Setting my orientee up for failure?

[NightNerd, MSN, RN]

I'm precepting a new grad who will be on nights (I'm day shift - lack of evidence staff on nights meant that I was chosen to precept for her first several weeks). We are in week eight by now, and I'm starting to feel like I've failed her. ? I'm hoping to hear any advice you guys have; I've got one more week with her and then she'll orient on nights for two weeks, then be on her own.

Our biggest issues, apart from normal stuff like time management, is retaining knowledge and being self-directed. She comes to me with the same questions over and over again, she wants help doing the same skills we've already practiced several times, and even balks at going into rooms by herself or recording her own assessment until she's talked to me about it. After eight weeks, not only am I exhausted, but I sort of feel like I can't trust her to do anything on her own. I have been working so hard to turn her questions around on her (I.e., "What do you think we should do next?" "What supplies do you need?" "What are your priorities this morning?") and to let her figure things out as much as possible without severely delaying or interfering with care. It's not just that she needs a lot of direction, but most of the time, she will not, say, draw labs or start new meds or whatever, until I remind her to look at her new orders.

Another coworker precepted for me last week one shift during a pre-planned vacation, and she is reporting the same issues. She said she spoke to our manager about it, and I also have been talking to my manager and our unit educators. Nothing is helping. My manager seems to think I'm being too nice, but I'm doing everything I can to let her work things out herself; there are times, though, where if I don't step in eventually, things won't get done at all.

I've precepted new grads before and typically enjoy it, but I feel like this is just not going well at all. I've also never gotten any formal training in precepting, so I'm wondering if anyone has any other thoughts or ideas? She is a very sweet woman, very earnest, and I know she was going through school at the height of the pandemic - but I don't know that this unit and hospital are going to give her the time and training she needs to succeed, and I worry for what will happen when she's off orientation.

[Davey Do]

Basically NightNerd, it sounds as though you have been a quality preceptor and have attempted to guide this new grad with her best interests at heart.

I especially like your method of turning the questions back on her. When we find the answers for ourselves, we feel better about, and more assured of, ourselves.

As I was reading your post, Kahlil Gibran's' The Prophet's "On Children" came to mind:

"Your children are not your children.
     They are the sons and daughters of Life’s longing for itself.
     They come through you but not from you,
     And though they are with you yet they belong not to you....

 The archer sees the mark upon the path of the infinite, and He bends you with His might that His arrows may go swift and far."

Conceptually speaking, you are not responsible for someone who "comes through you, but not from you".

NightNerd, you know what this new grad needs to learn, "The archer sees the mark upon the path of the infinite". However, this arrow may not possess the ability to "go swift and far".

[Closed Account 12345]

I am pro-new grad. I have always loved working with new grads. I have always enjoyed precepting. I've worked as undergraduate nursing faculty and a hospital-based educator. With those things in mind...

Not every new graduate nurse will/should successfully complete orientation for their first position. Orientation is a time for teaching, but it's also the time for evaluating whether or not someone is a good fit for the unit.  Eight weeks into orientation with a preceptor who cares and is really trying, if a nurse lacks self direction, critical thinking skills, basic prioritization, and clinical competence, that person might not be a fit for the unit.  Our number one job as nurses should be keeping patients safe, and a nurse who can't remember to check labs or give medications simply isn't safe. 

I am all for giving new graduates time, practice, support, and grace, but by 8 weeks, new graduates in many positions are already done with orientation and independently caring for patients. That's a problem, too, but the point is you should have noticed significant improvement in her performance over this period of time.

Have you expressed these concerns directly to your orientee, or will she be blindsided by your feedback?

At this point, I would request a meeting with your manager, educator, and orientee. Discuss your concerns and expectations. Develop specific goals, and offer helpful feedback for how she can meet those goals. I'd probably set a relatively short deadline to demonstrate progress before meeting again.  In 2 weeks, we need to see growth in the following areas, as demonstrated by these measurable behaviors.  We will meet again in 2 weeks to follow up and discuss next steps. 

Every single shift of those 2 weeks, remain positive and encouraging,  but offer specific feedback. "You did a great job inserting the NG tube today. I liked that you gathered all of your supplies and reviewed the steps before we went into the patient's room. I was proud of you when you advocated for John Brown's pain control. I noticed that I needed to remind you to check orders and pass medications  throughout the day. Think about it tonight, but tomorrow morning I want you to let me know your plan for how you'll independently manage orders and keep track of when meds are due for the shift."

I know it's difficult to disappoint someone who is sweet and likeable as a person, but that should not be a factor in this nurse's success/failure. She doesn't need to be a nurse in your unit if she can't learn to be safe and competent (at a level appropriate for a new grad).  Letting an unsafe nurse pass orientation is a disservice to patients, unit staff, and even the orientee. 

Who knows? Maybe she'll surprise you and get it together in the next couple of weeks! Alternatively, she might need to begin her career in a slower paced, lower acuity setting.  That doesn't make her a failure, and it doesn't mean she won't become a great nurse down the road.

 

[NightNerd, MSN, RN]

@Closed Account 12345 thank you, that is really important to hear! I do think she will be a great nurse someday, but this is a smaller, weirdly fast-paced unit where she will not have the kind of support she will probably need. And I have made every effort to acknowledge what she's doing well while also pointing out specific opportunities for improvement, precisely because I didn't want her to be blindsided with any further feedback down the line. I am really trying to give her every chance to demonstrate her learning, but it just seems like nothing is sticking right now.

I did express my concerns to both my manager and our educators a couple weeks ago and we did all meet with her to create an action plan. It doesn't seem like anything has improved significantly despite that. I did wonder if nights might be better for her with (hopefully) fewer distractions, but I just have a feeling it's not going to go well regardless of which shift she's working on. And I don't think this is something that will improve by extending her orientation by a week or two; she may just need to work up to this kind of acuity.

[JKL33]

I have always advocated that all orientees should be given the benefit of regular, pre-planned meetings held in a format for open discussion of how the orientation is going with manager (or educator or whomever will ultimately decide the orientee's fate), preceptor and orientee. For instance, we will plan to meet together every 2 weeks, give or take. All meetings involve discussing things that are going well and things to work on. There is ample opportunity for the orientee to state what is working or could be done differently and how they feel they are progressing. As the orientation moves along things that aren't going well (as determined by sufficient time but insufficient progress) need to be discussed in a straightforward manner.

3 hours ago, NightNerd said:

My manager seems to think I'm being too nice

This shouldn't be about that. Basic kindness should be maintained no matter how the orientee is doing. Rather, perhaps the problem, worded differently, is a failure to convey the situation as it stands. These things should be conveyed in a straightforward manner while out on the floor (at appropriate times) and then monitored and revisited in the meeting, especially if sufficient progress hasn't taken place.

I have on occasion heard that all of this is just too much trouble, but I'm talking about 10 minutes several different times during the orientation. I think we owe that to all parties, especially the new grad. It isn't too much to ask. I believe that if hospitals want new grads to serve their needs, they have some responsibility to actually help them lay down a solid foundation rather than just churning through people.

[JKL33]

PS - another benefit of regular meetings is that on the rare occasion when things are actually going quite poorly and the new grad may not be able to successfully come off orientation, it can be said that people really tried. Rather than some of the stories on here about how the preceptor or manager really started getting pissy at the 11th hour and the grad was left with a week to change everything/prove themselves or else be fired.

I don't like situations where someone is going to have to be disappointed, especially when they haven't really been treated fairly throughout the process.

[NightNerd, MSN, RN]

31 minutes ago, JKL33 said:

I have always advocated that all orientees should be given the benefit of regular, pre-planned meetings held in a format for open discussion of how the orientation is going with manager (or educator or whomever will ultimately decide the orientee's fate), preceptor and orientee. For instance, we will plan to meet together every 2 weeks, give or take. All meetings involve discussing things that are going well and things to work on. There is ample opportunity for the orientee to state what is working or could be done differently and how they feel they are progressing. As the orientation moves along things that aren't going well (as determined by sufficient time but insufficient progress) need to be discussed in a straightforward manner.

This shouldn't be about that. Basic kindness should be maintained no matter how the orientee is doing. Rather, perhaps the problem, worded differently, is a failure to convey the situation as it stands. These things should be conveyed in a straightforward manner while out on the floor (at appropriate times) and then monitored and revisited in the meeting, especially if sufficient progress hasn't taken place.

I have on occasion heard that all of this is just too much trouble, but I'm talking about 10 minutes several different times during the orientation. I think we owe that to all parties, especially the new grad. It isn't too much to ask. I believe that if hospitals want new grads to serve their needs, they have some responsibility to actually help them lay down a solid foundation rather than just churning through people.

@JKL33 thank you for your reply. We probably haven't been meeting with her as regularly as we should as a team, though I try to touch base every week to see how she's feeling about her progress and if she needs anything in particular. I make an effort to give her feedback in real-time, both positive and constructive, since I know when I was new that made it stick better. But as far as her interaction with our manager and the educators, it's not happening very often. Probably that's why she's texting me on our days off asking questions about her work schedule and the like...

Honestly I feel like this hospital in general is a little insensitive to the needs of new grads, just based on observations of others' orientations. The words "sink or swim" and "let her drown" have been used to describe management's ideal approach to this particular nurse's orientation at this point, which seems very unhelpful and cruel. I'm trying to be a little more hands-off to see what she can do and figure out on her own, but I also want her to know that it's okay to have questions and not know everything as a brand new nurse! It may be a blessing in disguise if she were to part ways with this hospital, but I'm sure that would be a major let-down, since I know she really does want to do well.

[BagelBomber, ASN, BSN, RN]

I started as an RN almost one year ago, and one of my fellow orientees finished orientation (against her primary preceptor's wishes) and ended up having full-blown panic attacks at the start of nearly every shift. She too, was a very sweet woman, but our floor was simply too fast-paced with a very high acuity that she simply wasn't prepared for. I think YOU as her preceptor have done everything right. I LOVED when my preceptor would flip questions back to me and really get my critical thinking going. I was taking a full team of patients and my preceptor was simply double-checking documentation by week eight (obviously if there was something that I hadn't done before I would ask her to observe). I don't think you've set her up to fail at all- but is it possible to extend her orientation period?

[LibraNurse27, BSN, RN]

This sounds really tough. Somehow I have (luckily) ended up orienting only extremely competent new grads, sometimes to the point I joked they were orienting me! I would be uncomfortable in your position. Your orientee is lucky to have such a kind and patient preceptor. I've seen preceptors become frustrated with new grads and mistreat them, belittle them, etc. Or not give feedback and then blindside them as described in other threads. 

It sounds like you've done everything you can. You have notified manager and educator early and kept the orientee in the loop. All that remains is to see how she does the next few weeks, decide whether you think she's ready or if you think it makes sense to advocate for extending her orientation. It should probably be a group decision between you, night preceptor, educator, and manage. If the worst happens and she is let go (or hopefully transferred within the system!) I'm sure you will be compassionate, gentle, and encouraging. Even if it sucks at the time to be told you're not ready, I think it's worse to be allowed to perform a job you're not competent at that may allow you to harm patients and/or destroy your mental health. 

[NurseBlaq]

I think maybe take JKL's advice and start having post-shift meetings with the orientee maybe every 3 days, not two weeks to discuss what could/should be improved and have question/answer sessions. Also, as others have said, maybe advocate for her orientation to be extended.

You're not being too nice; being hateful is not necessary as you're both adults. Maybe she needs encouragement. Assign her one patient on your assignment and have her be in charge of that patient's care for the entire shift. Check behind her but hold her accountable. If she does alright, assign two the next day and keep going until she's able to manage the entire assignment with you monitoring and stepping in when necessary. If she's truly not getting it, have a one-on-one talk with her and just flat out ask her what she's not understanding. I think a real talk will help you to understand if she's truly a good fit for the unit or not. Maybe her confidence isn't up. I don't know but the only way to truly know is to talk to her, preferably one on one so she's comfortable opening up to you and won't feel attacked with a group ragging on her.

But I've seen things like this before where new grads were book smart but didn't have 'it' to actually work on a unit. I hope you're on a med-surg unit, if not that's where she needs to start. I'm a strong advocate for new grads doing a year on a med-surg unit. Just my opinion though.

[JKL33]

3 hours ago, NightNerd said:

I try to touch base every week to see how she's feeling about her progress and if she needs anything in particular.

I think it sounds like you have tried really hard on your end of things! ?

In case my comments read as a critique of what you have tried to do, I want to clarify that they were specifically about management accepting an active (but minimally time-consuming) role from the outset; maintaining awareness of how the situation is going and hosting a forum where people are encouraged and built up and where it is ensured that everyone's on the same page about where things stand. Maybe an idea you can put forward for future consideration.

Well, at this point don't be afraid to be straight forward. As far as that aspect goes you have the ideal situation because you have been kind to her; you haven't been ignoring her or sabotaging her or playing disingenuous games. So, with confidence you can state things like, "There are some elements that we need to pull together; these will limit you from being able to be on your own - for instance, remembering to check lab work" (etc.). That is not unkind. It is a fact, and her job is going to depend upon her doing these things.

Good luck!!

[JBMmom, MSN, NP]

I think that if all preceptors put as much thought, effort and heart into teaching new grads as you have it would be a whole new world! She's very lucky to have you, no matter how things turn out, because you have her best interests at heart, not only as a future coworker, but as a person navigating a new and challenging career. It sounds like you are very consistent with positive and constructive feedback, and she's unlikely to be taken completely by surprise no matter how things turn out. Have you asked her how she feels that her orientation is going? Does she feel like she's where she should be, and what areas does she identify as weaknesses of hers? 

As many other people have mentioned, sometimes things don't work out. It's not a judgment of a person, or their intelligence or capability as a whole, but not everyone is right for every work environment. Orientation is the time to figure out, for all parties involved, whether it's the right fit for all. No one really "fails" orientation, if it's just a matter of finding a better fit. I hope that the next few weeks feel productive for you, and for her, and you can all come to the best outcome.