I am also trying to work more shifts back to back on the weekends, but this comes with consequences. Sometimes I forget that this is a job that involves many people & constant human interaction with not just patients, but also staff. They all influence me more than I thought. In fact, I started to become paranoid and thought that my preceptor was gossiping about me. I didn't have proof of that but I felt terrible for 12 hours. I kept hearing rumors and I just felt crushed from the pressure. It was awful. I have a lot to learn.
It all started with an incident. Lately, I've been trying to cram all my shifts together to get the endurance needed to become a nurse. For the past 4 weeks, my preceptor and I have been working hand in hand. It has been mostly me shadowing her closely for the first two weeks. But after that, she began to gain confidence in me and gave me one, then two patients.
She wanted to try me with three patients today, but then something happened. My first two patients were much older & extremely high fall risks because they were AxOx1 and had active UTIs. I suspected that we couldn't have 1:1s on them because we were short staffed (again). One wanted to beat her husband with her cane and it was sad to see his little limp body crying in the hallway. Apparently, she's convinced that he cheated on her. It turns out that it was true! ...60 years ago. But you can't blame her for perseverating on it for almost a century. (NEVER CHEAT ON YOUR SPOUSE is the lesson here). The other one also had severe dementia, but she could still furiously press the nurses' call button and yell "help, HELP" every 3 minutes. Oh and they both had an ostomy for me to clean q2h & neuro checks. Since I was a 'primary' (my preceptor didn't want a Corpsman to help me because she wants me to do it all on my own), I would drop everything and run if either one of them would try to leave the bed.
One of them did leave the bed. How did I know? Because whoever was messing around with the alarm while trying to help her to the bathroom while I was on break forgot to reset the alarm. When I went to do my hourly checks on the homicidal lady, all I saw was an empty bed. Then the Flagyl I had up was still running (it wasn't supposed to be done for 2 hours), but no patient! I followed the line and saw that the catheter was on the floor, dripping. I announced that I was coming into the bathroom and when I went in, I saw my lady tugging at her tele leads, diaper on the ground, ileostomy open (leaking red bile now, btw), pee all over the floor and what looked like gallons and gallons of blood on the toilet (I had given her heparin earlier that morning)! Luckily, she hadn't fallen. So I snatched her up, put the gown over her, placed my gloved hand on the bleeding site, and walked her back to her room and placed a new IV (after 3 tries) while she was wiggling around.
My third patient was in airborne isolation to r/o TB. I didn't have an N95 so I had to use a helmet and a papper (machine that blows air down into my helmet) to be able to enter the room. I had him running intermittently on Zosyn q8 and Vanc q12. My preceptor would watch me prime and hookup the bags, program the pump, and flush the PIV through the room window to make sure I prepared it right. Then she'd mask up, walk in, & administer the ATBs. I also had to get three sputum samples by the end of the day, a urine sample, and draw stats lab for his trough levels (his creatinine was up to 2 today). He was a hard stick so I would use his feet. He had continuous meds, like usual, but was also very nauseous and wanted only ice cream to eat so I had to get him new ice chips (because they were stale) and heat his soup. He started to fail to thrive so it got to the point where I went down to Subway to give him something he'd like to eat. Then I'd push Zofran, make sure his SCDs were on, make sure he'd do his spirometer, his oral care (because my assessment note indicated that he needs more of that), and ambulate him around the room while hooked up to the meds. He wasn't really a fall risk but because he said he had syncopal episodes at home we kept him in bed in SCDs and a bed alarm, which he kept telling me that he didn't like.
Then something else happened. One of my other disoriented ladies went catatonic. Then her head whipped back, she was unresponsive, and her pupils were pinpoint. Her blood pressure was extremely low and she was barely breathing. My preceptor called a CODE Stroke. Then I rushed to stabilize her. At this point, I was still in the TB room but I started to see the commotion. My guy's Zosyn was done so I d/c'd it but kept him on the NS flush. I was programming it to run continuously, so I put it on rate 999, and was just about to input the VTBI when the stroke happened. I couldn't see with my helmet on so I pressed the start button and ran out of there to help. After quickly stabilizing the patient, the Rapid Response Team arrived and I tried to gather my thoughts. Then it hit me.
I had programmed my IV as a bolus.
I ran back into the isolation room and suited up as fast as I can and turned off the pump. I assessed my patient (he was perfectly fine) but the damage had been done. I had pushed around 250 mL of sodium chloride without a doctor's order. I had to tell my preceptor and then I had to tell the doctor. No interventions were necessary but it was very embarrassing. It could have been worse. But it is still a grave mistake in my eyes.
My preceptor said that it wasn't a big mistake, but it was still a mistake. However, she didn't demote me to two patients because of that! It was because my charting wasn't exactly the way she wanted it. Charting for her is very confusing to me because there are some invasive devices that I have to chart on, such as PIVs, Foleys, but some that I can't, but are still there such as ports. She also doesn't chart by exception so I can't miss anything. And even if I charted everything, I still had to do it in the right order.
All the progress I made during these past few weeks felt like it was all for naught. Was my preceptor giving up on me because of the pump mistake? Was she just parading me around to taunt her power to the rest of the staff? One of the Corpsmen asked me to help her transport a patient so I did. While we were walking down the hall she said, "why do you let [the preceptor] talk down to you? You can just ignore her." I told her that I couldn't. No matter how my preceptor acts towards me, she is still teaching me. And for that, I'm grateful.
Don't get me wrong, I'm very thankful for my preceptor because she is guiding me to be a stellar nurse. But an occasional compliment or reassurance that I'm making progress wouldn't be such a bad thing. It sucks when I'm only being talked to when I make a mistake. It seems that my charting is always "nearly at [her] standards," but not quite. It's demotivating. I'm only human. One time, I saw her talking to her Corpsman on the screen and every time I walked by, they would hush. Were they talking about me? I thought I was improving...I felt crushed.
This was the last straw. Now I felt like I wasn't being taught--that I was being bullied. I decided to call the Professor on break and ask her if I could talk to my preceptor about how I was feeling. I also wanted to ask Professor if, on the chance that my preceptor and I couldn't see eye-to-eye, that she let me reschedule my shifts so that I can try with another preceptor. Any other nurse would have been much nicer.
Professor listened to my complaints and my proposal. She encouraged me to talk to my preceptor about what I was feeling and had me practice it to her over the phone (I didn't do too well). Then she told me that changing preceptors wasn't really an option unless my preceptor insisted on it. I had to work it out with my preceptor.
Dejected, I went back to finish the rest of my shift. I couldn't look anyone in the face. People were wondering because I wasn't my usual smiley, jokey, flashy self. When my preceptor saw me, she demanded to know if I was 'really' doing my q2hour ostomy checks on my ladies. I said "yes, of course. Up until 1300 before I went on break." And she said, "well, I don't know, because while you were away my Corpsman saw that the bag was red and her stoma was swollen and extra beefy and now her H/H fell 4 points so..."
How can this day get any worse? I felt like a spotlight was on me. I practically begged my preceptor to take one of my patients back, but she said no. She would help out more with the ladies but she would still entrust the patients to me. She didn't say why, and then she left. Then one of the other nurses called out, "Hey, bed __ needs some help. His leads are off and he needs a bunch of other stuff." Without hesitating, I jumped up and said, "Oh, he's mine! I'll take care of him." It was nice to know that even as bad as I felt, that I would still take care of my patients. Inside I felt like I was the WORST NURSE IN THE WORLD, but I still wouldn't let my patients see that. I can still be a professional. I can always drink my sorrows away later. But for now, I still had two more hours left at my shift and I'll be DAMNED if I turnover a neglected patient to the oncoming shift.
Without prompting, my preceptor came back into the room and said that my charting "only had 1 or 2 mistakes on it, but I changed them online so it's ok now," then flew away again. That was the best compliment I could hope for. My patient looked at me and said, "that nurse preceptor of yours only has one speed, doesn't she? Even after ten hours I only see her as a blur." We both laughed. I really needed it. I came up to my preceptor before handoff report and asked her if we could talk about...things.
"Well, I just want to discuss...my performance today. We can talk about it together or you can also call my professor."
"Which is it? Talk to you or to your professor?"
"Well, we can talk first, if that's ok."
"Ok. Let's talk. Come with me to the nursing station."
Before I could ask her to go to a private room, she began our conversation. "Is this about the stat lab? Because when I tell you to draw blood or get a specimen I want you to do it now."
"But didn't you teach me that the flowsheet charting was more important than anything?"
"Yes, but this is more MORE important. I feel like you want me to give you a black & white answer, but that's how nursing is. Everyone is different. Charting is different for different people. That's just the way it is. That's why I don't want you to copy your notes forward, I want you to start your assessments from the very beginning without looking back at yesterday's notes."
"Okay, but it's hard for me to know how to improve if you don't set a precedent. I can't prioritize if our priorities always change! I'm not trying to shortcut on charting but based on other nurses' charting your notes have way more content. You don't like charting by exception."
"I never leave anything to chance. And you should be the same way. But if it makes you feel better, my standards are very high. Not everyone can achieve them. And you seem to be intimidated by me sometimes."
"Yeah, I am. Because your opinion is important to me. You are teaching me."
"Then keep at it. I think you're making progress. You just have to do things over and over. I've already been a nurse for a year. You still have a long way to go."
"Then how do I know if I'm improving."
"You are. I just don't have the time to tell you. I have four other patients and I'm watching you while you take care of your two. When you can show me that your charting is not just excellent, but that it is perfect, then I will move you up to three patients again. It's better to be perfect with two patients before you move up. I know you can handle three patients but it's just not up to my standards quite yet. But you'll get there."
"Are you sure I'm not getting in your way?"
"Of course not! We just need to communicate more. It's easier for me to catch & fix your mistakes if you tell me what you're going to do. Now, when am I going to see you next?"
"Good. I'll see you in a few days."