Preceptor Problems... HELP!

[CallaRN]

I'm going to try not to go into great detail, but i was hoping someone could give me some advice....

The other day I was thrown with a random nurse b/c my preceptor was involved with a CRASH ECMO case. So I am paired with this nurse who's been in the NI for 3 years. I personally have been on the unit for about 6 weeks, still working with my primary preceptor, and asking tons of questions. However, I do all of the care, she is there to support me and help if I need her. I always have great experiences, and learn so much each day!

Anyways, this nurse I was with on Wednesday was the type of nurse that I never want to be like, and I feel that I gave compromised care to my patients because of it!!!! I was so upset at the end of the day! Here's a summary of the day. We have a ex-28 weeker 3 weeks post NEC, bowel resection and she had been on the ventilator for 2 and a half weeks (just getting off 2 days prior to the day I had her). They d/c'd her morphine and Ativan (which they were using ATC) and all she had for me was a lousy 45 mg Tylenol PRN order. This little one was in PAIN! Crying, Tachypneic, quivering chin, uneasy, restless, arching, moaning, and inconsolable UNLESS BEING HELD!!!! here's the thing... she loved to be held and even looked at peace when in someone's arms... So another nurse who had her a few days prior thought she was withdrawing from the pain meds etc. Anyways, here's the point to my story... I asked the nurse i was with that day if I should go talk to the NNP about some type of pain management and she blatantly says "no she's fine"... so then I go to put my gown on to pick her up and the nurse was like "you need to chart. dont pick her up" (mind you this is a SCREAMING child)and so I said "OK, I'm going to find a volunteer then" and she says "NO, this girl is going to be spoiled if everyone keeps picking her up!!" ANd all I could think was that this poor girl has gone through sooooo much and had just been extubated... meaning she hasnt been held in 3 weeks!!! I was getting fumed at this point, but being a new orientee I didnt say anything... thankfully, a volunteer came by and I secretively asked her to help me! CAN YOU BELIEVE THIS NURSE!! So I'm doing my charting, and we have to do a pain score with each assessment... and I gave her a +3 which i thought was way low for what I was assessing and this NURSE says that is way too high of a score!!! I broke out our pain scale and I said NO!! if anything she's way higher than a three! She shrugged and said "well I wouldnt have given her a 3!!" Anyways, I'm getting totally frustrated... Besides we have an admission coming in as well. ANd that was a whole other story.... BUt this nurse was just totally lazy and didnt want to do anything!!! Orders from a surgeon were written on the new admit. and she blatantly did not fax them because she didnt want to do them right then! And in a ICU ORDERS MEAN STAT! most of the time unless written otherwise....

I was just beside myself, until I vented to another nurse who of course picked up on it that things werent going so good. I told her that the nurse I was with wouldnt let me hold the child and continuously let the child cry and she said it was pure ridiculous.!!

Withdrawal, Pain, irregardless of what it was, the child was happy being held. What do you guys think? what do you think I should have done? and how can I, as a 22 y/o new grad, stand up to people like this!? I know its important to be able to confront the person but what would I say? Our team leaders and CNS are incredible and I shared this with them, and they're deciding on what to do... It's not only that I dont want to be paired with this nurse again, it's also that I think she should be reviewed for quality of patient care. IMO, I would never put down a screaming child, I would get pain meds ordered, or have a cuddler there all day!!!! (Granted we had a KUB done, and it lookeds great) THe patient should always come first... and in this case, i dont think she did that day... I cant stop thinking about this shift, and about what I should have done differently.

And another quick question... in your units, do you find that they d/c pain meds a little too quickly? I'm a firm believer in pain control and sometimes I just don't get it!!!

[NICU_Nurse, BSN, RN]

Okay. Let's see. First of all, I believe you were correct in your assm't of that baby. The first thing I thought before I'd even gotten 2/3 through your post was withdrawal (from the morphine). The uncontrollable crying, jitteriness, arching, tachy, these are all signs of withdrawal, and she probably should have had a PRN Ativan/Versed order that would be slowly weaned over the course of a few days/a week (or whatever worked best for that baby). One of the things that works with some of these withdrawing babies is containment- likely the reason that being held was so comforting to her. I swaddle my drug babies TIGHT so that they almost look like little mummies- it calms them down, which is precisely what was happening. You picked her up, she felt contained by your arms and chest, and she stopped crying.

I will never tire of saying this and it is one of the most frustrating things in the world to me, and people WILL disagree with me on this (it's happened more than I believe it should have at work), but I firmly believe that:

IT IS IMPOSSIBLE TO SPOIL A BABY THAT YOUNG!!!!!!!!!!!!

Grrrrrrrrrrrrrrr!!!

Babies that small NEED TO BE SOOTHED when they are crying- they are usually too young to have an understanding of manipulation. They have an emotional or physical NEED and it must be met! There is a REASON that they are crying, and even if the SOLE REASON is because they need attention, well, DAMN IT, it has been PROVEN that babies need attention and affection, so freaking give it to them already! When we're talking about a six month old crying because he/she knows that you'll come pick it up, that might be a different story. Neonates and infants have no other way to communicate! They cry, we try to figure out why. Think of Erickson's stages of development- Trust vs. Mistrust- and imagine what you (not YOU) are doing to these babies who are crying to have a need met and largely being ignored.

I'm not yelling at *you* here. You are new. You have excellent instincts, IMO. Next time, chart YOUR assessment of this baby's pain. If it's 8, then darn it, chart an 8. Of course, you as a new trainee are having to defer to your more experienced nurses, and it's impossible for you at this point to know if your instincts are correct. It's a shame that you were paired with this nurse, because I feel that she needs some re-education on infant pain management.

Did you know that mother nature designed babies to develp a certain way for a reason? I read a theory that the reason infants of all species are so "cute" (ie, large eyes, big head) is so that, considering how defenseless they are, the mothers will bond more easily with them and thus ensure their survival. They've done studies and found that images of children and adults who retain some of these characteristics are considered preferable to to other people when polled and presented with slide-screen images. This is one of the reasons that many of the young starlets in Hollywood resemble each other- petite with large eyes (think Winona Ryder)- and why the public prefers certain stars over others. It's subconscious, but it's been studied scientifically and that theory makes a hell of a lot of sense to me.

Even if a baby is crying ONLY to be held, why would we deprive that infant of that? As you said, on a vent for 3 or more weeks, this baby has missed out on the oportunity to bond with ANYONE, and likely the only touch he/she is used to receiving is painful, traumatic, invasive touch. It is OUR responsibility to do what we can to nurture these babies and teach them that touch can be wonderful and calming and soothing; that they can depend on adults to love and care for them and not to hurt them. This is necessary and follows the widely accepted theory of development by Erickson that we all learned in nursing school.

Next time, in a discreet way, I say go right to the NNP.

Phrase it in a non-accusatory manner:

"I am new, and I just needed some reassurance, so forgive me if I'm totally off-base here, but I was speaking with another nurse who felt that this infant may be experiencing withdrawal symptoms. She's tachy, arching, screaming, irritable, jittery, diaphoretic (whatever- inconsolable, just list the presenting symptoms). She's been rec'ing ATC Morphine and now has nothing ordered. I really feel that this baby is extremely uncomfortable, and has a pain score of 5+ (the ACTUAL score according to the chart, not what you compromised on). Is there ANYTHING we can do? Perhaps a PRN order of Ativan to be weaned over the course of 3 days? ANYTHING to make her more comfortable? I understand that you're the NNP and you would certainly know better than I, but I feel very strongly about this and was hoping you could help me."

Don't accuse the other nurse (out loud!) of not caring or not doing what needs to be done; do it in a way that is neutral (no need to offend people right off the bat) but also present the symptoms and basically build your case for this baby. You're the advocate (and that other nurse should be, as well!). If the NNP says no, there's little you can do, but at least you tried. If that fails, get your cuddler ASAP, whether the other nurse likes it or not. However, ultimately, this other nurse is not the final word- that's why you have an NNP or resident or MD present on or nearby the unit.

Though the KUB was okay, I'd also be looking at how recent the resection was- this baby COULD very well be in pain. Surgery is painful. An adult would never stand for inadequate pain management and it irks me that babies often HAVE to. They are not vocal- that's why WE'RE there.

Forget your age- this shouldn't be an issue for you (though I understand how you might feel about it). Very soon, you're going to be a 22 year old nurse on your own making your own decisions (ie, without a preceptor coupling your assignment and taking partial responsibility). While you will still have people to answer your questions, the final decision will reside with you. There's no need to be rude, simply present your case when the time comes and pray that, if you're correct, someone is there and willing to listen.

When I was brand new, it was not uncommon for me to ask THREE people the same question until I heard enough to either be satisfied or to come to my own conclusion by combining other people's opinions. I always worried that I'd offend someone (What? MY OPINION isn't ENOUGH for her?) but I eventually realized that no, it's NOT enough for me. I have no idea if what you say is correct. I need reassurance. No offense, end of story. Which, btw, is why this board became my second home- the nurses here are FANTASTIC and have done more for me than any of my preceptors or mentors have done, precisely because this forum is anonymous and allows me to make a total fool of myself if I'm incorrect without jeapordizing my professional reputation.

((((((((((((((((((((((((((((hugging you))))))))))))))))))))))))))))

Tomorrow is a new day. Take advantage of it. Just because you're young doesn't mean you're wrong.

[NICU_Nurse, BSN, RN]

Holy crap, that was longer than yours! Sorry. I'm an empassioned woman.

[Brownms46]

CallaRn not much to add on here, as NICU_Nurse has done an excellent job in her posts. But I feel compelled to say to you, be very careful in how you approach, and talk with this other nurse you were unfortunately paired with.

Please don't talk about her or the situation, with others in an accusatory way. In fact talk about this situation with your preceptor, and your CNS, but keep to min those who don't need to be involved.

I would be very careful as to who I voiced my frustratons with. You sound like a very knowledgeable and caring professional. I guess I'm just an old traveler who has seen too much, and just wanted to give a little cautionary advice. Good Luck!

[NicuGal, MSN, RN]

Wow....that was certainly a sucky day! I have to agree...be very careful in how you approach this subject with anyone....you probably should just tell your preceptor the facts( and make sure they aren't good friends, if they are go to the CNS or unit manager) and not make any judgemental calls (ie she is lazy, she is mean, etc ).

You are, unfortunately, going to run into this sort of thing for the rest of your nursing career. And believe me, if this is your first job, you don't want to start off with the rep as being "the narc" or " the know-it-all" I have seen a lot of things in my 17 years and those that are labeled like that usually end up quitting because life becomes pretty miserable.

I think that you are going to make a wonderful nurse, and like Brown said, keep it professional, and don't be talking about it to too many others....things tend to get back to people. Good Luck!

[Brownms46]

Ditto on everythng NicuGal said! Just one other thing I thought of. Do not alienate this nurse. Be warm, and polite everytime you speak to her. This may not be the case in this unit, but I have worked where there were family members in the same unit. I have worked with an mother and a daughter, and aunt and niece, and so on. And the mother and daughter looked nothing alike!