Precepting new nurses...

[mommatrauma]

I have been a new staff preceptor for the last 7 years...I have precepted both brand new RNs and 12 year LPNs as new RNs and I've precepted nurses that are seasoned just new to the ER...I have seen nurses both make it and nurses not make it...My question is basically something that concerns my latest orientee...Brand new nurse...level 1 trauma center...her only hospital experience is working as a tech in the ICU prior to graduating...She had 8 weeks classroom orientation doing mandatories, critical care, and all the paperwork stuff...She then had 12 weeks clinical time...She had some rough spots in the beginning with documentation, prioritizing and time manangement...which we worked through and I helped her get her own system down...By the time she came off orientation, she was doing well, notes were well written and organized...her patients were taken care of in a reasonable amount of time, which I figured would continue to get better with her confidence and experience...and she seemed to be holding her own...she seemed much more confident about making informed decisions...We have the option of extending orientations twice if we feel they aren't ready...considering her improvements, she was doing well and I set her free into the wild...For the first few weeks she did well...asked questions, asked for help if she felt overwhelmed, continued to get the job done...She at baseline lives at a higher stress level because of long standing personal family issues and low self esteem....Also, the techs at work started to complain that she was being too needy, asking them to do everything...which I discussed with her and chalked it up to inexperience and helped her try and figure out where she was falling behind in that she had to ask the techs to help her so often...I also spoke to the techs and told them to kinda give her a little lee-way and be patient with her...she's just learning...We are not a huggy lovey bunch...we're ER nurses..and I think there is a tendency that if someone seems like they are not doing well it causes resentment among the other staff members, because having trouble can sometimes be misconstrued as "not pulling your weight" to some people. I fear that my orientee is becoming a victim of "eating our young syndrome" both by our fault as a department and her own fault...Over the last few weeks her stress level has increased...She is a very sensitive person and tends to take everything personal...so it is making her work environment very stressful because she now dreads coming in to deal with the staff that may not be so helpful to her...I have just learned that she has been having a few patient care issues over the last three weeks as well, ie poor charting, meds not being given in a timely fashion...etc...but I also hear alot of bi**hing about both pt care issues and personality issues from the chronic malcontents that every department has...I feel for her...she is a good kid...she wants to please and eagerly tries...she has the potential to be a good nurse, her patients like her b/c she makes them feel comfortable and is attentive to their needs...I felt confident when she ended orientation that she needed some experience under her belt, but I had given her the basics to build upon...but now with all this stress, it seems like she has forgotten everything I taught her....She is eager to learn and listen to people that will help her but some people are so frustrated with her that they aren't giving her the chance any more and are kinda just sitting back and letting her fall. Her self esteem is at an all time low and her stress an all time high...I think part of her problem is that she needs to leave her emotion at the door...because of her sensitivity, she wears her feelings on her sleeve and now its spilling over into her patient care, which I can't have...She feels very comfortable with me, and I feel like i have to take her under my wing and help her, whether its as an ER nurse or to realize that maybe she needs to try a less stressful department for a bit until she can get her focus back to patient care and get her time management better...The problem is I'm afraid she's backed herself so far into a hole I'm not sure how to help her get out of it, before they will have to possibly terminate her. She knows she is messing up and that she is not focused, but wants to really work in the ER...I apologize this is already so long...I have already set aside a meeting outside of work for her with me so we can just sit and try and work through some stuff, and I plan on sitting with the manager and educator to see if I can buy her one more chance...she's already being watched like a hawk...and because she has already stressed out the co-workers, I also have to sit with a few of them and try and get their feedback on how we can help her as a support system to get her back on the right track...I've already spoken w/2 co-workers that were done with her...but I have coaxed them back in to believing that we need to support her not make it harder than it is...I am well aware that maybe this is not for her....but what I am looking for is ideas how I can help her...I want her to have a second chance, and at least if she still fails I can say I did everything I could to help her...I was her preceptor so I feel like I need to be her mentor as well, but I need to help her feel comfortable with more than just me...I can't be there 24/7...How do I accomplish this without making anyones stress levels higher and ensure that she gets a fair shot...If you made it this far, God Bless you!! Any ideas are helpful...and before you respond, keep in mind...we were all new at some point and it doesn't come easy to everyone...thanks

[MAGIK GIRL]

could you ask anyone on the night shift to take her under her wing? maybe just out of sheer respect for you. maybe you, her and the phantom night shift nurse could sit down and talk and come up with a game plan.

i too had a rough time with my orientation 15 years ago. hey, i see a pattern here! i did ok though, here i still am........

[pricklypear]

We had a grad nurse like yours on our unit. Unfortunately, the flaws that held her back in the beginning didn't go away. The limited self-confidence, sensitivity, very low stress threshold. She was very smart, and knew the unit - having worked as a tech while in school. We helped her out as much as we could in the beginning - hoping that she would grow and learn to trust herself. Even after more than a year she was reduced to tears a few times at the end of her shift and often felt "everyone was out to get her." We all felt so bad for her, but there really wasn't anything we could do to help her - it was all internal. You can only put the baby birds back in the next so many times after they fail to fly.

I can't even imagine starting out in ER, especially a busy trauma center. I admire all of you who did and made it. I had to learn how to prioritize the hard way - on the floor. But I learned valuable lessons that helped me make it in ICU.

I'm thinking that she should do some time in another unit to gain some confidence in her skills and learn how to manage time.

Good luck mommatrauma - you have such a good heart!!

[pebbles, BSN, RN]

I had a VERY similar situation last year. Only difference was that this was a student doing her three month preceptorship, or "senior practicum", which is part of the requirements to graduate.

She was just completely overwhelmed, and so any learning she was capable of was overshadowed by her stress and panic. By four weeks in, she had lost the ability to problem-solve that she had started with on her first shift, due to stress.

She eventually withdrew and started her practicum again the next school term, in a different hospital, on a much less acute ward. This is what I would reccomend for your new nurse, because she is headed for burnout pretty soon if no intervention is taken. That, and harming a pt when her skills and confidence collapse.

Your manager should be the one to talk to her, and see about placing her somewhere else, imo. And soon!

[Maggie Mae]

You may have already posted the answer. Sorry I started to skim. I am a new nurse, 9 months. I work on a busy tele floor 7p-7a, 9-11 patients a night. Every week that I work there is something that I need to ask a question about. Depending on the night I get help or shot down.

Learning to be a nurse has been the most brutal work experience I've ever had. Even the "helpful" nurses have an alarmist style of teaching,( for lack of a better term ), and scare the hell out of me. The worst is "What do you mean you did, or didn't, or don't know, etc., and they think they are helping.

The profession can be very unprofessional at times. I know there are a million reasons for that, really valid reasons. That said, how we treat each other in nursing needs to be really honestly looked at. It is not working, we are our own worst enemys. Give the girl a chance. Maybe she will decide she needs to go to a differnt enviornment. One can't just sow seeds and expect flowers, they need to be nurtured for as long as it takes.

[pricklypear]

That said, how we treat each other in nursing needs to be really honestly looked at. It is not working, we are our own worst enemys. Give the girl a chance. Maybe she will decide she needs to go to a differnt enviornment. One can't just sow seeds and expect flowers, they need to be nurtured for as long as it takes.

I think mommatrauma's trying to think of what would be best for the new nurse. I agree that sometimes there is a mindset of "well, she's been orientated, she should be able to function like the rest of us." But the point is, needing to be nurtured and "not cutting it" are 2 different things. She could harm someone or jepardize her license in an environment like that.

[pebbles, BSN, RN]

I think mommatrauma's trying to think of what would be best for the new nurse. I agree that sometimes there is a mindset of "well, she's been orientated, she should be able to function like the rest of us." But the point is, needing to be nurtured and "not cutting it" are 2 different things. She could harm someone or jepardize her license in an environment like that.

Exactly. Being "new" is different from being in over your head, overwhelmed to the point where clinical competence is jeapardised, etc.

ALL experienced nurses will look at a new grad and try to make that distinction, and how to best help the nurses become successful. That's what this thread was about - problem solving to help the new grad. :)

That being said, some of the things a new grad misses ARE things that they were taught, or should have been taught, in school. It's natural to miss things, but sometimes this will prompt a suprised reaction from senior staff. Especially if they don't have a LOT of experience with fresh grads. It's nothing personal, and try not to let it get to you. (On my ward, our new grads didn't "realize" that post-op vitals should be done evry hour for four hours once out of the recovery room, even though I know darn well that this is taught in school, and they did the vitals once in a 12-hour shift. Now we know what to look for, we check for this knowledge when the newbie gets his first post-op)

[mommatrauma, RN]

I had a VERY similar situation last year. Only difference was that this was a student doing her three month preceptorship, or "senior practicum", which is part of the requirements to graduate.

She was just completely overwhelmed, and so any learning she was capable of was overshadowed by her stress and panic. By four weeks in, she had lost the ability to problem-solve that she had started with on her first shift, due to stress.

She eventually withdrew and started her practicum again the next school term, in a different hospital, on a much less acute ward. This is what I would reccomend for your new nurse, because she is headed for burnout pretty soon if no intervention is taken. That, and harming a pt when her skills and confidence collapse.

Your manager should be the one to talk to her, and see about placing her somewhere else, imo. And soon!

And this is alot where she is right now...trust me, she has daily meetings with the managers....and the nurse educator....but alot of what you describe is alot like how she is...she can't get past the stress to problem solve properly...We are working on finding out the best option for her...

[mommatrauma, RN]

You may have already posted the answer. Sorry I started to skim. I am a new nurse, 9 months. I work on a busy tele floor 7p-7a, 9-11 patients a night. Every week that I work there is something that I need to ask a question about. Depending on the night I get help or shot down.

Learning to be a nurse has been the most brutal work experience I've ever had. Even the "helpful" nurses have an alarmist style of teaching,( for lack of a better term ), and scare the hell out of me. The worst is "What do you mean you did, or didn't, or don't know, etc., and they think they are helping.

The profession can be very unprofessional at times. I know there are a million reasons for that, really valid reasons. That said, how we treat each other in nursing needs to be really honestly looked at. It is not working, we are our own worst enemys. Give the girl a chance. Maybe she will decide she needs to go to a differnt enviornment. One can't just sow seeds and expect flowers, they need to be nurtured for as long as it takes.

Alot of what you say is true, which is part of the reason she has been having such a bad time...I am trying to give her a chance...but the chance she has can't be something that stresses her out more...noone should feel how she does about coming into work...They do need to be nutured, however, its not an infinite process either..."as long as it takes" is just not realistic in the ER...at least not in the level 1 trauma center...I can't speak for everyones...I'm doing the best I can with what I have to work with...but like someone else said, if its inside, there isn't much I can change...I can take the horse to the water but I can't make them drink...Some people make it...some don't, its not for everyone, and if it makes her feel like she's going to have a nervous breakdown every time someone gives her a hard time, she may need to move on, for her own sanity..It's not safe for her or her patients to work in those conditions...I am just trying to make sure that we explore ALL of her options, so when all is said and done...I know I did the best I could to help her...

[fuega]

You know what mama I think that you have done all that you can. She probably is a good nurse but if we sat down and thought about it. All the good nurses in the ER were either techs or are just born to rock in the ER. I have no doubt in my mind that you are a great preceptor, but she is just unable to fullfil her part. This job just doesn't sound like a good place for her right now. If she has all these problems that you say she does there is nothing you can do. You know as well as I do that in order to be a good ER nurse you must be confident;your patients life depends on it. If she has low self esteem that is someting that she needs to work on slowly and by herself. You could tell her all day long how good of a nurse she is, but you know that one mistake or that one person that treats her badly, and it will all be down the drain again. I am not saying that this is the end for her but from what I see I think that she might need to work in MED/SURG to improve her nursing base and then move up to to ER. Thats why we have specialties maybe ER just isnt her nitch, you know. Having stress at home and then dealing with all the stress at work isn't like it is for her like it us to the rest of us. I enjoy work it helps keep my mind off things. I hope that I have helped in someway, please take care and don't take it to personal, this just might not be the right timing for her. Everything happens for a reason. I was a teach when I first started and I was fired because I just wasn't cutting it, and I am so grateful for that now 6 years later because now I am a very successful nurse and it took that to get my head out of my you know what to realize that being emotional and not having confidence in my desicions was not the right mind set to work in the ER. It was my dream job and I lost it for the same reasons that this gal is experiencing. She will see eventually what she needs to do and if getting transfered or let go is the way that it has to happen then unfortunately that is the way it has to be. You seem like such wonderful person you just need to know that you have already done all that you could. You really have I don't know many people that would have given her as many chances as you have. It is sad to to say but you kow how our department is sink or swim. Because when it comes down to it you have to be able to make critical and responsible decisions and if your head is in the clouds thinking about how crappy everything is then something very bad could happen.

good luck MAMA:)

[RN@34]

]I am a new grad and the thought of starting out in the ER scares me to death. There is a certain comfort level that needs to be acquired before jumping in to such a fast paced department. I am starting out on a busy med-surg unit-the same unit I did my transition time on. I would love to have started out on a more specialized unit, but I did some soul searching and realized that a couple of years experience on this floor will be the most beneficial to me at this time.

]I also know that from day one there are experienced nurses that can be approached :) for assistance and then there are some that will not even speak. ]Why is that? I wish I knew! Being a new graduate is hard enough without being treated by some like we have plague. I say that to say this-Why in the heck would she want to stay in a department where she does not feel supported? ]What about that thing they preached to us about in school? TEAMWORK!!!