studog12

Hey @0.9%NormalSarah, Good tip. I’m trying to take the approach of getting the important details I don’t get in report right after report and then get going to be as efficient as possible with patient care. Afterward, if I have time, I then can dig more, read notes, etc. Thanks for ICU reference. I guess I kind of have the brain of one, just not necessarily the desire for the adrenaline rush. Ha. Appreciate your comment!

Thanks, @LovingLife123. Really appreciate your input, and it’s good to know you take the time to look things up and have a good baseline before you start your day, too. It seems like taking the extra time to look things up, as time and the flow of the day permit, is always the safest thing to do. It helps prevent errors down the road. Thanks again! Ethan

Hey Caroline, Thanks so much for your thoughtful and encouraging response. It means a lot to be recognized for being safe by being thorough, as often times speed and the revolving door business mentality is what seems to dominate hospital life, too often at the expense of safety. Even though I am experienced, sometimes I wish I could just be a fly on the wall to observe and learn how other good nurses do things so I myself can be better. You can always ask (like I do on here), but it can be a little awkward to ask about routines in person, particularly if you’re more experienced (“Why is he asking about such a basic question? Doesn’t he have a good and efficient routine by now?”). I think you are spot on about communicating strengths and weaknesses, especially with preceptors when moving to a new speciality. I try to be as aware as I can of my own and be open to suggestions from anyone, experienced or new, that can make me better. And I think when you’re in training mode and you have different preceptors with different styles and pet peeves, I’ve gathered that your own habits and preferences can clash (for lack of a better term) with theirs. Consequently, just trying to be open and humble by listening and even adapting temporarily to their suggestions so as to not create tension in the relationship, even if you disagree, is a wise thing to do. And as everybody says, one you’re out on your own, you can establish your own flow and do what you think is right. Thanks again for sharing your experience. All the best to you during this very difficult time for nurses… Sincerely, Ethan

Hey, everyone. I’ll try to keep this as brief as I can so as not to exhaust readers. So, I am a PCU nurse with about 5 years of experience, and at this point I feel pretty confident in my clinical skills and the knowledge I’ve acquired (though I know there is always tons more to learn). The issue I am having is my workflow, in that I worry I am too slow or over analyzing things. My routine goes something like this on a “regular” night: Get report, look at the MAR and orders to see if something was missed throughout the day that needs to be immediately followed up on. Or if there is, say, a q 6 or 8 hour antibiotic due soon that needs to be brought in with my first assessment. I then complete all of my assessments and return to the computer to write down which patients have AM labs, review the patient’s lab results (sometimes from admission to current date if it’s not too much, in order to look at trends and get a better overall clinical picture), check micro for cultures as applicable, and then vitals to note which meds to hold or question, as applicable. I also fill in anything I didn’t receive in report, like history, consults, bed status, etc. I then begin my med pass as normal. The thing is, I always seem to be behind other nurses. But, I don’t know if that is because I over analyze things or if they don’t look at orders and labs and other important details. I can’t tell you how many times I have caught orders that were missed that would have been caught had the patient been reviewed thoroughly and systematically. That’s not to toot my own horn, and I don’t ask annoying and petty questions during report—it’s just pointing out that even though I am slower in my routine, I think it’s because I am being conscientious and trying to do a good job. But I wonder if others are doing what I’m doing and doing it faster, or if they’re not checking all they should. In light of the aforementioned, do you all get the perception I am taking too long? For the most part, I am able to give meds and see patients on time, prioritize seeing sicker patients first, at least lay eyes on them during report, and keep up with things (at least on night shift…ha.). But, when I was training in the past, I got the impression from my preceptors sometimes that I was taking too long (granted, I was newer then). More recently, when I was “up training” for ICU to help out during the height of COVID last year, I still got that sense sometimes from the ICU nurses I trained with. I am acutely aware the floor or unit moves very quickly at times, and that you never know when sh** is going to hit the fan. But I also hate not knowing what’s going on with my patients and feel an urgency to fill in missing details from a bad bedside handover, say, or when getting an admission right before shift change. I am also aware you have to use your clinical judgment and prioritize patient care and safety, so that may mean dealing with a sick patient all or most of a shift with an incomplete report or clinical picture due to lack of time to review properly. All that to say, do you all have any suggestions about what I can do to improve my current routine? Do you have a similar routine? How do you all balance the need to have solid information and prioritizing patient care and safety? I really appreciate your time. A part of me has the ICU bug and would like to give it a shot, but even though I have five years of experience and feel confident in my clinical knowledge and ability, I don’t feel particularly confident in my routine and don’t want to run into problems with it if I were to transfer to ICU. As you all know, even though details matter and ICU nurses tend to be on top of things, stuff can happen very fast and you don’t want to get too far behind and overwhelmed. Thanks again and hope you all are well where you are. Sincerely, Ethan

Thank you both so much for the thoughtful responses. I ended up getting to shadow some of the ICU nurses for a few shifts as part of an "uptraining" program for PCU nurses when the pandemic was hitting us hard in the beginning. The shifts went well, but after revisiting again firsthand what ICU nurses do and actually getting some good hands on experience helping care for critically ill patients, I found I just didn't have the fire in my belly to do it. A part of me thought it was cool and intellectually stimulating, but given my lack of will to deal with the extra stress and to work with other nurses who are just more type A than I am, I decided it was best to stay put. Plus, this particular ICU was very short staffed and didn't have techs to help with patient care, and for me that was a significant concern. Again, I really appreciate the words of wisdom and support from both of you. I read every word and took it all to heart and thought about it carefully. God bless and all the best to you both, Ethan

Hey everyone, I’ll try to keep this as short as I can. So, I’m at a crossroads and I don’t know what to do. To give you some background, I am a PCU male nurse with about 3 1/2 years of experience working in a cardiac/neuro and a multi system PCU. When I first became a nurse, I got a job in a cardiac ICU, and it didn’t go well. I had a terrible experience with my preceptors, and I was so stressed out during those 4 months I was orienting that I literally haven’t been the same since. Needless to say, I ended up resigning. Now I am more sensitive to stress, have less energy, and it just seems I lost part of my vitality, even though I take good care of myself (I.e., eat well and exercise, although I do have an irregular sleep pattern due to currently working nights). Anyway, despite that initial bad experience, I was able to get back on my feet with my career in PCU and that’s where I have been since. Ever since I left the ICU, though, I have always been curious about what it would be like to go back with some experience under my belt. I have become a good nurse—I am systematic, conscientious, caring, and a good team player. I am also a good critical thinker, have a calm demeanor, and intellectually curious, all of which I think would be a good fit for ICU. However, my main issue is I am more sensitive to stress and do have anxiety (more OCD-like anxiety than generalized), so I wonder if the inherent stress of the ICU would be too much for me. Sometimes I think it would, sometimes I don’t. Even with my mental health issues and the traumatic experience in the past, I am still able to handle the PCU and the stress of hospital work. But it’s just back and forth for me in regard to whether I should give the ICU another try. The unit I would be going to is lower acuity, so it wouldn’t be a big jump in that regard. However, I am also apprehensive about the culture of ICUs in general—they tend to breed strong personalities (understandably so) and unfortunately they aren’t always kind either. Being a sensitive type, I think I would have a hard time being in an environment that’s always tough and where everyone is mostly on edge. One good thing about the ICU I am considering is that even though there are nurses who aren’t as friendly, the manager and ANMs seem to be, which is encouraging. The ANMs and rapid response nurses are actually trying to recruit me to the unit, so even though I have my personal issues, I must be doing something right to be noticed and for them to have confidence in me, especially since one of the ANMs is apparently pretty particular. Anyway, I’m just stuck. On the one hand, I like the sweet spot of PCU, in between med-surg and ICU. I also have wonderful coworkers who are very nice and I fit in very well in that regard. However, the ICU thing has always been something in the back of my mind, and now that I have some experience and more confidence, I wonder if I should take another crack at it. I did shadow in the ICU I’m looking into last week for “up training” due to COVID-19 in case there is a big surge when the country reopens again, and I did enjoy it and learned a lot. I was nervous and anxious but found my confidence increased each day. However, I still find myself going back and forth. I think my PCU manager would take me back if I transferred and ended up finding out it wasn’t for me or if things didn’t go well. To be sure, I would try to stick it out at least 6 months or even a year ideally, but it would be reassuring to have a backup plan. I suppose it would be more embarrassing than anything to have to transfer back, as the failure to thrive there would be more public and known since I would still be in the same hospital. Most importantly, I want to make a wise and informed decision, whatever it is. What do you think? Should I try it out? Stay put? I really appreciate all responses and guidance. God bless everyone and thank you for all you do. I hope this message finds you well during this pandemic. Sincerely, Ethan

Thanks, Ruby. I appreciate the support!

Hey Everybody, I am a new nurse working on a busy telemetry floor on the south side of Chicago. I have a couple of issues to put forth that have been bothering me for a while now. Sorry about the length, and I did try to cut it down, but I don't think I can adequately describe my situation otherwise. I would consider myself a thorough person when I do anything in life. I really try to do things the right way and do a good job, and I take pride at still doing them this way behind the scenes. So, when it comes to my nursing assessments, being a new grad, I try to do them as I was taught, which is, obviously, assessing everything from head-to-toe. So, as I do them, I try to actually think about what I am hearing with the heart and lung sounds, to take about 15 seconds for each quadrant when I listen to bowel sounds (I mean, who seriously has 5 minutes per quadrant like they say in the books??), check skin, pulses, edema, actually assess their orientation status, etc. I also take their vital signs. This, on average, with normal verbal interaction with the patient, takes probably 7-10 minutes. On nights, we have 5 patients, so on average for my initial assessments and vitals, I would say it takes anywhere from 40 to 55 minutes (give or take) to assess all five patients. Let me also mention that I am more of a slow-paced guy, meaning in general I don't like to have to rush through things. I prefer to take my time, slow down, process what is in front of me, and not do things as if I have to meet some sort of deadline all the time. I'm also much more people-oriented than task-oriented. And with this in mind, I try to be consciously aware of time so I can pace myself and not get too caught up with one task. But, even with this mentality, I still find that most other nurses around me (newer and experienced both) seem to get things done significantly faster than I do. This makes me wonder what I am doing wrong. Am I still going too slow? Am I being too detailed? Are they cutting corners? I am not in any way intending to be accusatory here, but I honestly don't know how others can do thorough assessments on their patients and still be that fast, you know? I know with experience that it becomes easier to recognize certain things and to know what to pay attention to with greater detail, but, isn't there still a minimal standard of thoroughness that everyone is required to meet? Again, I don't want to inappropriately imply that others are cutting corners because God knows maybe it's just me, but for the life of me I just can't understand it, given that objectively, with the time noted above, I think I am being efficient. But I am afraid that if I move any faster, I will start missing important details that I would otherwise notice. And, honestly, doing it any other way, I think, would require me to take short-cuts, which I can't in good conscience do and honestly have no idea how to do (I mean, are there safe short-cuts?). Side note: I realize that the detail nurses are taught to go into in nursing school with assessments is completely unrealistic in the real world, so just for clarity, I do understand that a healthy compromise is necessary (i.e., listening to the lungs in 2-3 places for each one, not 6, etc.). Lastly, to give a little insight into the OCD part, when I do my reassessments (we do 3 assessments total on our floor), I take vital signs and listen to the heart and lungs, and only chart on what I actually did, which in these cases, is the heart and lungs and other things like skin/edema and things you visualize without realizing it when you go into the room. Although, sometimes I question whether or not I should chart on these things, too, because I never actually consciously look at them (i.e., is the patient's edema still severe, or has it decreased to moderate or mild now? You know what I mean?). This was just suggested to me by one of my preceptors because, I presume, it looked like I wasn't charting on enough things for my reassessments. Anyway, all we ever hear is, "Don't chart on things you don't assess," and instructors and managers alike are VERY strict about this (for good reason), and yet, when I actually try to apply it, it seems like I am charting too little (as suggested to me by some of my preceptors). So, I recognize what seems to be like a gray area, and I chart a little more (such as the skin/edema example above), to which I have had other nurses ask me, "Did you REALLY look at that edema?" (or fill in the blank). It just feels like I am damned if I do and damned if I don't. Even though I am on my own now, this has been an issue I recognized in school that has still not settled for me, mainly because of the inconsistency in feedback I have received. Which makes me wonder why other (particularly new) nurses don't have this same struggle, which makes me ask myself, "Am I crazy, or is this OCD-like?" By the way, I do have Pure-O OCD, but I recognize it and have been able to control it well. At any rate, though, this issue seems like one that would be more common to every nurse, given that nursing standards claim to be so black and white when it comes to charting. Anyway, I would really appreciate thoughtful answers/encouragement. I've racked my brain a ton over this and can't seem to figure it out, which is why I am questioning and doubting myself and thinking that maybe it really is just me, in which case I would love advice about how I can be better and improve because that is ultimately what I want. Thanks so much for your time, everyone. Best wishes, Ethan

@Susie 2310, thank you for your reply. To kind of respond to your response point by point, yes, I definitely check to make sure that I am giving the correct medication and taking the time to look up what I am giving and why it is being given to the patient. In fact, pharmacology is a subject that fades fast if you don't constantly refresh your memory and learn new things. Scanning medications through the computer is a way to make the process a little faster, but I still make sure the computer order matches what I am giving. In regards to the IV medications, I always check compatibility, too. I would say even at the time I felt comfortable with basic IV skills; this was a blunder I made because, well, I guess I lacked the awareness/knowledge in this instance. So technically I wasn't fully competent. Perhaps you might think that I am not completely competent with these skills, but as far as what I know now, I am competent, and should something come up in the future I will certainly not hesitate to ask about it. I know the "not knowing what you don't know" phenomenon applies here, but IV skills are not complex (not to belittle their importance), and I really do think I know what I need to in order to administer IV medications safely each time I do it. As far as slowing down is concerned, you're right. I am in no rush when giving medications, but there is always a time constraint in nursing, and I think there should be a healthy incentive to pace oneself overall. But in certain situations, such as administering medications, it is crucial to make sure one gets it right rather than try to do to much and compromise patient safety. Probably the number one issue I had with one of my day preceptors was she pushed me to the point where I didn't feel like I could take my time with things because she was always on my tail to be faster. And, quite frankly, it was a miserable learning experience because of it. With regards to the breathing trial, I confess I did not look up the policy, but I did have it taught to me and I should have asked my preceptor to explain it to me again and to stay nearby should I have needed him. I am working my way to being autonomous, so there is an element of space between us; but I should have asked and made sure he was close by. The magnesium administration follows along the same lines--I just should have consulted with my preceptor when I realized that I had not worked with those pumps before and had her there with me while I hung the mag. Again, thank you for your feedback and your wisdom. It sounds like you are a detail oriented and very competent nurse. Ethan

You are probably right, and I have been able to let that go with time. Like I said, recent events have just resurrected past feelings, you know? Thank you.

@Been there, done that, thank you for your reply. Well, for the magnesium instance my preceptor asked if I was comfortable hanging it, and I told her I was, and I really meant it. I had hung enough IV meds to be comfortable enough doing it on my own, and I would never do something I wasn't comfortable with without help present. I was just unfamiliar with the pump, was working my way through the process, and then when I was having difficulty then proceeded to ask for help. The lesson there was I should have had her come in with me once I realized I was unfamiliar with the pump. For the potassium/heparin instance, my preceptor was in the room with me, and to be honest I don't remember if I started to hang it and then she informed me of the error, or if it had been hanging for a short time and then she noticed it and informed me. The reason I don't remember was because it was brought up after the fact and not by her, but my supervisor who had solicited her feedback. For the breathing trial instance, my preceptor should have been in there with me. I think he basically said something along the lines of, "Ok, so you need to do this, this, and this" and included in that to-do list was a breathing trial. He didn't ask if I had done one before. And don't get me wrong, I am not averting my own accountability. But I do think it was appropriate for him to make sure I knew the correct protocol and routine, etc. He is a young nurse, though (and a good one), so I can't act as if he has the experience of a seasoned nurse. Also, in regards to the IVs, going through the process of hanging an IV med was never explained in detail while in school; we just practiced doing it. There was never any critical thinking-type questions like, say, "Why wouldn't you want to hang a secondary with certain primary infusions, such as insulin, heparin, or Levophed?" or "What should you always make sure to do before you hook up an IV line to a patient?" Etc.

Thank you so much for your kind reply. It really means a lot. I wish this were not such a taboo topic and that everyone would be more empowered to be more open and honest. And yes, I can tell you I will never make the same mistakes again. I have had a step-wise routine for hooking up IV lines ever since, look through all of my IVs to see which ones can have secondaries (and if none can I grab an extra pump or channel), and I will most certainly be at the bedside the next time I do a breathing trial.

Hi All, I know that there are already other threads about this topic, but I decided to start one just so I could get some direct feedback. So, I am on orientation in an ICU at a nationally known hospital, and I am also a new grad. Recently (but not too recently), I made a couple of mistakes and I guess I just need to vent, as I have been discouraged and a bit worried. My first mistake (while on my current orientation) involved turning one of my patient's sedation off to do a breathing trial, and instead of staying at the bedside and monitoring how he did, I left to go check on my other patient, for some reason not thinking that I needed to stay at the bedside. I had never done a breathing trial by myself, just been shown one by one of my day preceptors. The patient had restraints and couldn't pull out his breathing tube or any lines, but I still felt bad because it certainly would have made him uncomfortable had my night preceptor not caught it. My other mistake was I hung potassium as a secondary line with heparin, not thinking that, duh, if I hang the potassium with heparin, the heparin infusion will stop, which is a big deal, as this is a high risk med. Another mistake I made while in school was during preceptorship, and I am embarrassed to even talk about this one. I went to hang some magnesium, as I had hung many IV medications before and felt comfortable doing so. However, I had not worked with these particular IV pumps before, and as I was setting up the line and priming it, I didn't realize that I had not installed it in the pump, and I had already hooked it up to the patient. I began to program the pump and kept wondering why it wasn't working, so I checked the roller clamp to make sure there wasn't an issue there, and eventually I just went to get my preceptor for help, trying to be safe and do the right thing. However, by the time we returned to the room, the magnesium had already infused into the patient as a bolus...I guess when I adjusted the roller clamp I either didn't check the drip chamber or I did and it wasn't dripping--but then started to after I walked away. Talk about almost having a heart attack. The patient ended up being fine, and I honestly have no idea why I didn't think in that moment, "Duh, you have to install the line into the pump." I was tired and working the day shift, which is common, but something that one just has to work through. Anyway, I have to be brutally honest about all of this because I just want some honest and candid feedback about it. The thing is, I am a VERY, VERY conscientious person, even to a fault and to the point of perfectionism. I would NEVER want to harm a patient, and I make patient safety my number one priority. I have caught safety hazards from other nurses as I began to care for my patient after report, and yet, I still screwed up, and I just feel so stupid. How could I make such a mistake, particularly the one with the mag bolus? I mean, why did I just not "think" in that moment? I have gone over it in my head a thousand times and still can't come up with an explanation, other than I was sleep deprived, or I was rushed and felt intimidated working with a tough preceptor (referring to my most recent mistakes) and got too ahead of myself. Anyway, that mistake with the mag happened while I was in school, and I have moved on. But my recent mistakes have resurrected anxious feelings, and I am just uneasy because I don't want to make another serious mistake in the future, especially if I am not realizing I am doing it, you know? I will be the first to admit that I have a tendency to space out in terms of my attention span, but I recognize this and am ALWAYS present in the moment when at my job, ESPECIALLY when right in the middle of patient care. To wrap up, if it came down to it I would quit my job in a heartbeat if I knew that my personality or way of doing things or whatever was going to be a liability to any of my patients. I was drawn to nursing and ICU nursing for all the right reasons, I still think--I enjoy continuous and in depth learning, am very detail oriented, enjoy quality nurse-patient interaction with 1-3 patients, and, though cliche, am driven by helping people, particularly on such an intimate level. I guess I just need some encouragement or some honest input about whether I am cut out for this profession. I still believe in myself, as I know and have read about other nurses making mistakes, even serious ones that have had major, even fatal repercussions for patients. But I just needed to put my thoughts and feelings out there and get some feedback. Thank you so much for taking the time to read this. I know it is a repetitive topic but very important nonetheless. Yours, E-Stu

@Been there, done that Well, I didn't ask her, but let me explain a little bit. From the get-go she was very adamant about getting me to "move along," trying to push me to be efficient while being thorough simultaneously. That sounds good in theory, but the excess pressure she put on me was counterproductive and ended up making me worry more about my efficiency than my effectiveness (at least it seemed like I had to sacrifice one for the other). Plus, she had a difficult temperament and wasn't very inviting to me in terms of asking questions, so rather than just ask her about it I hesitated because of my intimidation. My mistake, I know, and I won't make that mistake again. The speed will come with time; I always need to focus on being safe first. Unfortunately because I didn't speak up she has concerns that I am not safe, which couldn't be further from the truth.

Yeah, that's a good idea. I have recently begun to write down abnormalities that I see on my sheet of paper so I will KNOW what I assessed. I guess I can also write down anything I realize I miss during my initial head-to-toe when I am charting in the complex assessment, and once I am done go back and assess those things all at once to sort of cluster my care. But it's nice to have some validation that it is easy to forget something when one has so much to remember and take care of in a patient's room at the beginning of a shift.