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struggling new grad: may not make it past orientation

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by Sheika34 Sheika34, BSN (Member)

598 Visitors; 17 Posts

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So i am a current new grad on orientation on week 5. I am currently taking 3 pts & I know this may sound insignificant but I can't but notice that I am behind, performance wise, the other oreintees. We are supposed to be able to take care of pts based on the number weeks we are on orientation so I should be able to take care of 4-5 pts. But I do not think I am progressing as well as I should.

I have been able to get more feedback from my preceptor. She has been giving me advice and talking to me about my time management... which is something I struggle with but has been slowly improving on. & she always says I'm doing good. But sometimes I'm wondering if she's just telling me that to preserve my confidence. I honestly believe I would do better if she would tell me what all I need to fix.

The reason why I think I'm not a good fit for my floor is because I don't think I act as independently as I should. I have had various situations where my pts would appear to

be in distress & I just feel like I go into a panick. None of the situations I was in was a reason for panic, mind you. & I do have a gut feeling that these situations are not as bad as they seem but instead of trying to effectively resolve it I always get my preceptor and it turns out it something that could've been easily resolved with just a call to the doctor. Just simple things. If I can't effectively resolve simple problems how am I going to operate on my own and with more complicated problems? I feel like this is a sign of lack of critical thinking skills and therefore I should not be on a high acuity med surge/ Tele floor.

anyways at this point I don't see myself making it past orientation. I know some ppl have said you just have to find your niche... so I've been thinking about transferring to another unit if possible. Ultimately I would prefer one with a lower acuity set of patients or slower pace(if such a floor exists). any advice?

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153 Likes; 6,127 Visitors; 509 Posts

As you are on a med/surg floor, the acuity really isn't going to get any lower elsewhere in the hospital. And in acute care, the pace is always too fast.

Time management takes time to develop. It's like juggling many, many balls. It requires seeing the big picture and what all needs to be done. If you are passing meds, take the patient to the bathroom, make sure they have water, Kleenex, etc. Get them to use the incentive spirometer. If they have fluids running, replace that bag a little early if you are already going in there. Do a little education on their medications when you give them. Make sure they have a hat in the bathroom if they have I&O's ordered. Bring supplies to do foley care when you do your skin assessment. If they are always asking for a PRN, know when it's due and be prepared to do other things at the same time.

It's tough to transition from tasks to big picture. Just take a breath and figure out what the big three goals for everyone are for the day and focus on how to accomplish those goals. Every time you go in, make sure it's not for just one thing. What else can you do? What can get the patient closer to his or her goals for the day?

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not.done.yet has 8 years experience as a MSN, RN and works as a Professional Development Specialist.

283 Likes; 4 Followers; 42,876 Visitors; 5,168 Posts

Time management and anxiety management are the two biggest hurdles for new grads. What helped me was this.

At the beginning of your shift, after you get report but before you start your med pass, take a piece of notebook paper. Turn it landscape and make columns, one for each of your patients, putting their room number at the top of your page. On the left side, write the hours you will be there, from 0700 to 1900 or 1900 to 0700, whichever the case may be. One row for each time; ie: 0700, 0800, 0900 etc all the way to 1900.

For each patient, scan through their chart, starting with the MAR. Write under each patient's column and corresponding time that you will be passing meds (I would just put the word "meds" for standard med pass times like 0900. For something out of the ordinary, I would put the name of the med). Then add in blood sugar checks due, wound care, etc. This will let you see your entire baseline work flow throughout your entire shift. As you accomplish each task, cross the item off.

This calms the brain, shows you where your time gaps are that will give you a chance to chart. It starts letting you get the rhythm of your days, prioritize your tasks and leaves more brain space to start developing the critical thinking aspect. It is satisfying to check things off and helps with clustering tasks together.

You are new. That comes with a big honking serving of humble pie. Nobody expects you to be anything but new, which means recognizing changes in condition is more important than necessarily knowing what to do about them yet. That's why you aren't independent yet and why even once you are, you will still need your hall buddies and/or charge nurse to help guide you. Stop worrying about whether you are keeping up with your peers and listen to your preceptor. Comparison is the thief of joy. Learn to cluster tasks, to delegate efficiently and effectively and trust that you are on your way. You will get through this and you are going to be just fine.

Edited by not.done.yet

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598 Visitors; 17 Posts

Time management and anxiety management are the two biggest hurdles for new grads. What helped me was this.

At the beginning of your shift, after you get report but before you start your med pass, take a piece of notebook paper. Turn it landscape and make columns, one for each of your patients, putting their room number at the top of your page. On the left side, write the hours you will be there, from 0700 to 1900 or 1900 to 0700, whichever the case may be.

For each patient, scan through their chart, starting with the MAR. Write under each patient's column and corresponding time that you will be passing meds. Then add in blood sugar checks due, wound care, etc. This will let you see your entire baseline work flow throughout your entire shift. As you accomplish each task, cross the item off.

This calms the brain, shows you where your time gaps are that will give you a chance to chart. It starts letting you get the rhythm of your days, prioritize your tasks and leaves more brain space to start developing the critical thinking aspect. It is satisfying to check things off and helps with clustering tasks together.

You are new. That comes with a big honking serving of humble pie. Nobody expects you to be anything but new, which means recognizing changes in condition is more important than necessarily knowing what to do about them yet. That's why you aren't independent yet and why even once you are, you will still need your hall buddies and/or charge nurse to help guide you. Stop worrying about whether you are keeping up with your peers and listen to your preceptor. Comparison is the thief of joy. Learn to cluster tasks, to delegate efficiently and effectively and trust that you are on your way. You will get through this and you are going to be just fine.

Thank you for the advice! & I do have a brain sheet but I think I may need to revise as you said since it's not working out like it was. Right now I just feel so incompetent & now I'm questioning why am I even doing this. At this point I'm just worrying about my clinical thinking skills.

Today i I have a patient her PRN morphine for pain. Her respiration's were good, her b/p was good (in the 120s/70s. So I saw no harm & I didn't wanna leave her in pain. But as soon as I have it her whole demeanor was different she started saying she couldn't breathe and she just looked different & she seemed to be in distress. & I know it's morphine & sometimes ppl are effected by it like that. I assessed her & she seemed ok, followed commands, and was awake. But I'm new, 5th week on orientation, & I wanted to be sure. The last thing I would want to do is harm so one because I think I got it under control. So i asked one of the nurses to check her as well to be sure. & everybody was looking at me like " can't you assess her since your a RN"... or at least that's the vibe I got from the frowns I received. But my charge nurse was nice about it & checked & everything else seemed ok. She just said keep an eye on her.

anyways I felt like a complete idiot. Like I can't even give meds and I always seem unable to resolve the simplest problems for myself.

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not.done.yet has 8 years experience as a MSN, RN and works as a Professional Development Specialist.

283 Likes; 4 Followers; 42,876 Visitors; 5,168 Posts

Thank you for the advice! & I do have a brain sheet but I think I may need to revise as you said since it's not working out like it was. Right now I just feel so incompetent & now I'm questioning why am I even doing this. At this point I'm just worrying about my clinical thinking skills.

Today i I have a patient her PRN morphine for pain. Her respiration's were good, her b/p was good (in the 120s/70s. So I saw no harm & I didn't wanna leave her in pain. But as soon as I have it her whole demeanor was different she started saying she couldn't breathe and she just looked different & she seemed to be in distress. & I know it's morphine & sometimes ppl are effected by it like that. I assessed her & she seemed ok, followed commands, and was awake. But I'm new, 5th week on orientation, & I wanted to be sure. The last thing I would want to do is harm so one because I think I got it under control. So i asked one of the nurses to check her as well to be sure. & everybody was looking at me like " can't you assess her since your a RN"... or at least that's the vibe I got from the frowns I received. But my charge nurse was nice about it & checked & everything else seemed ok. She just said keep an eye on her.

anyways I felt like a complete idiot. Like I can't even give meds and I always seem unable to resolve the simplest problems for myself.

So in the future you will know - assess LOC, respirations, basic vital signs and if all is okay, round back on her in 15 minutes and see if she is any better and reassess again as needed. You did fine. Follow those same steps for any time someone is showing similar symptoms. Don't forget to set a bed alarm too.

You have to give yourself time. Again, you sound like you are concerned about what people are thinking. That isn't the most important thing right now. You have no critical thinking skills yet. Your brain has to get the fundamentals of time management down before it will have room to puzzle through things. You are erring on the side of careful and that is good - you DID recognize a change in the patient's condition, right?? See? You know how to see that - which is ahead of a lot of new grads. You knew something wasn't quite right and you followed up. Next time you won't need to ask, you will know what to do to assess; just use caution not to let it slide into the realm of anxious/paranoid. You will be fine. Feel free to reach out to me if you like. A little support can work wonders.

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30 Likes; 1,221 Visitors; 119 Posts

I've been a nurse over 30 years, I still use a brain sheet. Just need to leave enough room for problems that come up. Sometimes I use a couple sheets for all my patients.

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My heart goes out to you because I was exactly in your shoes a year ago and thought I'd picked the wrong career. I really struggled during my preceptorship, and wanted to quit several times. A lot of it was just nerves and fear. Plus I was under the misconception that I had to know everything right out of nursing school, and so was ashamed to ask for help/advice. Big mistake! Why? I finally learned that it's not all about how I looked or what people thought about me, but ultimately about the patient's SAFETY. In fact there are seasoned nurses on my floor who still ask for a second opinion. You might think you look incompetent for asking the charge RN for a second opinion, but actually you are being smart. Better an early intervention now, than having to call a code on a patient later. Trust me you are on the right path, and it will get better. Just stop comparing yourself to others. Measure your progress by how much you are learning everyday and by how much better you are today than you were yesterday, or a week ago.

As to time management, that will come. I still struggle with it, and often have stay on after shift-end to catch up with charting. But I don't mind, because at end of the day the most important thing for me is that my patients are safe, stable and cared for.

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Leader25 has 35 years experience.

55 Likes; 2 Followers; 4,234 Visitors; 660 Posts

Thank you for the advice! & I do have a brain sheet but I think I may need to revise as you said since it's not working out like it was. Right now I just feel so incompetent & now I'm questioning why am I even doing this. At this point I'm just worrying about my clinical thinking skills.

Today i I have a patient her PRN morphine for pain. Her respiration's were good, her b/p was good (in the 120s/70s. So I saw no harm & I didn't wanna leave her in pain. But as soon as I have it her whole demeanor was different she started saying she couldn't breathe and she just looked different & she seemed to be in distress. & I know it's morphine & sometimes ppl are effected by it like that. I assessed her & she seemed ok, followed commands, and was awake. But I'm new, 5th week on orientation, & I wanted to be sure. The last thing I would want to do is harm so one because I think I got it under control. So i asked one of the nurses to check her as well to be sure. & everybody was looking at me like " can't you assess her since your a RN"... or at least that's the vibe I got from the frowns I received. But my charge nurse was nice about it & checked & everything else seemed ok. She just said keep an eye on her.

anyways I felt like a complete idiot. Like I can't even give meds and I always seem unable to resolve the simplest problems for myself.

Even very experienced nurses and doctors ask for a second opinion,nothing wrong with that and it is safer for the patient.

The rest is just a new nurse thing,how is your life off shift,are resting or burning the candles at both ends?Do you set aside a time at home to scan educational materials from your orientation?

What educational resources on patient care are available on your unit?

We always carried around a small spiral book as a resource, with on oncall problems and procedures.

Hope this helps,best wishes,keep posting how you are getting along.

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KeepinitrealCCRN has 5 years experience.

5 Likes; 2,473 Visitors; 107 Posts

So you actually seem like you are doing well. You know your weak areas (these areas take time for everyone not just you) and you seem to be extra careful which is much better than not caring or not knowing when to address something or let another nurse/your preceptor know what is going on. Maybe you can request a meeting with your preceptor and the manager so you can really see where you stand and if there is something you need to work on or if its just the normal things all new grads go through. good luck!

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