Where should I realistically be at this point in orientation?

[cblossom78]

I'm a brand new nurse, I graduated in May, just passed my boards last week, and I've been working as a graduate nurse for a hospital in the emergency department. I've been on orientation for 4 weeks out of the 12. Prior to this, I haven't had any clinical experience outside of nursing clinicals. Now the issue is I'm constantly making mistakes and it's very frustrating. I understand mistakes are inevitable but it's not a good feeling when they are preventable. I thought at this point, I've been making reasonable progress but I can tell my preceptor is losing confidence in me. I always ask her for help and supervision if I'm not 100% confident and I will do anything to gain experience. I feel like I rely too much on my preceptor where she feels like I should be more independent now and take more initiative. But when I try to improve based on her criticisms, another issue arises from that. I feel like I'm getting support from my preceptor but not the right kind of support. Is it too early to beat myself up? Should I be worried about where I'm currently at or is this normal?

[Davey Do]

To commiserate and compare notes, cblossum, back in '86 when I was an LPN with
2 1/2 years experience mainly in psych, I got my wish to work in the OR as a scrub nurse.

I was all thumbs for the first three months. The assistant OR director discussed whether I was cut out to be a scrub.  Surgeons yelled at me for not knowing my job. I felt very discouraged, but kept plugging away, trying to eat, breathe, and sleep scrub nurse.

Then, everything fell into place! I excelled! I could tell the circulating RN where quickly needed supplies were located during a surgery. Surgeons who once yelled at me were asking if I didn't want to first scrub on one of their cases. I could braggingly relate many other situations.

With my experience as a basis, cblossum, if you are where I was, four weeks into my orientation, you are still in the "all thumbs" stage.

Good luck and keep plugging away!

[Cricket183, BSN, RN]

It takes a new nurse a good year or more to start to feel like they know what they are doing and ER is an incredibly tough place to start.  When you say mistakes, what kind of things are we talking about?  Because there are mistakes and then there are MISTAKES.  And are you repeatedly making the same kind of mistakes?

In my experience, nursing school-even really good ones-do not prepare you for the reality of nursing.  I went to a great school (TWU) and had great clinicals at some of the best hospitals in Houston & Dallas and when I started out, I didn't feel like I had learned anything!  That's very common.  It's a steep learning curve and you're only 4 weeks in.  So, yes, give yourself some grace.  It's OK to rely on your preceptor at this point but you should be becoming more and more independent as your orientation progresses.  It's normal to beat yourself up when you make mistakes.  I can still remember a few I made in orientation and that was over 20 years ago!  Try to reflect and see where your mistakes are coming from-are you trying to rush?  Are you distracted?  Those two things are usually where mistakes originate-so slow down and concentrate (I know it's the ER and that seems impossible!).  Have an honest conversation with your preceptor and share with her what you wrote here.  Ask her for feedback and for advice on where and how to improve.  It sounds like she is trying to be supportive and wants you to succeed.  Also be honest with her on how she can be supportive to you.  You mentioned you didn't feel like you were getting the right kind of support so tell her what that looks like to you.  A good preceptor will be willing to discuss it with you.  I always had an "interview" with my preceptees and asked them things like: how do you learn best?  How do you receive correction/constructive criticism?  Do you like to dive in headfirst or are you an observe first then do type of person?  It helped me to know how to adjust my teaching.  Anyway, I got off on a tangent..,but my point is let your preceptor know what you need.  Best of luck to you!  You got this!

[JBMmom, MSN, NP]

Take a deep breath. Four weeks in an ER is NOT enough time to feel competent or confident. As was already mentioned, it's more about the types of mistakes you're making. Are you rushing in your work too much? Are you not organized from the beginning in order to make yourself successful? Are you not using the tools available to help prevent mistakes like scanning and following the five rights? You say your preceptor is losing confidence, have those words been stated? When on orientation we are often in a constant state of anxiety and will guess what other people are thinking when that could be wrong. Ask your preceptor to sit down and talk things out. Have concrete goals for what you are expected to be able to do on your own at this point and what you should be going to them for.  You may be asking all the right questions or you may be second guessing yourself so much that you're asking questions you don't really need to but you're nervous to make a mistake now. 

It's a 12 week orientation for a reason, and you're only a third through it. And even after orientation you're not going to be confident and independent immediately. Nursing takes time. You've chosen a challenging environment in the ED, you'll get there. 

[Been there,done that, ASN, RN]

Only your preceptor can really answer that. Do you get weekly reviews? Have you been given an overview of what is expected each week?

May I ask why you decided to start out it ER?

[vampiregirl, BSN, RN]

Please be kind to yourself!

Safety comes first. Making sure you are learning steps to ensure patient safety in the processes you perform is critical. As you build muscle memory, you want to make sure all the safety steps are in your process. While I understand the importance of speed in the ER, allow your speed to come from being able to competently perform processes and tasks safety. 

This is also a time to start figuring out your organization system. While on orientation, typically you will use the organization system set forth by your preceptor. Once you are off orientation, likely you find you modify your organization system. Feel free to "steal" others organization tips as well. At one place I worked, we used brain sheets that were just shredded at the end of the shift. I ended up making my own and it was a game changer for me. Mine was simple but it kept me organized.

I was absolutely terrible at IV's years ago when I started in EMS (prior to being a nurse). I decided this was going to be an area that I set my own goals for me. In time, this became an area in which I actually not only became proficient but excelled (hence my user name). Pick some goals for yourself.

It's easy to look at the whole overwhelming picture right now but also take time to recognize areas where you ARE right on target. And that doesn't even have to be technical skills all the time - interpersonal skills are just as important. While you are trying to figure all the technical skills, learning how to interact with patients in a calm, compassionate but confident manner is also so important.

Best of luck to you as you continue your nursing journey!

[canoehead, BSN, RN]

I really think four weeks is much too soon to draw any conclusions. You know where the bathroom, med room and utility rooms are. You can do an assessment head to toe? I'd be good with just that right now as a preceptor, as long as you were still asking questions, and making progress.

[DallasRN]

JBMmom said:

It's a 12 week orientation for a reason, and you're only a third through it. And even after orientation you're not going to be confident and independent immediately. Nursing takes time. You've chosen a challenging environment in the ED, you'll get there. 

Lots of great information has been shared but I think this sums it all up.  Perfectly.  ER is a tough place to work.  Even for those with years of experience but wishing to transition into ER from other areas, it can be difficult.  Set your own personal goals (written) and day-by-day, check them off.  You'll get there.