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

[TarheelGirlx3]

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!

[Cowboyardee]

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.

Nah, not really. I would expect a seasoned ICU nurse to know exactly what the problem was, though it's understandable that a newer one might not and there's no reason or excuse for going out of her way to make a newer nurse feel stupid rather than just correcting her.

As was mentioned at least once upthread, the problem in this scenario was not how much insulin was ordered or even necessarily DCing the dextrose infusion. The problem was, very specifically, that subq insulin should NEVER be ordered q1h, because its peak action is maybe 4 hours from administration, and duration of action is longer still. You will wind up pumping additional insulin into a patient long before the last dose has fully taken effect, making overdose almost guaranteed. If the physician wants q1h checks and adjustments (which is reasonable here), an IV insulin infusion should be ordered because the peak duration for IV insulin is about 30 minutes.

In a lot of cases, what separates a good ICU RN from one that's merely OK is the ability to not just realize that something's wrong (as the OP did) but the ability to point out why it's wrong and articulate a reasonable solution. You'll get your way a lot more often in discussions with physicians and other departments if you can make a reasonable case for exactly why and how you disagree with their suggestion/order/etc.

To the OP - there's no shame in not having an encyclopedic knowledge of critical care concepts for a nurse one year out of school. It does get better. Just understand a few things:

1 - a situation like this can be avoided if you have thorough understanding of the concepts at play and are able to articulate your concerns in a clear and compelling manner. Next time you see a situation like this, you'll know what to say.

2 - when you know something is wrong but can't effectively make your case to a doctor, please ask a coworker for advice. Maybe they can clarify things for you.

3 - there are times when you can, should, and MUST refuse to perform a doctor's orders. That's your job. If you're certain that an order is incorrect and may cause harm to a patient, you must refuse to perform it. You said you can't refuse a doctor's order - yes you can.