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Discussion

Precepting in the OR

I am precepting a new grad nurse essentially (she transferred to our department after less than 6 months in med-surg as a new grad). At this point, I am half thinking she did so because she thought OR nursing would be a lot easier, and as we are a satellite hospital with a small OR suite, this may be true. However, she is still not picking up with orientation well and she is on month four of a 6-month orientation. This nurse is not assertive in speaking to surgeons or anesthesia—she is so shy that I have to constantly remind her to speak up in Time Outs so the room can hear her. She stands back and waits to be assisted or stands and watches many things and does not initiate many basic things on her own. I have to constantly correct her in prepping technique. She doesn't know how to manage her time effectively, and I am half tempted to let her fail a bit so she can start to figure out her "next steps" in how a case runs, but I don't want the room to fail. Another thing I have noticed is that when I make a comment to correct her, she always seems to have an excuse of why it's not her fault and does not seem to take the criticism without some sort of rebuttal. Finally, when she is done with her cases for the day, she is one of the first people to ask to go home early; she does not attempt to help close out other rooms or stay to work on projects like monthly outdates, all things that would help her really learn this specialty. All things considered, I personally don't think she is a good fit for the department, but when I express my concerns to our educator, she says she is not seeing these things when she checks in with her.

Has anyone been in a similar situation with an orientee? How did you handle it? I want to help, but I am quickly becoming more frustrated with the situation, and I worry about her taking care patients alone when she is off her training in two months because right now she is NOT ready. (Our ortho docs will eat her alive.)

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    We all know the OR is a terrifying place when you are learning, so I am not shocked that in 4 months she is still overwhelmed.  BUT, all of us long term OR nurses do the same thing when it comes to our rooms.....Momma Bear to make sure everything goes smoothly.  Sounds like it is time to step away and let her fail a bit (safely). It's the only way to ensure that she learns that she never wants to forget certain things.

    I have one that does this too, she will not get in there and take command of her room, and has no OR timing because she is fairly new (1 year).  I just started putting her in rooms and letting her get griped at and she is slowly getting better.  It takes time to find that rhythm especially when you are learning 50 different surgeries, 1000s of instruments, different specialties, different personalities, a computer charting system, how to enter charges, etc.  They are just going to have to find their own way and struggle like we did. 

    I would concentrate on making sure she has the safety basics down (positioning, prepping, counting, etc.) then let her flounder on the other stuff. Do not do it for her. Sit in the corner and do not get up.  You are only there as a safety resource.  It may be a good idea to have her switch circulator preceptors every week as well.  Every circulator brings something to the table, and has their own way of doing things. It may benefit this new nurse to see this, and be at the mercy of different circulators.

    Best of luck!

     

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    hl111 said:

    Has anyone been in a similar situation with an orientee? How did you handle it? I want to help, but I am quickly becoming more frustrated with the situation, and I worry about her taking care patients alone when she is off her training in two months because right now she is NOT ready. (Our ortho docs will eat her alive.)

    I'm an OR educator, and we are here to help with these situations! Please make sure you are contacting your leadership team and educator regarding the issues. There are a number of things we can try: remediation with the educator in a safe space such as a simulation, drilling down on specific goals (ie, goal for this week is speaking up and initiating the time out; goal for next week is focusing on prepping technique), and formally creating orientation improvement plans (think similar to a performance improvement plan aimed at those on orientation as a guide to be successful).

    On the flip side, what support have you as a preceptor received? Have you had formal education? It is perfectly okay to allow your orientee to make mistakes that will not cause patient harm. As a brand new grad in the OR, one day I forgot to place the bovie pad. My preceptor saw but didn't speak up. Not to set me up for failure, but because he knew that it wasn't going to cause harm to the patient and me having to crawl under the drapes after asking the surgeon to step out of the way definitely made an impression - I haven't forgotten a bovie pad since!

    Are you providing feedback to your orientee on a daily basis? Feedback is probably the most difficult part of precepting. It's also not just about what the orientee did wrong. It's about a balance of "here's what went well... here's some areas of opportunity".

    And then there's the dynamics of being the orientee - countless new staff have mentioned in our meetings how they feel like they're stepping on the toes of their preceptor. Well, that's because the preceptor out of habit or out of a desire to protect the orientee from a surgeon angry over a delay step in to "help"... except it's not helping because the orientee doesn't learn the full routine of running a room.

    My facility has struggled so hard with preceptors and orientees splitting the work to the point that the orientees are unable to function independently when they're on their own without the second set of hands and we have had to revamp orientation. Once about a third of the way through orientation, in the first week in a surgical specialty, they are with their preceptor. Week 2? The preceptor is in effect "banned" from being inside the room. The expectation is that they are in the hallway right outside so that they are immediately available, but the orientee has true independence in running the room. Were there some struggles? Sure, and we even had surgeons complaining about a 7 minute delay... until we pointed out that when the last group of orientees came off orientation they were complaining about a thirty or more minute delay instead. They got rather quiet after that...

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    If you have concerns are you escalating these to your dept clinical educator as well as to the service line manager ? They need to be aware of the issues from your evaluation of the preceptee. Do you do daily written and in person evaluations with your preceptee, with an opportunity to highlight their successes and challenges ? Typically it should be done in a quiet  area where you are not likely to be interrupted . You need to verbalize your observations to your preceptee so that they know what is up and that they are not meeting the standard then give pointers of how they can improve and then set goals for their next shift with you. Make sure you write down your evaluation each day so that there is a record . This helps alot when there is documented evidence of failure to progress and a need for a PIP or termination. A weekly sit down with the preceptee, you, the preceptor , the manager and the educators is a great way to discuss progress and set goals or initiate a performance improvement plan / modification of training. Honest communication with the person is essential for them to understand that they are not making the grade and either need to step up their game (take the recommendations/ pointers you are giving them) or consider a different area to work in. It's concerning that she/he is not taking feedback appropriately and making rebuttals /excuses. To me this shows lack of accountability , responsibility and maturity in understanding the seriousness of the job. Those are definitely red flags in terms of being predictors of problems in future with this person. 

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