1 year into nursing, still feel like things don't "click"

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Specializes in Coronary Care.

So I graduated nursing school in May 2015. Just reached my one year mark as a new nurse in a coronary care ICU. I still have so many days where I feel like things just don't "click," or that I don't act on behalf of my patient like I should, and I only realize it after a seasoned nurse points it out. I have always been an overachiever and I am always extremely tough on myself.

Example, just today I received a patient from the ED, type 1 diabetic that came in for low BS (38 at home, came in to the ER via EMS). Received a few amps of D50 in the ED. Patient wears an insulin pump and as of late had been having issues with it. The orders in moving to the unit were: D5 drip @75, BG checks q1h and sliding scale insulin (SSI) to cover with each BG check. The patient removed the insulin pump while in the ED. When he got to me his BG was 231, so I gave 4 units per the SSI order. The Dr came up to the floor, and I pointed out that his BG was 231 (highest since he had been in the hospital) and he said oh wow hes really going up....let me change his fluid order to plain normal saline and lets see how he does. I made it a point to mention the hourly checks and SSI, and that because he was awake and conscious we could have him eat to regulate his BG. The physician changed the fluid order, kept the SSI orders and left. I rechecked his BG an hour later and it was 197. Per the SSI order I was then to give him 2 units. An hour after that it was 154. So then he only needed 2 more units. So he got a total of 8 units regular insulin across 3 hours. To me it was a weird order and setup from the start...but I sought clarification with the MD and discussed it with a more seasoned nurse. So the next recheck (after covering for 154) his BG was 63! But he was awake, alert/oriented, and was able to drink 4 oz of juice for me. Rechecked after 15 mins...BG 47! This was right at shift change (of course)..but anyways with the BG 47 I gave him more juice, some crackers, and an amp of D50..still alert/oriented, etc. But as I was reporting off the day nurse, who is very seasoned, looked at me when I told her the orders and huffed and said thats stupid, I wouldnt have done that, and she had a new grad nurse with her who also said no nope wouldnt have done that, so stupid..something to that effect. I told the seasoned nurse that I sat there with the doctor and clarified and that I couldn't just refuse to do it. Afterall, I anticipated the 2 units for his BG of 154 would bring it down to a normal range. And plus I could easily fix a semi-low BG with D5 or food! I didn't anticipate it dropping that much ...but it was just really frustrating and of course the whole 45 min drive home I was beating myself up thinking why didn't I insist to the doctor to do something different!?!

Will this get better with more experience?? I just feel like I'm such a bad nurse and failure during times like this!

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Specializes in Stepdown . Telemetry.

My guess is you were in slightly unfamiliar territory with this particular clinical case, you dealt with it and experienced certain outcomes, and good or bad, this experience will help guide you moving forward. This is how it happens. Also, when I have these situations, (yes they still happen 3 yrs later) my less desirable outcomes drive me to learn more about the case in question...eg type I diabetes...we are always learning here. Dont be too hard on yourself!

If i had to guess I would assume that the reaction of the seasoned nurse and the new grad saying it was a dumb move had something to do with you feeling worse about your own competence...

I hate when this happens! But walk tall, be empowered by the fact that you dealt with the hypoglycemia, rechecked and reassessed, and brought the patient back to safety!

Ps, just ignore the part where new grad chimed in...they are full of cr@p when they said they would have done the right thing, they have no idea what they would have done, but decided to cheaply fluff themsleves up at your expense. This person seemed silly to me.

Its sounds like you think things through and are doing just fine!!

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Specializes in Coronary Care.
My guess is you were in slightly unfamiliar territory with this particular clinical case, you dealt with it and experienced certain outcomes, and good or bad, this experience will help guide you moving forward. This is how it happens. Also, when I have these situations, (yes they still happen 3 yrs later) my less desirable outcomes drive me to learn more about the case in question...eg type I diabetes...we are always learning here. Dont be too hard on yourself!

If i had to guess I would assume that the reaction of the seasoned nurse and the new grad saying it was a dumb move had something to do with you feeling worse about your own competence...

I hate when this happens! But walk tall, be empowered by the fact that you dealt with the hypoglycemia, rechecked and reassessed, and brought the patient back to safety!

Ps, just ignore the part where new grad chimed in...they are full of cr@p when they said they would have done the right thing, they have no idea what they would have done, but decided to cheaply fluff themsleves up at your expense. This person seemed silly to me.

Its sounds like you think things through and are doing just fine!!

thanks so much for that! I had my yearly evaluation today with my manager and it went well. I know that I'm often way too hard on myself...but it gives me confidence that I'll get better and better with time and experience!

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Give yourself a break. Remember in school the levels of nursing competence? The novice level is expected to last two year. You are just starting to get your bearings. I will say look up the onset and peak times of insulin. It may help you next time when given an order like that.

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Specializes in Infusion Nursing, Home Health Infusion.

You are STILL a novice and will never stop learning throughout your career! It would be a lot easier to learn without having to deal with catty co-workers and I would have had to put them in their place. You did nothing wrong so there is no need to defend yourself to those nurses.The orders were reasonable but I would have taken into account the last dose of insulin given to him prior to the 154 BG. When was that going to peak and how much and what had he eaten or drank.It probably had not peaked yet and you added in more to the equation.

Back to the coworkers. Never allow your coworkers to treat you this way otherwise they may continue to do so! There are many things I may have said to those nurses.

"Here is the provider's number so you can call him/her and tell them how stupid they are".

"If you are willing to work 24/7 then you can fix the perceived problem but in the meantime I will follow the orders as I see fit"

or you can press the issue,"Can you elaborate on that please because it sure sounds like a criticism to me".

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Specializes in Critical Care.

Lol that new grad needs to zip it. The seasoned nurse too. Shame on her him or her! She or he is teaching the grad how to be a total useless diva.

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Specializes in Registered Nurse.

These things are going to happen no matter how long you have been in nursing. I had a case a week or so ago. Accucheck >500...Provider orders the scheduled long acting already in place along with a custom coverage amt. I told the provider I thought the coverage was too much. The provider said okay and did lower the coverage, but not a lot. Sure enough, in the early morning hrs., patient was symptomatic...accucheck

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Specializes in CICU, Telemetry.

1. You're fine. You're in CCU and you're not going to feel competent for another year or so, minimum. That's fine. Think about where you were a year ago compared to now. Exponential knowledge and growth, right? Exactly. Keep it up. You'll get there. Know that most of the experienced nurses who see things immediately and tell you about them aren't trying to be rude. ICU attracts nurses who are not always known for having stellar interpersonal skills. They literally don't realize they come off that way.

2. I LOVE dealing with co-workers by saying 'I was really busy today and I could easily have missed something. What specifically would you have done differently and why so I can adjust my practice next time?' This lets you learn and often exposes a knowledge deficit on their part if they were only trying to look smart and don't actually know. Twofer.

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Specializes in Stepdown telemetry, vascular nursing..

I'm super caffeinated right now, and I must admit that I did not read everything in detail. Also, my background is stepdown only.

The only thing that sounds questionable to me is the fact that regular insulin starts acting 30-45 min, and peaks in 2-4 hours, so how come the MD wrote orders for hourly sugar checks and sliding scale for this particular type of insulin?

I think you treated the patient well after noticing the blood sugar level.

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Specializes in Med/Surge, Psych, LTC, Home Health.

Back to the coworkers. Never allow your coworkers to treat you this way otherwise they may continue to do so! There are many things I may have said to those nurses.

"Here is the provider's number so you can call him/her and tell them how stupid they are".

LOL! Oh man, I can think of SO many doctors who would really appreciate that...

OP, you were WAY too hard on yourself. I concur with other comments; as the blood sugars were trending down, I would have thought twice before giving more insulin. But, I have 13 years experience! You WILL learn and things will get better! You sound like a good nurse!

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Specializes in General.

Hei. You did fine. All I see were part of learning while doing job. There were times that we almost never see that we are doing things right when the progress isn't what we expected. Having co-workers or superior that commenting like they can do things better than you is mostly frustrating, but I see it also part of challenges in day-to-day work. Been dealing with many with type I diabetic, sometimes the progress appears unexpectedly, but as long as we were with the patient through the event, we can anticipate most of negative outcomes, or at least minimize it. Working for one year should have made you learned a bit about how to be tough in dealing with Co-workers who used to show off and keep telling craps about their competence.

Dont be so hard on yourself. little failure here and there is human. Stay learning, give it a chance, then you will find the moment that you feel things "click", or you start enjoying your work. ;-)

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The reaction of the oncoming nurse is something called hindsight bias in Psychology, where some takes information and assumes they would have made a better call because they falsely think they already had this information. It is frustrating as a new grad, but consider that term when people act like that.

I am am still learning about all the nuances of insulin myself...and learned a lot reading this post. Hopefully this post will give us new grads incentive to really learn the onset/peak times of different insulin types. We learn the basics in school but it's easy to forget the nuances when you are in a high stress environment. Also, in my limited experience Type 1 Diabetics have a crazy fluctuations in blood sugar with very little insulin. I've learned to really watch for trends with them because they seem to fluctuate much more in general than a Type 2 DM patient. I think you made a good call with encouraging the provider to allow for food.

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