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Struggling New Grad

Love your blog! I’ve been a pedi cardiac nurse for two years and I’m orienting my second new grad (yikes!). I have this really awful feeling that she is not cut out for acute care. Week 4 into her orientation and it feels like day 1. We were giving an IV med yesterday and after several serious prompts she could not tell me that we needed to flush the IV before we could give the med. Another example, our medical director came by to discuss the anatomy of our patients and the nursing student we had was answering all the questions and she was just staring blankly at the MD or she’d answer I don’t know to questions about patients we’ve taken care of on several occassions. Any advice on how to help a struggling new grad?

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Orienting a Struggling New Grad

Patient safety is above all else and not everyone can work in acute care.  Orientation is the best time to identify these individuals because it’s not always apparent in interviews and on resumes.  I work on a pretty tough unit now and for every 3 that make it through orientation, one does not. Sometimes it’s more about saying you work in intensive care (or some other unit) more so than truly having a passion for the work and wanting to get better.

I would keep a tab of these instances that raise nursey concern.  There is a chance that they are not cut out for your floor.  And when you go to your manager about it, you need to have many specific examples.

If you’re on week 4, theoretically she can take one patient safely.  I would let her drown a little.  I would watch closely, but let her get overwhelmed and feel that urgency.  I’d let her miss things and do things inefficiently.  Give her a “stress test” without her knowing it.

And I would write down all the things that need to be addressed and I would talk with her three times during the day.  Around 1100, 1500, and after the shift.  Let her know that these are some unacceptable/inappropriate things that happened or these are some things that you should just know.  Talk to her about better ways to manage her time.

I would correct things in the moment that will harm the patient, but things that won’t..  I’d let her slide and then correct when we talk.  For example, if her telemetry alarm keeps going off and she’s not responding appropriately, I’d ask her to go to the monitor, tell me the rhythm and tell me what she’s going to do about it.  Now.  Conversely, if she’s not managing her time very efficiently I’ll just let her get behind and then recollect to let her see how far behind she’s gotten and how we can avoid that in the future.  

At the end of the day, see what she thought.  Did she like it?  Did she like that she was in control even though it was rough?  Did she hate it?   Is she mad?  Does she care that she screwed up? Or does she want to go home and look up the things she didn’t know?

With my new grads, I do a lot of “tell me the order that you’re going to manage your time this next two hours?” kinds of questions.  Time management is something that takes some time to develop but is absolutely essential in your development in your career.

I frequently ask critical thinking questions to gauge their understanding.  “So if their CT says this, what do you expect their clinical presentation to be?”  “Because they have an intraventricular hemorrhage, what color do you expect their CSF to be?”  “Which doctor do you call for increasing seizure activity?  Your intensivist, your neurologist, or your neurosurgeon?”

“I know you know to do certain things but I want you to critically think about WHY.”  If there is no interest in the why and merely interest in just what do I need to do.. that’s a red flag.  Especially with such a sensitive/critical population.  These people tend to not last in critical care or they become unsafe care providers.

Constantly challenge them but also praise them a lot when they do the right thing.  Even small things.  When you’re challenging someone who must learn a lot of difficult information, it can be really discouraging sometimes.  Don’t forget about praise.  Even if it’s something small.. “hey, you really managed your time well the last couple hours when you had that doc come up to do that big dressing change in the middle of passing your meds.  Woo hoo!”

Something that is really important for you to decern as their preceptor is if they will end up being a safe care provider.  And you can tell this by their attitude.  Do they have a willingness to learn?  Do they actually care about doing the right thing and look up polices/procedures or do they want to get things done quickly?  Do they attempt to build rapport with physicians and advanced practice providers?  Will they do the right thing when presented with a shortcut?  If they’re slower to learn but WANT to be great, you can work with that.  If they are slower to learn and .. well, don’t really care about being a good nurse.. you can’t really work with that.

God-speed, preceptors!

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