Precepting med-surg nurse

WestCoastSunRN, MSN, CNS · Nov 23, 2016

What a great question! I have some perspective on this as I was an ICU nurse (and preceptor) for 10 years before taking 8 years off to homeschool my kids. I am reentering now and did my clinical hours in a very high acuity medical ICU. I had several preceptors. I am an experienced nurse but had been away from the bedside a long time -- so the clinical hours were so important!! Here are my thoughts:

I understand the task orientation. It is very common, and management of tasks coupled with prioritizing care is probably the number one skill to be developed in a critical care setting. I also understand how a preceptor is ultimately responsible for the patient and that does and should weigh heavily. So we could say that the top skill to have as a preceptor is learning to know when to step in and when not to... and being OK with "good enough". "Good enough" should never compromise patient safety! But I know how we critical care nurses are. We are control freaks and it makes us good at what we do. I hope you don't take that wrong.... I am painting with a broad brush, I know- and I am one of those control freaks -- maybe you aren't.

So you need to be having time to talk with her about what you are seeing. You also need to teach her how to prioritize. Yes, she may learn some of this by watching you, but at the end of the day, she is going to need to do it herself with YOU being the observer.... no matter how painful that may be to watch -- because undoubtedly she will NOT perform exactly the way YOU would. You will need to be her shadow and become less and less "visible" to the patients and to her while still keeping an eagle eye on all that is happening and being ready to intervene if needed. You might come up with code words or gestures between each other that will cue her in certain ways if she isn't picking up on them herself just yet. The WORST feeling as someone coming into a new area is to be interrupted and made to feel stupid -- and even the best-intentioned preceptors can do this in the interest of patient care. But even more importantly, often newbies function at what the expectation is. She will likely rely on your help if it is always there. She's got to be weaned off of that. Precepting is both a skill and art and it takes time and experience to develop. I applaud you for doing it. It seems you are really seeking your orientee's best interests as well as your patient's!

Lev, MSN, RN, NP · Nov 24, 2016

Thanks for your reply. Yeah, I have been working on the ok with "good enough." I have modified her assessments (mostly the cardiac rhythm assessment because she has no tele experience and will document sinus rhythm for a patient who is tachycardic for example even though I have explained this to her).

I think I need to be present but not interfere unless patient safety is at stake. Is that a good way to look at it?

WestCoastSunRN, MSN, CNS · Nov 24, 2016

Well, yes... I think that sounds reasonable. That said, it does sound like she has competencies she needs to work on --- ECG interpretation for sure. Hopefully this is a part of her orientation to the ED?

But as she gains competency on paper, then she needs to work out that competency at the bedside obviously. But it sounds like you are well tuned to her needs at this point.

Natasha A., CNA, LVN · Apr 28, 2017

I work in the ED and I'm precepting a nurse who transferred from one of the med-surg units. She is doing great in most areas. Has good time management skills and is eager to learn.
In the past couple shifts we've had a couple ICU patients. I did not see the urgency.
I had a patient who was desatting on BIPAP and then high flow and taking a long time to recover and the 4-5 times that it happened that shift, I was the one who noticed her distress, notified respiratory therapy and the MD, medicated her, and documented what happened and my interventions. At the time I had to act and couldn't go looking for her.
She is very task oriented. I know this is pretty typical for a med surg nurse. I was one myself.
How do you teach that critical eye, and one over?
Should I be taking the critical patient and make her be at my side and explain everything I'm doing? Should I take over the assignment so she can see me balance the critical patient(s) with the others. I think she was busy with the other patients and kind of depended on me to be her safety crutch and take care of the sick one.
I don't want to seem possessive of the patient who needs attention. The fact is, I am possessive because they need help and I am the one around and equipped to give it. Maybe she is sensing this.

Hi Lev

Great post. Can you please elaborate on having the "critical eye?" Do you mean detecting early signs of deterioration in critical care? Knowing the biomarker assessments or labs?

CCU BSN RN · Apr 28, 2017

If I were your orientee, this is what I would want:

1. First and foremost, make sure the patient gets the care they need, whether you do it yourself or go pull your orientee. Either/or, but thank you for putting the patient first.

2. Later on in the shift, when you've had some time to simmer down and your orientee isn't overwhelmed (maybe best done at the end of the shift, because what I'm suggesting next would probably make me cry, but I'd still want to hear it), be blunt and honest. Ex. 'We need to figure out a better way for you to be able to break your tasky routine when someone is declining. You need to be able to put routine tasks on hold at a moment's notice and rush to your critical patient's bedside. Today, I noticed that your patient was declining and treated them, because you could not be found. This would be unacceptable if you were off of orientation. I care about your future here, and want you to become competent as soon as possible. Let's both go home and think about ways that we can better handle the situation when it happens next time.'

3. Admit that you're not perfect and that you need your orientee's help to learn how to teach him/her best. Find some positive thing about your orientee and say it to them. You can't only provide negative feedback, and it sounds like there are plenty of positive things about this nurse. This is also an appropriate time to share something stupid that you did when new to the job and what you wished you had known then.

Overall, if you manage to have a convo with your orientee where you both go brainstorm ways you can do better, and you both still like and respect each other at the end of the day, you win at precepting.