Precepting Med-Surg Nurse to ED

CX_EDRN · Oct 8, 2016

I think the first shift or so is just a general orientation- this is where this, this is what we do when x happens. Big, generalized stuff. Then you can begin to see areas of strength/weakness. Ask what he/she thinks are his/her weaknesses and where they need to improve. The RN may not have monitor experience, but does have experience in assessments, medication administration, etc. Make a goal or two for each week and then either move on or cover it some more. Ask how they learn best. Watch one, do one is generally used in my ED. Remember that the first few shifts will be overwhelming and be patient and encouraging. I went to the ED from the floor and I really value my time on the floor, I knew how to use pumps, etc much better than most of the ED RNs and my preceptors took from me just as I did from them. My favorite preceptor was a male RN who would sing silly songs to me when things got tense, you may or may not want to use that strategy.

Oh, and some specific things that really helped me:

Being to name who/what my resources were at any given time/situation

Being asked patho/associated labs/imaging for each presenting symptom

Being asked what meds to give in what order (ACLS, RSI, etc)

Being asked what I was going to do in the next 15 minutes

Being asked to constantly prioritize my patient care

My preceptors were tough but expected excellence from me. I wouldn't change a single thing about it and credit a lot of my success directly to them.

CX_EDRN · Oct 8, 2016

Oh, and I forgot to add that I was expected to go through our trauma lockers repeatedly until I had memorized where most of the equipment lived. It was not uncommon for a charge to walk up to me during a shift and say- hey where are the thoracotomy trays? Oh, the second locker halfway down? Okay. And then walk away. But it was done in a way that made me think on my toes without making me feel stupid.

Lev, MSN, RN, NP · Oct 9, 2016

Thanks for the tips. I came from the floor to the ED and it was not an easy transition, even with telemetry experience.

Lev, MSN, RN, NP · Oct 23, 2016

Ok some updates. She is more experienced than me in years (half in a different country) however, knowledge is far behind. Did not know to do blue top before purple topped blood cultures.

She is also taking on too much at a time. She had two patients, I told her I was going out to get one for myself. She comes into the room when I bring the patient back and starts taking over and starts assessing the patient. I understand that she wants to help but leave me alone for a second! I left the room to tend to HER patients who needed to be hooked back up to the monitor, labs, meds, bathroom, and belonging sheets. Hopefully she got the message. I will speak to her explicitly about it.

If she doesn't know the monitor should I be giving her patients who need tele to care for alone? Should I be assessing them to? She documents the cardiac rhythm, but she copies the rhythm that the EKG machine spits out which is not always right. (I checked her assessments to make sure she was documenting it correctly).

I've given her lots to read and told her to review EKGs first.

Thoughts?

offlabel · Oct 23, 2016

Ok some updates. She is more experienced than me in years (half in a different country) however, knowledge is far behind. Did not know to do blue top before purple topped blood cultures.
Thoughts?

Blood cultures are sterile. Are you not supposed to fill them before filling unsterile tubes?

Slobgob · Oct 25, 2016

She wasn't talking about the coag blue top. Both blue (Aerobic) and purple (Anaerobic) tops are both blood cultures.

The blue goes first, but honestly if your line is already primed with blood, I don't personally see the reason you couldn't reverse the order. But I'm not the brightest.... :)

MDMBSNRN · Oct 25, 2016

I've worked in both ED and ICU, but I've only ever precepted in various critical care units. Usually for orientees who are unsure of rhythms, I take them into the room, and ask questions. "What rhythm do you see on the monitor? Do we need to immediately intervene related to the rhythm/rate/blood pressure? Do you have any concerns about the rhythm, or how it relates to the patient's chief complaint?" I try to be gentle with these, and not make my orientee feel like I'm belittling or insulting them.

During downtime on the unit (which is seldom), I also tried to make it a point to show my orientee rhythm strips (especially of concerning rhythms like A. fib, A. Flutter, V. Tach, V. Fib, and various degrees of heart blocks). I would ask what the rhythm was, and ask my orientee what should be done if the patient converts into one of these rhythms. Together, we would review treatment algorithms for each rhythm.

As far as giving her telemetry patients alone, I wouldn't feel comfortable with that. I would supervise, even if from a distance, until I felt that she was more competent with identifying various rhythms, and knowing what to do in the event of an acute cardiac issue.

Lev, MSN, RN, NP · Oct 25, 2016

I've worked in both ED and ICU, but I've only ever precepted in various critical care units. Usually for orientees who are unsure of rhythms, I take them into the room, and ask questions. "What rhythm do you see on the monitor? Do we need to immediately intervene related to the rhythm/rate/blood pressure? Do you have any concerns about the rhythm, or how it relates to the patient's chief complaint?" I try to be gentle with these, and not make my orientee feel like I'm belittling or insulting them.
During downtime on the unit (which is seldom), I also tried to make it a point to show my orientee rhythm strips (especially of concerning rhythms like A. fib, A. Flutter, V. Tach, V. Fib, and various degrees of heart blocks). I would ask what the rhythm was, and ask my orientee what should be done if the patient converts into one of these rhythms. Together, we would review treatment algorithms for each rhythm.
As far as giving her telemetry patients alone, I wouldn't feel comfortable with that. I would supervise, even if from a distance, until I felt that she was more competent with identifying various rhythms, and knowing what to do in the event of an acute cardiac issue.

Thanks this helps. We had a patient in a-fib the other day which is a fairly regular occurrence. However, she doesn't know what that means as far as the hearts electricity, does not know interventions if it were to go faster.. etc. She was able to document a-fib off the EKG but that was about it. I was just kicking myself because I went into the room to draw labs on the patient and noticed he was in a-fib and felt I should have known that an hour ago - in my mental back brain of patient facts.

The other thing that happened which was alarming is that she started rolling my patient out of the room to go upstairs - I was with her - and the O2 tank was empty. I had told her to check the O2 - I guess she hadn't heard me. Fortunately I glanced at it and realized. This patient was practically breathing with only 1 lung and was on a venti mask at 12 liters.

MDMBSNRN · Oct 26, 2016

Not checking an oxygen tank is simply poor practice. I understand that we all get busy sometimes, and none of us are perfect as nurses or people. I also understand that mistakes are made, and things are sometimes forgotten. But checking an oxygen tank should not be something that slips your mind as the bedside nurse. Especially not when the patient is on 12 liters of oxygen, and has multiple pulmonary/respiratory complications/issues.

At some point in the orientation process, it may be time to talk to your unit educator. If you are teaching, and trying your best to orient her to the department without results, it is worth mentioning to the educator. At all the facilities I have worked at, the educator was responsible for handling length of orientation, helping to schedule classes, and ensuring that new hires were growing in skill/competency during their orientation periods. I am sure it is much the same at your hospital.