Woes of a green (overwhelmed, possibly disillusioned) med-surg nurse

[loshie08]

My name is Ansley - I've known I wanted to be a nurse since I was 10, and I've always known that med-surg would never be my "home" in the field of nursing. (I'd like to go back to school and get a master's at some point, I love the ICU and the NICU. I love having fewer, but higher acuity patients.) I graduated May '14, and started working in September. My preceptorship was a full time, 6 week, night shift position in a PCU in Florida. That was fantastic. Being an ICU step-down we took a max of four patients, and being night shift we sometimes had a tech, often we didn't. By the end of my 6 weeks (320 hours, I think?) I was taking all my patients independently of my preceptor, and she basically acted as a tech for the floor and let me have at it. I felt very comfortable with nursing at that point.

Fast forward to the present, I'm working days in a 30bed med-surg unit that has an odd, inexplicable reputation for being the busiest, most difficult floor in my "364-bed regional referral trauma II hospital"(according to google.) I take 5 patients, and we have 3-4 techs on the floor. The unit I trained on was a 17 bed unit just down the hall full of veteran nurses - it's a unit specifically for training new grad nurses, and the load was 4 patients, but because of the unit I was going to, I took 5 patients and was comfortable. When I was sent to my "home unit" things fell apart. I went from a unit with a great work flow to a unit that was pure chaos, and I had to go back to taking 3 patients and build up to 5 again. I was embarrassed and I felt stupid. Even now, over two months of taking 5 patients on my own, I'm really struggling. Some days I run around on my feet from the moment I finish taking report until 1230, 2 'o'clock. We have these little personal phones, which is great, until you're trying to pass meds and you get called every 5 minutes. I know I can't be in two places at once, but when a fall-risk patient - which, almost every single patient is - needs to go to the bathroom and all your techs are busy, what do you do?

I recently had a day where I discharged two patients and admitted two, one of which was a chest pain patient. It was one of those days where all the other nurses and techs, including the charge nurses, were just as busy, if not busier, than I was. I had a patient with chest pain who had called for pain meds and I was never told until 2 hours later. I talked with my manager about the day and the lack of safe, quality care, but all they can say is "delegate delegate delegate".

I'm not providing quality patient care. I look at my patients and ask myself who needs the most help today. Most times it's an elderly patient or someone who can't speak who needs someone to take the time to say, "you are getting out of bed today, let's go for a walk." Often it's the patients who haven't had a BM since their admission 5 days ago and I need to be proactive about getting a BM in. When I do take the time to look a little deeper and spend more time with a patient than just the required assessments/meds, I end up so busy that I'm ready to cry at the end of the day.

My report is lousy. It's never organized and it's pretty much all over the place and here and there. I'm trying to incorporate all the hospital policy specifics like VTE, safety precaution stuff, etc, and there's a specific sheet the unit uses, but I'm going to sit down today and try to work up my own organizational sheet for my work days. I had one that worked very well when I did my preceptorship but the nurses on my unit all give report by the worksheet they use, so it didn't really help. Compared to my previous clinicals/preceptorship experience, the nurses where I work give a really funky, disorganized report. 0_o

In the morning, I clock in around 6:40, not being allowed to clock in before 6:38. I used to come a little earlier and start getting some info on my patients before report, but not anymore. I start getting report about 6:50, and am typically done with report by 7:30 unless it's just updates and then I'm generally done much earlier. Things get sticky here. They want us to chart bedside so we get all of our charting done as real time as possible, and spend more time in the pts rooms. (while they're still trying to sleep? :/) If its new pts, then I'll roll through w/ my computer, but I prefer just taking my clipboard and jotting notes and charting later. The computers are huge, difficult to roll around all day, and create a pt/nurse barrier.

I think my biggest issue is having not figure out how to work my morning. I want to assess everyone before I give meds, but then after charting all my assessments, its already 845, and then I have to give 8,9,10 ocklock meds, things end up late, and when I'm getting called every 10 minutes to take someone to the bathroom and give a patient PRN meds, plus trying to round with the drs who come in the morning, it can be 11 before I finish my morning tasks.

Sometimes I pull all my meds and then assess/give meds, instead of doing all my assessments/then giving meds. I can't decide which one works better. It seems like it all depends on what kind of patients I have. If they're cool and not demanding then I can get it all done, but when I'm getting requests for pain medication every 20 minutes, bathroom calls, and sending patients to and from the floor for tests, I get so discombobulated that I get even further behind.

I'm finding it very difficult to stay on track mentally. I feel like I'm working in a mental cloud. Especially after 4pm. What is this? I'm only 24. I should have energy. I've been getting sick a lot more this past 6 months, too. Working with a head cold SUCKS. It makes it so much harder to think.

I know 5 patients isn't that many compared to what some nurses handle. I know I'm a bit green, and sometimes it takes time, but in the process of time and all, I'd really like some advice - tips on what I should be looking at trying to change, anything. I want to be a good nurse. I want to be able to get my patients out of the hospital sooner. I want to be on top of my day instead of underneath it. I'm okay with not being perfect, but wow things are rough right now.

I feel like if I were left alone and no one called me 6 million times a day, I could be sooooo much more efficient, but that's not a realistic expectation. I'm not planning to stay in med-surg, but I'd like to become a proficient, or even adequate med-surg nurse while I am here. I think Florence Nightingale would be ashamed of me? I know I'm ashamed of myself.

[RachRN11]

First - congratulations on joining the fulfilling career of nursing!

I just want to point out that you being concerned and want to better yourself is a good sign! Hang on to that, it shows that you are a good nurse, even if you don't always feel like it.

Med-surg floors are ruthless. They're tough, they're busy, they're chaotic. So what you are experiencing is not out of the ordinary. Which doesn't make it less sucky, but don't feel like it's just you. Also, I know you may feel like you should be better at this but you've only been at this for a little under a year! Nursing is all about experience. My preceptor told me, when I first started, that the first 6 months I will feel like I know absolutely nothing, it would take me a year to begin to feel comfortable and it would probably be a good 2 years before I actually knew what I was doing. Nursing is mostly experience.

I first started out nursing on a surgical floor where we could have up to 9 patients each (not that we liked it...at all) so it could also get a little chaotic. What I found worked for me was after getting report, I would set up the patient's medications (we had computers on wheels that had drawers and lock on it). As I was passing medications that were due, I would also do the assessment. After that was done, I would go back around and help people get up, walk and what not. But what worked for me may not work for everyone. The key is to try different routines until one of them works, establish a good rapport with your CNAs so you respect each other and work together. Sometimes health care is a lot of trial and error (that's why it's called a practice).

Regarding real-time charting - we were expected to do that too, but sometimes it just isn't possible. Do what you can. Patient's come first, not charting.

What helped my reporting was exactly what you are thinking of doing - I made my own sheet. Since I made the sheet, I was able to follow my train of thought better and give more cohesive reports.

I think the most important thing for you to do is to be kind to yourself. Realize that you are new to this and that it takes time. We've all been there. I realize that some nurses forget that they were once new too, but most of us understand and empathize. We're all there with you in spirit. You got this!

[RNperdiem, RN]

You don't say anything about your CNAs. What are they responsible for? An important survival skill in med-surg is to get enough assistance from the CNA. I have worked med-surg with some of the superstars of the CNA world. These CNAs were energized and committed to the care of the patient. Not all CNAs are like that. Some of them you need to manage more directly. Some tend to hide out(smoke break, breakfast, snack break, smoke break etc).

Everyone figures out their own ways of getting through the busiest part of the morning. It sounds like you are flexible enough to find what works. Getting back on track after lots of interruption is a skill in itself.

[Sarah922]

Hang in there!

I work on a busy med-surg / ortho floor where we typically get 5 patients on days where it's tough to get all of your AM assessments and meds done, especially when coordinating times for PRN pain meds, therapy times, and rounds. I agree with you, a good brain sheet is essential to keep you organized throughout the day and will probably help your report. I had to make my own and incorporate our specific interventions and unit goals to help me remember everything.

Do you do bedside rounding? Once we started I felt much better with my AM schedule because before I began to think about meds, I had been in every room , met everyone, and essentially done snap shot assessments and identified any potential needs before starting assessments and meds. For me this helped me keep some peace of mind that everyone was okay and stable ,and I didn't feel rushed.

As far as CNAS , at our hospital they give report to each other. I always try and make it a point to give an updated report with my plans saying things such as "Mr. X has therapy at 8, so I'm going to take his meds out first, and then once I'm finished with him ,I need to do ______ with Mr. Y." I'll ask them what their plans/ priorities are or AM care so we can in rooms together if it works out ( it doesn't always). I find if your CNAs know what your doing and know your plans they are more receptive to working together as a team for the patient rather than you each doing separate jobs. This may cut down on some of your interruptions that can be managed by your CNAS if they aren't tied up ( such as help with meals, bathrooms).

And with demanding patients, I've found that it's okay to say things like "I'm going to be tied up in another room for a little bit after I leave your room, is there anything you think you might need that I can get for you now ( PRNs?) ". I used to be terrified to say things like this because I thought it would make me seem incapable of managing the workload, but that's not the case at all.

It might take some time, but you'll find your routine and what works for you!

[loshie08]

You don't say anything about your CNAs. What are they responsible for? An important survival skill in med-surg is to get enough assistance from the CNA. I have worked med-surg with some of the superstars of the CNA world. These CNAs were energized and committed to the care of the patient. Not all CNAs are like that. Some of them you need to manage more directly. Some tend to hide out(smoke break, breakfast, snack break, smoke break etc).

Everyone figures out their own ways of getting through the busiest part of the morning. It sounds like you are flexible enough to find what works. Getting back on track after lots of interruption is a skill in itself.

Our CNAs (techs, whatever) do vitals 3xa shift, blood sugars 3x, try to get baths, and mainly assist with toilet trips/changes and "fetching" (I need a coke/sprite/etc). There are some that rock, but some are difficult... Use their personal phones, sit around instead of being proactive about keeping pts clean. Days definitely go smoother with my great techs.

We are supposed to bedside round, but few nurses do.... Thanks for the reminder, I'm working the next 4 days so armed with my new brain sheet I may try refocusing on bedside report and doing assessments and meds together.

Thanks for the encouragement. I don't want to be caught up catering to my problem patients (the least sick are always the loudest!) all day, to the neglect of my sick pts, so hopefully I'll learn the knack of managing my days better soon.

[Graduatenurse14]

I could've written most of what you wrote!

Just yesterday, I initiated a conversation with my boss about my desire to do better with charting and time management. I was able to share a successful delegation interaction with a nursing assistant so that was a bright spot! She was attentive to my concerns and seemed pleasantly surprised that someone would take an offensive approach rather than wait until being forced into a defensive position.

She gave me good tips, was very, very encouraging and is putting me in touch with a clinical educator who I can use as a resource.

Perhaps you can speak with your boss?

[TheNGTKingRN]

Wow ... you took the words from me. I feel like you do. I am having so many weak moments and break downs. I'm a new grad and I just am so relieved that I am not alone

[BigMama3]

Hey there Ansley et al,

I too am a new grad and as of tomorrow will be at my place for 4 months (and already ready to run out the door) And like you I too feel that I am not providing quality care to my patients (and isn't that what we became nurses for??)

I don't know if this will help but...I have been floated from LTAC (23 patients) to Short term Acute (19 -21 patients which made me so stressed out I can't even think about it) to my current Dementia unit (19 patients). Plus a girl I graduated with is now working on a Med Surg floor and completely stressed out all the time.

So, this is what I'm thinking for you. Try and work on your floor a bit longer ( don't know what the transfer policy there is) then transfer the second you can. This doesn't seem to be for you and that's ok. I truly believe that the nice part of being a new nurse is deciding (and sometimes quite quickly) that this isn't what you wanted to do. Take whatever experiences you can get from it (sounds like you are learning a TON and are becoming a GREAT organizer) and parlay that into your next position.

Also, I read in a new grad book that "Start each day with a clean slate" it has beome my mantra if not you tend to focus on what you messed up UGH!

Good luck and know you are not alone in our crazy, new grad, I have no idea what the heck I'm doing world!!

[BigMama3]

I read posts on this website quite often to know that I too am not overwhelmed especially as a new grad...good luck!!

[toomuchbaloney]

I have been an RN forever, but recently started a new job.

Hang on! Try to stay positive and continue to focus upon those things that you can improve to make you feel better about your ability to work safely, competently, and professionally.

Many of us are aware that even for seasoned nurses there is a learning curve. The rule of thumb is that it takes about 6 months in a new job or specialty before you don't feel simply dangerous or incompetent in many routine scenarios; in about 12 months most nurses feel relatively safe and competent but far from expert. It takes at least 3 years (with personal time spent studying and reading) to develop a level of expertise in an area or specialty of nursing (although some act as though they are expert waaaay before that).

You can do this.

Good luck.

[Here.I.Stand, BSN, RN]

Deep breath!! Two months in you're just barely getting your feet wet. It WILL take some time to feel comfortable. A few years back, I was an experienced RN working in an LTACH with 4-5 patients on days; even a year in, some days I felt like I was constantly trying to get my head above water. (If you've never been in an LTACH, it's like med-surg except the pts have been sick longer, and many are on ventilators and tubefeeds.)

We got COWs sometime in there, and they had 6 drawers that locked. First thing I did was label each drawer for each pt, pulled all of my meds and crushed the ones that needed to be crushed, and then started my rounds. It saved a lot of running to and from the med room. Things like ambulating, if the pt is a 1-person assist, can be delegated to the CNAs. Yes they're busy too, but when I was a CNA I managed to ambulate and get the pts up in chairs. In my LTACH, mobility was part of the CNA's routine duties. Of course I would go in to help if they needed more than 2 people and/or if the pt was on the ventilator, but they got everything ready first--pt cleaned up, on the sling, chair ready. And again I DO get they're busy too, but 1) they can't pass meds, address abnormal labs, give blood, communicate updates to family...and 2) they're finishing on time; you're not.

I also agree w/ RachRN11--that pt care comes before charting. Some things like med administration, changing a drip etc. I chart in real time; but something like an assessment that's done 1-2x a shift? What I've always done is do my assessments/vitals/med pass on everyone, and THEN go back and chart for roughly the time I did it. So in Epic, even if I don't get to my charting until my shift is almost over, I'll create a column for 1600 when I did the assessment. My hospital (not so much my own NM) says they like charting in real time too...but NO, I'm not going to delay pt care for it. It just isn't going to happen. I have yet to have anyone argue with me that documentation takes priority over my next pt, even if their pie-in-the-sky ideal is real-time charting. If it was documented, it was done (converse of "if it wasn't documented, it wasn't done"), so if I put it in for the 1600 hour, it was done at the 1600 hour.

Hugs!! It gets better. And you have NOTHING to be ashamed of!!!!

[loshie08]

Thanks for the encouragement! My new paper brain is helpful. I'm currently in the middle of two weeks of m/w/f but once these are over I think I will be okay again. My four days in a row after this post were pretty good.... It's odd, it's always either crazy or boring. For the first time on my unit I had only 4 patients for an entire shift! I also talked to some night shift nurses I look up to (and dread giving report to) who reassured me that days have a lot more to deal with than night nurses. It's a gradual, slow process, but I think I'm still making progress. And I think going to an area I am passionate about - like critical care and pediatrics/nicu, I think it will help. Medsurg just isn't all that fulfilling for me, and I think that's okay, as long as I can accept that I am getting much needed experience at the moment. :)