best nurse I can possible be, I want to be good with all aspects of care and keeping my patients comfortable and safe. I'm giving it more time before I say anything to my supervisor, and if I continue to see something I'm questionable about I'll bring it up as unjudgmental as possible.
Thank you for responding, I don't know what I'd do without this forum.

I just wanted to tell you that there are sometimes some other interpretations for what you are seeing. Just wait'll you hear some of the truly bizarre explanations for the weird things I've found, that if I hadn't seen them with my own eyes, I wouldn't have believed. I depend on my coworkers; patient care is really a team effort. I was a very by-the-book nurse who has learned to give my teammates the benefit of the doubt.

But there does come a time when you need to take it up the chain, and I do not hesitate to do so if I feel that a serious problem has occurred.

I predict that you will become a good nurse because your concern for the patient is central to your practice.

litlamp · Oct 11, 2008

Why am I sensing that this statement infers that shortcuts are against facility policy? I did not say that a quick check was done in place of a full assessment, only that sometimes a quick check is sufficient until a complete assessment can be done.
Also, even a quick check will take a few minutes. If your patient has apnea after 10 seconds, you'll probably know right from the doorway, because you'll hear no sound vs. a regular breathing pattern.

No, I'm very sorry, I didn't mean for that to sound like an accusation. I meant it as how I'm being preceptored.. which has included all the short cuts but not anything as you just mentioned.... that it does not replace a full assessment. I observed my preceptor not do a full assessment (I didn't leave her side from the patient to the computer for charting) She charted as if she did complete a full assessment.

I predict that you will become a good nurse because your concern for the patient is central to your practice.

Thank you... you don't know how much this means to me right now! On my last roundings, so far, I've had such kind complements from both families and patients and no matter what has happened throughout the day it's that moment that means the most to me. If they are comfortable and I've been a good nurse for them it can turn a bad day into a good one. It's becoming my favorite part of the day.

Thank you for understanding how I feel, and thank you for all the insight I've been looking for.

UM Review RN, ASN, RN · Oct 11, 2008

No, I'm very sorry, I didn't mean for that to sound like an accusation. I meant it as how I'm being preceptored.. which has included all the short cuts but not anything as you just mentioned.... that it does not replace a full assessment. I observed my preceptor not do a full assessment (I didn't leave her side from the patient to the computer for charting) She charted as if she did complete a full assessment.

I see why you're concerned and believe me, that is a very valid concern. In future, when you are on your own, you might not be able to observe such careless practice, and all you can do to protect the patient from nurses like that is to first make sure you assess completely. Do the best you know how for your patients. Keep learning, keep getting better. Don't be like them. Whatever you do as a nurse has to be able to stand on its own.

So if the nurse before you assesses no sutures and you find sutures, chart what you see --"Sutures to R eyebrow clean, dry, intact, wound well approximated." Let those who review the chart make their own conclusions as to why, 1/2 hour earlier, the patient was described as a/o X3 with intact skin.

You might want to start noting what you're seeing in a personal logbook or journal for the eventual conversation with your supervisor, because a lot of what you're observing is concerning. However, you do have to choose your battles carefully, so my advice would be to stick to discussing things with your supervisor that were absolutely verifiable.