Sense of Dread....When Will It End?

[AICU RN]

I'm one of the lucky ones, I get that. I graduated from an accelerated BSN course in August and by November I landed the job I wanted in the hospital I wanted. I count my lucky stars everyday.

I am working in an Adult ICU in a very big teaching hospital. The set up of our new grad fellowship is wonderful and it lasts five months. I have been there just over 2 months. My preceptors are really incredibly smart and are very understanding and patient. I am very happy with that aspect of my job. I also feel like my nursing school did a good job of preparing me for "the real world."

My issue right now is this sense of dread when I leave the hospital. For example, today I did a twelve hour shift. It went really, really well. I felt really good taking care of two fairly (sorta) stable patients. My preceptor didn't have to correct anything all day. I asked tons of questions about CRRT (one of my patients had just been taken off of it) and Good Pasture's (my other patient might have it). Everything went perfect and I reported off to night shift with no issues. So now I can't sleep because I keep running through things in my head trying to figure out what I missed. I almost want to think of something just so I can prove to myself it's not the end of the world and get some sleep. This happens every night I work and I just am really having a hard time dealing with it.

Is this normal for a new grad in the ICU? I know no one feels comfortable here right from the start but am I over-worrying? Obviously, no one can tell me how long it will take me to stop doing this every night but does everyone go through it? How long did it last for you? How do I get some stinking sleep?? :zzzzz

[cardiacrocks, BSN, RN]

I can relate to the OCD and the constant going over things in your mind when you're not at work. I work on a very busy cardiac floor, we do all drips and also deal with some major stressful events! I have a 45 min. drive home, I am always thinking about my night, often I have called to tell the person who took over for me something I had forgotten in report. I've only been on my own for about 3 months, but I feel I'm doing a pretty good job, you sound like you are too. Cut yourself some slack. Remember even off orientation you always have other nurses to look after you and you ALWAYS have help, there is always someone there to help out. No matter how long you've been a nurse you sometimes need help, or need to run something by another nurse. For example, "hey can you come look at this PPM dressing, does this look normal to you, etc." Good luck, and remember do one thing always, BREATHE!!

[llg, PhD, RN]

Research shows that the feelings of inadequacy usually diminish in about 6 months (give or take a couple of months, of course). A little bit always remains ... but hopefully ... it evolves into a more healthy sense of responsibility that provides a foundation for vigilence.

[tokmom, BSN, RN]

I really feel for you newbies. That is a lot of worry you carry around. Take it from somebody that worried about everything that didn't get done and suffered burn out to the point of getting out of nursing. Only after taking a break for 4 yrs did I realize that I couldn't worry all the time.

Part of being new to nursing that new grads suffer from is black and white-itis, lol. Everything is by the book and if it falls out of the norm then they panic. Eventually you don't panic because you will know what to expect from previous experience. Like the OP was talking about with LOL getting VAP because mouth care wasn't done at 6 pm. You just realize that you did oral care earlier and if it doesn't get done at 6pm the world won't fall apart. All of this simply comes with experience. I bet you are smarter this week then you were when you first started, correct? See?? You are learning!!

Really it will get better. Give yourself some time. You will be excellent nurses because you care. :hug:

[AICU RN]

JJ,

Ha! That seems like a lifetime away :rotfl: . But, thanks to you guys at least I know I'll probably make it that far. I'm sure in no time at all I'll start a thread about all of the ridiculous thing my very own newbie nurse does and hopefully by then I will fully come to the realization that the world won't end.

CardiacRocks,

Thanks for your kind words. Sometimes I think the drive is the worst part of all because I freak out so much on the way home. Once after a particularly bad day, I got off the highway to get gas. I got back on in what I just kind of assumed was the right direction. I didn't realize that it wasn't until I had driven 15 miles all the way back to my hospital's exit. I do get what you're saying about teamwork and always having someone who has your back and it's probably one of my favorite things about my workplace. I learn things new every single day and asks questions all the time. I don't know everyone's names yet and especially their job titles so if I figure it I'm excited and asks them lots of questions. I've been in rooms with doctor's and said "Excuse me Dr. So and So, I'm new and I was just wondering what type of doctor you are." When he tells me what he takes care of, I listen to my patient's plan of care from his specialty's standpoint and take notes. If the doc seems particularly nice I will even say, "I read in your notes that you think he might have (Fill in Terrible ICU disease here). I saw that it might cause this, this, and this. Is that right?" or something to that effect. I work at a teaching hospital and most attendings are so cool and will take the time to explain it in great detail (sometimes even more detailed than I wanted...).

I ask NAs a lot of things from how they stock their rooms the way they do, where they keep the EKG machine, and which pads work better under skin that constantly weeps. I ask UDCs how to spell doctor's names, where the extra paper is, and a hundred million other things. I ask dieticians why they chose that TF for my patient and I've learned residents are my friends . I learn tons of things everyday and I don't ever plan on stopping.

llg,

Six months? That's good to know. Although I'll just finish my 5 month residency program so it might be a smidge longer for me. I actually talked to a girl the other day who just got off orientation and she told me though the sense of not knowing anything hasn't really gone away yet, she does become a little more comfortable everyday. When I stopped to think about it I realized she was right. I am getting better everyday.

Tokmom,

I'm all over black and whititis as you call it. The funny thing is at the hospital I used to come from, I saw a lot of bad habits. I saw a lot of good ones too, just kind of more of the bad ones. I know that the world won't end because I couldn't do mouth care at 6pm. Of course, my patient isn't going to get VAP and deep down I know that but somehow I think that if I don't get every single solitary nursing task done no matter how ridiculously mundane it seems (ie. mouth care when I did mouth care every other time) that she is going to suffer horrible consequences because of it. When I was an NA/UDC I used to watch new nurses and laugh in my head when they freaked out about seemingly inconsequential stuff. I would think, "Of course that's not going to hurt your patient. It's no big deal, move on." It's SO different when it's you who's in charge of that human being in that bed. When my patient coded for the first time, I was guilt-ridden and worried and playing out the whole thing in my head for days. See above post about driving in the wrong direction! I am learning, though. I was telling my preceptor how I felt like I wasn't really catching on and he didn't really say much. Later, I went in and drew my patient's labs from his A-line, labeled them correctly according to institute policy and tubed them down without him being in the room. Later he says, "What would you have done with that A-Line 4 weeks ago?" and I said I wouldn't have a clue. He's like see how much you're learning already.

I hear stories about nurses who had to get away for similar reasons and I really want to calm myself down before it comes to that. I actually love my job and couldn't imagine truly giving it up. I just invest such a huge part of myself into every patient that it takes its toll on me. Little by little though I'm learning that I can breathe, relax, and enjoy the ride. Thanks for all of your sweet words.

[carolmaccas66, BSN, RN]

Write it all down in a journal - everything, even the curse words you think of!

I also do yoga/pilates to help relax & exercise helps a lot of people.

If you do forget anything, just ring & tell the staff on the next shift. No biggie here, I've had to do it so have many other people.

[Babs0512]

To the OP, once you've become more confident in yourself and more knowlegable as a nurse, you should find that you can leave work at work (most of the time). There will always be those cases that were difficult, or an error was made, or just a particular bad day - at those times, remember that you are only human and you did the very best you could. Blessings

[fiveofpeep]

You need to relax and learn to prioritize what you let bother you, otherwise you are going to go crazy.

I'm a big perfectionist like most ICU nurses, but some of the things you fret over, like an IVPB being clamped for 20mins or being late for oral care are just not that big of a deal.

What helped me learn was to stop focusing on myself and my mistakes and instead focusing on the patient and how your actions affect them.

I know this might not be a popular opinion, but if you were my preceptee and you complained about the things you are complaining about I would probably roll my eyes and wonder if you are only complaining about such trivial things to seek excessive reassurance.

You also run the risk of your preceptor thinking you aren't prioritizing correctly (even though you probably are), which is very bad feedback to have in the ICU, if you keep complaining about small things when there are bigger fish to fry.

It will get better with time but you need to actively try to pick and choose your battles or you will go insane!

[AICU RN]

Carolmacca,

I should have thought about that lol. I was a journalism major in a previous life and I love to write down my observations/feelings/etc. I really do need to start exercising again, too. So thanks, I appreciate the feedback.

Babs,

Thanks . Sometimes I think I am too Type A for my own good.

fiveofpeep,

I wanted to let you know I love your name and you are one of my favorite posters comments to read. I was a lurker for a long time and I read a lot of them.

Maybe I gave the wrong impression. The incident with the IVPB was with a different preceptor than my main preceptor and was when I first started. At that point, I wanted everything to be so perfect that I was worried about being late on the med. I honestly hadn't realized that it was a common mistake. Now, after watching a lot of different nurses, of course I realize it isn't a big deal. The ICU is just really overwhelming for a new grad sometimes.

However, my main preceptor (I was with him for my first 6 weeks in the ICU) is my age and obviously a member of the opposite gender which I think has a lot to do with the point I am about to make. He is an AWESOME nurse who is incredibly thorough and one of the smartest people I have ever met. He has only been a nurse 3 and a half years which is amazing to me. He's a great teacher and loves to ask me questions and does a great job explaining rationale for things as well as making difficult concepts easier to grasp. However, he gives very little to no feedback. I have learned that if he doesn't have to tell me anything, that's his way of saying good job. That's his style and that's all well and good but when you're a new grad in a place like ICU it is nice once and a while just to hear things like "Good job on your charting" or "You had a good day today." So I know I sometimes talk about trivial things I didn't get done (and believe me usually I only think about most of them to myself) but, yea, sometimes I guess I am looking for some positive reinforcement.

I know that you're right about picking my battles and it is something that I will make a concious effort to improve upon. But sometimes I still don't know what the big things are. Like the other day when I tested my pt's stool and it was hem positive (occult not frank), I had to ask my preceptor, not my regular preceptor, if it's something that needs immediate attention or if it's just a kind of it is what it is thing. She told me it was okay to call the CCM attending and he told me he thought it would be and it's no big deal. So I am learning what things I can let slide, but there are still things that I need to figure out where they fall on my level of freak out.

Susan

I feel bad. It seems my posts are always so long lol.

[caliotter3]

Mouth care? Yes, that is overdoing it a little. Work on relaxation techniques and possibly prioritizing what you need to worry about. Worry about missing the first dose of med X, very important and ordered stat, instead of mouth care. Or something else more important than mouth care. While mouth care has its place in the scheme of things, you know there are more important matters to lose sleep over if you have to lose sleep! And yes, it does get better with time.

[fiveofpeep]

I wanted to let you know I love your name and you are one of my favorite posters comments to read. I was a lurker for a long time and I read a lot of them.

Aww that is so nice. Thank you :) And here I am being all grouchy to you.

The ICU is just really overwhelming for a new grad sometimes.

I certainly understand. I started as a new grad too and hell, even as an experienced RN it can get overwhelming.

However, he gives very little to no feedback. I have learned that if he doesn't have to tell me anything, that's his way of saying good job. That's his style and that's all well and good but when you're a new grad in a place like ICU it is nice once and a while just to hear things like "Good job on your charting" or "You had a good day today." So I know I sometimes talk about trivial things I didn't get done (and believe me usually I only think about most of them to myself) but, yea, sometimes I guess I am looking for some positive reinforcement.

I can also understand that. My first unit was really punitive and I only ever heard when I did a bad job unless I solicited the feedback myself. Definitely keep bringing up mistakes that you think need to be addressed, but a good way to get them to tell you that you are doing a good job is to ask them at the end of the shift how you are doing.

I would do this every day when I was orienting and I even do it on rough days now that I am experienced. Most of the time this will help draw out a compliment about your time management, organization skills, etc. I dont know how stingy your preceptor is with the complements though.

I just worry that if you have a critical preceptor, they might misconstrue your heightened concern over marginal errors and say that you aren't prioritizing. Ugh. This has happened to me before.

Once I had a patient that was in her early twenties and was a very very very unstable 1:1 neuro patient. Towards the end of my shift she went into this crazy wide QRS rhythm that the 12-lead machine couldn't even identify. It almost looked like Vfib. I have a very exaggerated personality and was visibly concerned about it.

And of course, all I ever heard about that night from my charge was that I shouldn't have worried even though I did a really good job that night and put out so many fires. I just don't want you to have the same problems.

Towards the end of my first year, I finally learned to really reign in my personality and keep my worries and concerns to myself. It all depends on the culture of your unit, though.

I know that you're right about picking my battles and it is something that I will make a concious effort to improve upon. But sometimes I still don't know what the big things are.

I understand. I just worry for you because I was really OCD my first year and took so many small things to heart and it really killed me and burned me out and I didn't even fret about the things you do, so I just worry you might burn out even faster.

Whenever I mess up and am giving myself a hard time I remind myself that I need to make mistakes so that I can learn. And let me please reiterate that the best advice I received was to put the focus on the patient instead of on your own performance.

It helps you to not take things as personally. Now that doesn't mean, make yourself feel guilty if the patient is, god forbid, harmed. It just is a way of thinking where you can be like "Well, I need to do better next time because of how this affects the patient" instead of "I am a horrible nurse for making that mistake."

I feel bad. It seems my posts are always so long lol.

You are not alone

[AICU RN]

I get what you're saying. I just don't want you to think that I'm going around to my preceptor like, "OMG I was 20 minutes late with my Colace! Is my patient going to die?" Because I'm not, honest. My preceptor knows my personality and he actually has a similar one and I guess he was like me when he started so he understands. He hasn't said anything negative about my time management or prioritization. He even recommended that I be moved to Stage II early. He just tells me things like a lot of you guys have been. Basically, that if it isn't going to harm our patient then it just isn't that big of a deal. The mouth care thing happened but it's not like I still freak out about missing it. It's more of a matter of the next shift coming in and being like, "Your orientee didn't chart her (insert some inconsequential thing here), didn't you teach her anything?" Not like they would actually do this because they are ICU nurses and know that's not a big thing but still, all of my preceptors have been so great that I don't want to make them look bad. I guess in that sense it does have a lot to do with the culture of my unit because there are about 12 new grads that started the same time as me and I'm sure the preceptors and educators compare us to each other. My husband is good at keeping me grounded, too, and always has been. I don't usually think I'm a terrible nurse, though, honestly. The previously mentioned day that I wanted to quit nursing wasn't because of something as stupid as mouth care. It was because we coded a patient who was a limited code and saved her life (although not the quality of it). I didn't realize she was limited until after the code was finished and if we had carried out her wishes she would not have lived. I played it over in my head because she was my patient the day before as well and got in report two days in a row that she was limited. However, we are not trained to watch our patient die and my preceptor and I just went into full on crisis mode. So, yea, that day I felt like I had let my patient down but I dealt with it and didn't give up. Thanks for worrying about me though.

[fiveofpeep]

"Your orientee didn't chart her (insert some inconsequential thing here), didn't you teach her anything?" Not like they would actually do this because they are ICU nurses and know that's not a big thing but still, all of my preceptors have been so great that I don't want to make them look bad.

Unfortunately, some people will do this, but just know as a new grad you are under the microscope.

The previously mentioned day that I wanted to quit nursing wasn't because of something as stupid as mouth care. It was because we coded a patient who was a limited code and saved her life (although not the quality of it). I didn't realize she was limited until after the code was finished and if we had carried out her wishes she would not have lived. I played it over in my head because she was my patient the day before as well and got in report two days in a row that she was limited. However, we are not trained to watch our patient die and my preceptor and I just went into full on crisis mode. So, yea, that day I felt like I had let my patient down but I dealt with it and didn't give up. Thanks for worrying about me though.

That sounds like a very traumatic experience. What happened? Was it meds only and you did CPR or DNR and you gave meds? I would be very upset about that too, but in this situation you are not ultimately responsible so that is not on you.

At least now you have learned that valuable lesson of knowing code status. When my patients are DNR or some other modified code I bring the chart into the room and look at the order and compare it to the ID band so I have reassured myself that I legally do not have to do anything. There's my OCD popping up hehehe.