URGENT- Are my assignments safe?

fergus51 · Aug 18, 2007

hello,

i don't think those were unreasonable. the feeder growers, obviously safe. the kid with the a line and stuff was a good experience for you since your other baby was stable enough. i take 2 kids like that at times. it was probably busy, but you will learn time management and caring for sick babies by doing it. it's the only way. if they gave you a second hard baby, i would be concerned, but you say the other nurses helped you and your other baby was ok. the error report may be more about the resident than about you. i would probably have prefered the a-line was taken out sooner too, but it didn't cause any patient harm and i wouldn't have worried about him bleeding out because of it. the assignment with the admit seems reasonable to me too. you only had one other baby and it was stable. the charge probably didn't realize that the admit would be as sick as it was. unfortunately that happens a lot in nicu. as long as people are willing to help you with that, i think it was reasonable. someone should of given you report. overall though it wasn't terrible.

if i were you, i would ask for the same patients back the next night. it gives you time to get to know your babies. other than that, i think the assignment were ok and you are probably just experiencing the normal stress that a new nurse feels in the nicu. i'm sure you were scared and perhaps the other nurses could have offered you more reassurance, but i don't think those assignments were unsafe. as long as people are still helping you out when you need it, i think you're in a decent unit. take a deep breath and maybe a bubble bath:) you are probably doing just fine as a new nurse and those feelings do get better with time.

llg, PhD, RN · Aug 18, 2007

The assignments seem perfectly reasonable to me ... assuming you had a decent orientation. They sound like typical NICU assignments of the "easy to average" variety. Almost all true level III babies have ET tubes, art lines, and PICC lines -- they shouldn't be a problem of you by the end of orientation. The tough babies to care for are the ones who don't have those things to make it easier for you to care for them -- and the new admits who are in the process of getting all their tubes put in place.

Similarly, a stable with a chest tube is no big deal. All you do is record the drainage and check the breath sounds and tube connections regularly. If there is no problem with the tube and it is doing its job, they don't involve a lot of extra work.

The presence of technology itself does not make a baby "hard" or "easy" to care for. In many cases, the technology makes the nurse's job easier by making it easier to provide the care the baby needs. For example, it's a lot easier and quicker to draw blood from an art line than it is to do an arterial stick. Now ... it's a different story if these babies were not stable. Were their conditions changing rapidly during your shifts? ... Or were they just hanging out, needing routine care? That's really the key point in judging the difficulty of an assignment. Did the babies just need routine care (including maintanence of their routine technology) ... or did their changing conditions require exceptional vigilence and/or special procedures?

It sounds to me that you are not comfortable with the technology that is used in your unit. You seem to be "thown off balance" by an art line, ET tube, PICC line, etc. In every NICU that I have worked, these technologies are not considered a big deal. They are the routine things that most babies have. In the NICU in my current hospital, the new grad orientees begin taking care of ventilator patients on the 3rd or 4th week of employment. By the time they come off orientation (at 16-18 weeks), they are expected to be able to care for an assignment of 2 relatively stable babies on ventilators. It's assumed those babies would also have a couple of IV's (PICC and/or UA), continuous feedings, and probably a couple of other things going on.

Are you working in a small NICU or one in which babies on vents are not common? Did you get experience with those types of babies on orientation? Are the other staff members helpful and supportive? Perhaps you need a little more time on orientation with a preceptor so that you can have a few shifts where you provide the total care of such assignments yourself -- with your preceptor NOT helping you, but rather standing back and being there only to catch you if you fall. Such preceptored experiences would give you the experience of being "on your own" before you actually are totally on your own.

Is there anyone in your unit (former preceptor, mentor, education coordinator, etc.) who you could talk to about this? Ask them whether or not these assignments are typical and whether other new grads are able to handle them. Sometimes, the best students are the ones who struggle the most in their transition from student to professional. As a student, you are so used to being the best and not being stressed by your work, that it comes as a shock to be so challenged by the "step up" that has to be made in the level of your performance. Not being used to struggling, they become more distressed than the new grads who have been really challenged by school and by orientation. Those less successful students have learned to dig in when it gets tough and find/use their resources becuase they have had to do that to get through school. Some of the best students (and new grads with preceptors who did a lot of the patient care work for their orientee) never learn some of the life lessons that help you get through a tough shift. Is that part of what is happening to you? Are you so used to being on top of things that you are struggling emotionally with finding that as a new staff nurse, you don't always feel secure and on top of things?

Learning how to work safely even when things get a little overwhelming is an important part of becoming a successful nurse. Even after many years of practice, there will be times you won't feel totally comfortable. You have to learn to stay safe even when you don't feel totally in control.

Sorry this post got a little long. I've spent 14 years running NICU orientaion programs and I can see a lot of possibilities in your description of the situation. I think your best bet is to find an advisor who knows you and your unit to help you sort this all out so that you can make a plan for yourself that will help you grow a little more at this point. Good luck.

SteveNNP, MSN, NP · Aug 18, 2007

I agree with llg, while it's always best to keep the same assignment for sake of continuity of care, your assignments were completely reasonable. I was in your situation a few years ago, when as a new grad I was given the same patients that the other seasoned nurses were getting, right off orientation. You will quickly improve your level of care, time management and critical thinking skills while caring for these patients. Always make sure you have a mentor or more experienced nurse nearby that you can use as a resource when caring for assignments like these. I would say that they are typical if not slightly better than what I'm used to seeing...It will get better! You'll look back at the end of your first year and realize how much you've learned and how far you've come as a NICU nurse....

grnmtngirl · Aug 18, 2007

That's all I needed to hear. Thank you guys!

I cried a lot this morning. I cried through my whole shower at home. My husband felt really bad for me and assumed one of my patients had died. My babies were relatively stable (barring the admit which turned into a nightmare that nobody saw coming which led to a lot of "excitement"). I still got all of my work done, meds given, things checked off.

Babies on vents don't matter to me so much. 2 stable babies on vents, cpap, etc isn't a big deal. The "technology laden baby" was a very young unstable baby who has coded in the past week and just had a lot of tubes which as you know require a lot of "paperwork" and documentation and it's time consuming as a new person to do a thorough check. I still take approx 30 min to do a phy assessment and care on a baby while I find the seasoned nurses can start the baby up about 15 min before the baby is due to feed and still be done on time. I'm sure the eye of experience counts for something in knowing if something is wrong. I have to judge (especially if I've never had the baby before which is how it seems to be progressing every night) based on my vital signs and a thorough careful assessment to the best of my ability.

I just don't want to make a critical error because they're in a critical state. I'm going to print off these posts and keep them because I think they address a lot of my problems and fears. I was somewhat challenged in school but never in a critical care environment. And I had a great orientation with very supportive preceptors. But I had very doable assignments and my preceptors jumped in to help and give me lunch/breaks. It's just different being on your own and knowing there's nobody there to check off all your work before the next shift comes in. It all falls on my shoulders.

I appreciate the feedback. I'll dry my tears and go back to work tonight and will not complain about my assignments. I'll trust they're giving me safe, learning assignments and will provide support if i I get into trouble.

Thanks for taking time out of your weekend to respond!

llg, PhD, RN · Aug 18, 2007

It sounds to me as if you have a great attitude, grnmtgrl, and that you are working in a unit that is able to support you through this period of transition. Use those resources and I think you will be fine. Yes, it's tough -- and one of the hardest parts is getting used to the added responsibility that comes with being an actual profession and not just a student or orientee. It sounds to me as if that is where you are struggling -- not so much with the care itself.

Find some good mentors to talk to and invest a little time and energy with making friends among your coworkers. When you are feeling stressed at work, it will help a lot to look around and see actual friends rather than just coworkers. That's the best single piece of advice I can give you. When you see friends as you look around the unit, it will be comforting to you -- and less scary.

fergus51 · Aug 18, 2007

I'm glad you feel at least a little better. Your fears and anxieties are completely normal. I wasn't a new grad when I went into the NICU, but I still left most days completely stressed out at the beginning. I even remember choking back tears on the subway going home one morning:)... It does get better. I don't know when exactly it happened, but one day I was able to go into work without feeling sick to my stomach and I left without worrying about what I might have done wrong during my shift. I even went to sleep easily without the unit and the patients on my mind. It will happen to you too:)

grnmtngirl · Aug 19, 2007

Just a followup-

I spoke with a great resource person last night who has offered to help me out with questions and has a great deal of knowledge regarding patho, technology, and developmental care. I think this person will be very helpful in my development as has offered to help as he can.

Also, I spoke to the charge nurse and asked that I be given assignments for at least 2-3 nights/row at a time (at least for awhile- whenever possible) to help transition into taking care. I always found in school that no matter how bad day 1 was, day 2 was always easier because I knew the patient and had an idea of what worked and what didn't in my routine. Also, it helps me to come into work and see what happened with the patient's care so that I can start to look ahead to how patients progress through the unit and what sorts of proactive things I can be doing and suggesting to residents at night to make sure my patients are getting the best care possible overnight and not just waiting till morning for an attending to come and write the order for the more senior nurses.

Thank you again for the posts. I had an awesome night at work last night, with yet again, a different assignment. Your posts reassured me that I would be ok and that my assignments weren't off the wall (though I assure you they felt that way!!!)

Thanks again!