Ok so I'm a new grad two weeks into training. I administer a lot of BP meds so I also do a lot of manual BP checks,every time I'm trying to take a blood pressure the correct way like they taught us in school (feel the radial pulse first then inflate the cuff,wait 30 seconds and then go 30mmHg more of what was the radial pulse cut off number) I get yelled at by my preceptor and then she questioned me if I also listen to the pulse with the stethoscope? Duh,of course I do,you kidding me,just because I want to get the feeling of the radial pulse doesnt mean I dont know the rest of the steps on how to measure blood pressure,then another time she asked my why am asculating the breath sounds in eight places (that the max I should asculate would be 4) Ok but this is what I was taught in nursing school,and I'm sure that a good reason behind this rationale,then she said that it takes me too long to assess the lungs (hello I'm new I'm not an expert in crackles,wheezes,so I want to make sure that what I'm hearing is right,after all I will be charting on this patient)Also my preceptor told me I shouldnt be carrying a drug book with me and took it away from me. I dont know,I'm surprised I'm getting yelled for doing the right assesments!:crying2: I cant afford to take shortcuts,I dont have experience yet
You do not have the time, nor the need, to do your assessments like you did in nursing school. Nursing school was about doing everything to the most minute detail. In the real world, you use your critical thinking to know which aspects of your assessments you perform in greater detail, and which areas you only assess in a cursory fashion.
As far as the blood pressure goes, I have never in all my years, in all my areas of practice, seen anyone perform a blood pressure like that outside of nursing school. Even in the ICU and ED. It doesn't make a difference, it's a waste of time, and if you have a patient for whom obtaining a blood pressure is distressing (painful, they are combative, etc), it's also disturbing to your patient.
While she shouldn't have physically ripped your drug book out of your hands, you really don't need to carry it around, particularly if it has become a crutch or a distraction. Are you looking up the same meds all the time? Are there faster ways of finding info on meds (ie in the EMAR)? Are you looking up things that you know, but you just want to be double-sure? At some point you have to be sure of yourself. None of us where I work carry drug books, because we have quick access to this via our computers. In the Emar, we simply right click on any of the prescribed meds, and get complete drug info on it.
Your preceptor is probably grinding her teeth watching you look up every drug, listen to breath sounds for forever, and taking 3x as long to do your VS as it should. Hence her attitude. I am not the most patient of persons when it comes to precepting, and I totally recognize her behavior. She's given you suggestions, you aren't following them and continue to be as slow as molasses, and she's reached the end of her rope with you. She's probably also recognizing that in a sink or swim environment, if you continue to take as long as you are now with each patient, you are going to sink. This reflects badly upon her, it's not good for you, and it's terrible for the unit as a whole. This is undoubtably stressing her out and further eroding your relationship.
Here are my suggestions:
*Request a new preceptor. You two are obviously not clicking, and it's not going to benefit you to have her for the entire orientation. Make sure you make a fresh start with the new one, though, and lose the attitude.
*Follow your preceptor for a shift. Pay attention to every little detail. See where she cuts corners and note where she concentrates her time. Newer nurses tend to focus on the wrong things. It is NOT important to do complete, thorough assessments on all your patients; focused assessments are so much more beneficial. A full head to toe assessment is great in theory, but if your other patients are going down hill and you haven't even assessed them yet because you're taking 5 minutes per VS and doing a 10 minute assessment on each patient, you aren't doing anyone any good.
*Understand that you ARE going to do things differently than in nursing school. There is more than one way to operate as a nurse. And again, nursing school makes you do things ueberthoroughly so that you learn all the details. Once you are out of nursing school, you use your critical thinking to decide when to be thorough and when to be succinct. Try things your preceptor's way, when she makes suggestions. She knows how you need to perform to be successful on the unit, and she's trying to help.
*Once you've shadowed your preceptor one day, start by taking just one patient, then the next day add another, then continue to slowly add another until you are taking the full load.
As far as the drug book goes: like intern67 suggested, place it somewhere that is readily accessible: by your computer, at your space in the nurse's station, etc. Leave it there, and reference it when you must. When I was a new nurse, I wrote down 5 drugs I gave every night, and then went home, looked them up, and made a few notes on them--mainly typical dosage and common reactions. You might find some similar activity helpful. I do not look up every drug, nor do I look up to see if every drug I'm giving is compatible, because I trust our pharmacists. Our drugs have been entered and double checked in pharmacy. Certainly if it is something new, or if I am mixing something I check if I don't know; but not every little drug I give.
Good luck; it sounds like you need it. Based on some of your own responses to suggestions here in this thread and some of your other posts, I think you should take a good hard look at yourself and your attitude. If you are at all snarky with your preceptor, you are in for one hell of a time. Learn from her, she's there to help you. Try doing things her way, you might find it works for you better than you thought. Once you're through with your orientation, you can practice how you wish, within reason, and you can incorporate the good things you learned in orientation into your own practice.
Don't tolerate "yelling". Yelling is not appropriate anytime. Nip that in the bud while you're a new grad.
You should be allowed to be a new grad, and the mark of a good preceptor is patience.
However, criticism from a preceptor is necessary and take it perhaps with the intent it was meant, meaning if you're going to increase your load you're going to have to step up to the plate and move ahead.
Specializes in Management, Emergency, Psych, Med Surg.
Just try to accommodate her until you get off orientation. Once you do, carry your drug book and take your vitals they way they taught you in school. Be safe, and it sounds like you are. We all went through this during orientation. Some instructors think that if it is not done their way then it is wrong and that is not correct. There are many safe ways do accomplish many tasks. Just stick it out. You should also ask for a meeting with her and your manager at regular intervals to get feedback on how your doing. And during that time, you need to let them know what you need from them.
I agree with what appears to be the prevailing sentiment: if you can get a new preceptor, that would be a good idea. If you can't, get along with the one you have as best you can, then do things your way when you are one your own. In any new endeavor, if you start out doing things thoroughly, your speed will automatically improve with repetition. But if you start out doing things sloppy, your quality will not automatically improve, and will probably get worse as you learn to accept lower standards.
That said, I've spent a fair amount of time encouraging a less experienced co-worker to become a "sloppier" nurse. But what I mean by that is to use better judgement in managing her time. I don't entirely disagree with the poster who suggest a focal assessment does more good than a full head-to-toe. I don't totally agree, either, but in my typical 12 hour nightshift, I assess most patients three times. At the start of my shift, I do a head to toe so I know what I have. At our facility, the standard of care is that every patient has at least one full head-to-toe by an RN in each 24-hour period, and that's usually done at midnight. Then, around 0400, we're to do a focal assessment, which on my unit includes neuro checks and whatever is appropriate to their problem, like assessing a cranial incision.
But, honestly, in most cases my first two assessments probably equal a full head-to-toe between them. If their skin integrity is excellent at 8:00, how bad is it likely to be at midnight? If their lungs are clear in all fields the first time you listen in nine places and their sats and RR are normal at midnight, maybe it's enough to listen to the anterior. At 0400, maybe orientation questions can be, "How do you feel? Are you having any pain? Do you need anything?" A lot of the time, when you walk into the room, you know some systems are working just fine and others are a problem, and I think it's okay to do the least necessary to confirm the ones are fine and concentrate more on the others. Checking a walkie-talkie 20-year-old for bedsores might be fun, but is it strictly necessary? Vital signs and feet will tell you a lot about circulation. A lot of my patients are older and more-or-less bedfast, so skin and lungs probably do need a fair amount of attention. I think it's not only okay, but actually better for the patient, to use a little common sense. On the other hand, on another thread, a poster described her grandmother not being assessed at all, and that doesn't have a thing to do with common sense. It shouldn't be about getting out of work, but about making your work count. Don't let things slide, but don't spend more time than you need to confirming what you already know. And try not to second guess yourself. I made A's on most of my tests in nursing school. If I had bought pencils without erasers, I could have made A's on all of them.
. it shouldn't be about getting out of work, but about making your work count. don't let things slide, but don't spend more time than you need to confirming what you already know.
this is a very important point - but it takes some time and experience after you get out of school. my shift started at 0245 for report. first assessment was at 0400 and i went with the cna while she did vital signs. usually the patient needed to get up to the bathroom or bedside commode - i could do a full skin assessment while this was happening. we kinda killed two birds with one stone working together like this. however i worked in a small rural hospital and we never had more than 10 patients, 5 per nurse. i learned to combine my assessment with other things - making the time count.
and try not to second guess yourself. i made a's on most of my tests in nursing school. if i had bought pencils without erasers, i could have made a's on all of them.
love that . . . .
we had drug books at the nurses station and in the med room but didn't carry them with us. now every nurses seems to have a pda with a drug book available and carry that in their pockets.
sometimes preceptors forget or don't realize what you did in school may not relate to what you need to do at your job. one simple example - one of my preceptors (a perpetual grumpy woman) asked me to go get a saline lock for a patient's iv line because we were stopping fluids. i looked and looked in the med room (where all our other supplies were kept too) and couldn't find one - when i went back and told her she looked at me like i was an idiot. and marched into the med room, opened a cabinet, pulled one out. well, that lock looked completely different than the one i'd used in clinical at other hospitals 70 miles away. and there was no label on the box. she was pretty peeved at me - for a pretty simple misunderstanding.
when i became a supervisor - i never had her be a preceptor - assuming someone is an idiot simply because they don't have experience is harmful to the teacher/student relationship. while not getting experience giving an im injection is sad, you are limited by what patient you get. our clinical instructor always tried to match us up with patients who needed lots of care so we could practice our skills. my first iv was in an er on an 18 year old girl with big fat juicy veins! i got right in! that was so cool and i really appreciated my instructor for assigning that particular patient to me.
i agree with most of the posters here - don't learn sloppy shortcuts that will make your patient care unsafe. stick up for yourself - you are a professional nurse now and don't have to take being treated as anything but a professional nurse.
Steph makes a very good point--it does take time and experience to learn where time can be saved, which supports the OP, and any other newbie, in erring on the side of thoroughness.
We recently had a new hire who, by mutual assent, was not picked up after an extended orientation. I didn't really work with her, but she was my Dad's nurse on a couple of shifts and I liked her. She made a couple of non-trivial mistakes with him, but no harm resulted and she did some other important things right. But from talk around the floor, she was at least perceived to have been openly critical of some excellent nurses who didn't do things the way she did in school.
She was (and I assume still is) very bright and hardworking, and I find it hard to imagine anything she may have said was intended maliciously, but she did rub some people who could have done her some good the wrong way, and it didn't look like she was ready to handle the pace on an acute care, med/surg floor. I hope she finds her niche, but her interactions with some of her coworkers are an example that a bit of diplomacy is also an important trait, and one that remains important no matter how long you've been a nurse.
:crying2: I cant afford to take shortcuts,I dont have experience yet
love that . . . . 
BluegrassRN
1,188 Posts
I agree with intern67.
You do not have the time, nor the need, to do your assessments like you did in nursing school. Nursing school was about doing everything to the most minute detail. In the real world, you use your critical thinking to know which aspects of your assessments you perform in greater detail, and which areas you only assess in a cursory fashion.
As far as the blood pressure goes, I have never in all my years, in all my areas of practice, seen anyone perform a blood pressure like that outside of nursing school. Even in the ICU and ED. It doesn't make a difference, it's a waste of time, and if you have a patient for whom obtaining a blood pressure is distressing (painful, they are combative, etc), it's also disturbing to your patient.
While she shouldn't have physically ripped your drug book out of your hands, you really don't need to carry it around, particularly if it has become a crutch or a distraction. Are you looking up the same meds all the time? Are there faster ways of finding info on meds (ie in the EMAR)? Are you looking up things that you know, but you just want to be double-sure? At some point you have to be sure of yourself. None of us where I work carry drug books, because we have quick access to this via our computers. In the Emar, we simply right click on any of the prescribed meds, and get complete drug info on it.
Your preceptor is probably grinding her teeth watching you look up every drug, listen to breath sounds for forever, and taking 3x as long to do your VS as it should. Hence her attitude. I am not the most patient of persons when it comes to precepting, and I totally recognize her behavior. She's given you suggestions, you aren't following them and continue to be as slow as molasses, and she's reached the end of her rope with you. She's probably also recognizing that in a sink or swim environment, if you continue to take as long as you are now with each patient, you are going to sink. This reflects badly upon her, it's not good for you, and it's terrible for the unit as a whole. This is undoubtably stressing her out and further eroding your relationship.
Here are my suggestions:
*Request a new preceptor. You two are obviously not clicking, and it's not going to benefit you to have her for the entire orientation. Make sure you make a fresh start with the new one, though, and lose the attitude.
*Follow your preceptor for a shift. Pay attention to every little detail. See where she cuts corners and note where she concentrates her time. Newer nurses tend to focus on the wrong things. It is NOT important to do complete, thorough assessments on all your patients; focused assessments are so much more beneficial. A full head to toe assessment is great in theory, but if your other patients are going down hill and you haven't even assessed them yet because you're taking 5 minutes per VS and doing a 10 minute assessment on each patient, you aren't doing anyone any good.
*Understand that you ARE going to do things differently than in nursing school. There is more than one way to operate as a nurse. And again, nursing school makes you do things ueberthoroughly so that you learn all the details. Once you are out of nursing school, you use your critical thinking to decide when to be thorough and when to be succinct. Try things your preceptor's way, when she makes suggestions. She knows how you need to perform to be successful on the unit, and she's trying to help.
*Once you've shadowed your preceptor one day, start by taking just one patient, then the next day add another, then continue to slowly add another until you are taking the full load.
As far as the drug book goes: like intern67 suggested, place it somewhere that is readily accessible: by your computer, at your space in the nurse's station, etc. Leave it there, and reference it when you must. When I was a new nurse, I wrote down 5 drugs I gave every night, and then went home, looked them up, and made a few notes on them--mainly typical dosage and common reactions. You might find some similar activity helpful. I do not look up every drug, nor do I look up to see if every drug I'm giving is compatible, because I trust our pharmacists. Our drugs have been entered and double checked in pharmacy. Certainly if it is something new, or if I am mixing something I check if I don't know; but not every little drug I give.
Good luck; it sounds like you need it. Based on some of your own responses to suggestions here in this thread and some of your other posts, I think you should take a good hard look at yourself and your attitude. If you are at all snarky with your preceptor, you are in for one hell of a time. Learn from her, she's there to help you. Try doing things her way, you might find it works for you better than you thought. Once you're through with your orientation, you can practice how you wish, within reason, and you can incorporate the good things you learned in orientation into your own practice.