Let me introduce myself. My name is Melissa, though most people at work know me as “Stafford,” a nickname that was given to me because we had 4 Melissa’s in our unit at one point. Can you imagine that? I graduated nursing school back in 2000, though that seems like last year to me. After spending a year and a half on a surgical floor, I have spent the rest of my time in neuro critical care. I am not an expert, but I’ve functioned as a nurse preceptor over the years, from student nurses all the way up to experienced nurses.
You are probably prepared for what to expect during your orientation, whether it be from discussions during nursing school, friends, or from personal research on the web (In case you don’t know, this very website is filled with wonderful information and links to other resources for orientation).
The role of the nurse preceptor? Responsibility, Preparation, and Personalities
I want to talk to you about orientation a little differently. I want to share with you orientation from my point-of-view, as a nurse preceptor. It is important to me that you understand…
Yes, I am a nurse preceptor… but I struggle too. Let me share with you some of the reasons why.
Being a preceptor, in my opinion, is a huge responsibility. It’s similar to a teacher/student relationship, especially in the beginning of orientation. Your success as a new nurse in my unit, in large part, depends on my ability to be an effective teacher. If I don’t do my job well, how can I expect you to be successfully independent after orientation? This is a responsibility that I take seriously, which means… just by agreeing to be a preceptor, I take on additional stress. Yet, despite the stress, it is something that I greatly enjoy doing.
Hopefully, the leader of the unit has done some planning. In an ideal world, they have:
- Chosen a nurse preceptor, in advance, of your first day
- Chosen the best preceptor based on your prior experience
- Given the preceptor some background information on your prior experience (or lack thereof) so he/she can anticipate where and how to start.
The reality, though, is that I may not get much information, such as any prior experience outside traditional clinical rotations. And, in some cases, like if your “regular” preceptor unexpectedly calls out sick, I may not get any notice at all.
3. Personalities/Learning Styles
While I look forward to getting to know you personally over time, my focus, in the beginning, is understanding you as a new nurse.
- What kind of background do you have? Meaning…
- New graduate: Someone fresh out of school. Something I keep in mind is that experience varies greatly between programs.
- Did you get a wide variety of hands-on experiences during clinical rotations or some type of ‘internship’, or
- Were you restricted either by the school or hospital policies on what you could even attempt?
- Were you a CNA, or is your experience limited to the controlled environment of the program?
- Transitional nurse: In my case, this is a nurse that has worked in some other department and is now new to neuro/critical care.
- Did you work on a med/surg floor with experience related to my unit? Or,
- Did you work in an unrelated area of practice, but are excited to try something new.
- Experienced nurse: Slightly different than transitional, in that I consider this to be a nurse who has experience working in critical care.
- Are you new to the neuro specialty? Or,
- Do you have experience in neurocritical care, but are new to my facility?
Regardless of your prior experience, other important considerations for me are:
- Do you learn best by first reading, seeing, or doing things hands-on? Does it depend on the specific scenario?
- Are you a direct person who is going to tell me what is or is not working?
- Are you more introverted, so I need to observe your non-verbal cues more closely?
It’s important for you to understand there isn’t a ‘wrong’ response to any of these points. I need to understand what types of experiences you’ve had (or not had) in the past, as this will help me plan our path during orientation. Knowing the starting point is how we build effectively on your existing foundation as a nurse.
It’s also important for you to know about me. More specifically, my style as a nurse preceptor. For example, I am often perceived as intimidating, as I take a pretty business-like approach to orientation. For this reason, I take the time at the beginning of orientation to talk about the things I do in an attempt to avoid being intimidating. I assure you that I am always open to questions and encourage you to give me feedback if you become overwhelmed. My intent is to set the stage for open, two-way dialogue at the beginning, as this is essential to a successful orientation.
However, regardless of what information I get at the beginning of orientation, I feel it is my responsibility to adapt and adjust both the assignments and my teaching style based on my ongoing observations. I hope that you will give me direct feedback, but even if you don’t.. I’m always looking for signs of success as well as signs of struggle.
Sometimes I am better at this than others…
Oh the paperwork. Trust me, I hate it as much as you. Honestly, it’s the bane of my existence. There are check-lists, skills validations, pathways, policies, lists of required CBLs, etc. It seems never ending.
The best advice I can offer here is to accept the fact paperwork is necessary to document your progress during orientation. Keep the paperwork organized, complete it as you move along, and keep a copy of anything you turn in. It’s terrible to struggle at the end of orientation to fill out paperwork that should have been done weeks ago. It’s even worse to find out the work you did was lost and try to re-create it from memory.
As a preceptor, I have a huge responsibility to keep track of all the new experiences we’ve had together, the new skills you acquire, and all the teaching I do throughout orientation. It’s also essential for me to document anything with which you may be having difficulty mastering, as well as the attempted interventions to help. My least favorite part of the job is when any nurse struggles during orientation despite me striving to do my best to help. Logically, I know that not everyone is meant for neuro critical care, but I am always concerned it’s a failure on my part.
Making an assignment
Making an assignment is probably one of the most challenging things I do as a preceptor. The general guideline is to start with the simple and work toward the more complex. Sound easy? I can assure you that it’s not. These are just some of the considerations I think about when making an assignment:
- Where are we in orientation?
- Is this Day One with a new grad?
- Are we nearing the end of orientation when I need to assess your readiness to be done?
- Are we at some point in between?
- What experiences have we had so far in orientation?
- What types of patients have we cared for?
- A fresh stroke who received alteplase?
- A patient with an aneurysmal subarachnoid hemorrhage?
- A seizure patient?
- What kinds of assessments have you done?
- Do you have a good grasp of a “normal” neurological assessment?
- Are you proficient at assessing a comatose patient?
- Have you cared for a patient whose exam is worsening?
- What kinds of equipment/technical skills do you need to experience?
- Have you cared for a patient on vasoactive medications?
- Can you efficiently care for a ventilated patient?
- Have you assisted physicians with bedside procedures like a central line or ventriculostomy insertions?
Remember the general goal of increasing the patient acuity level as we advance through orientation? There are many things that will have an impact on this progression.
Experience level: New grads are expected to progress slower than experienced nurses.
Patient population: The patient assignment I choose is the best I can, based on the patients in that unit that day. There will be times when the overall acuity of the unit is higher or lower than what we ideally need.
Dynamic patients: The reality of nursing in an acute care setting is that patients are dynamic… meaning they can (and often do) change at any point. What started as a “simple, stable” patient, can become one whose condition is critical and unstable.
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I always hope I make the right decision for the assignment every day, but the reality is that sometimes my choice turns out to be less than ideal. While on the outside, I will assure you that sometimes things happen, and point out why teamwork is so essential to nursing… inside I tend to beat myself up when I see you overwhelmed or frustrated.
There are A LOT of technical skills that need to be developed during orientation. This can be things like, starting IVs, drawing blood, changing central line dressings, and inserting feeding tubes, among many others. They are things that are easily checked off on a list… and add to the feeling of accomplishment. For this reason, you may tend to focus on these tasks. It’s normal.
My job as a preceptor, is to break through that task-based focus and find ways to teach more theory/disease based topics. For example, why are we drawing this blood? How are these lab results going to help us better care for this patient? In addition, it’s important that we talk about general anatomy/physiology of the disease processes for the unit.
The tasks are important, but the ‘why’ behind the task is what will really help put the pieces together. Finding a balance between the two is challenging, especially when neither you nor I want to be at work any later than necessary. And, does anyone really want “homework”?
I’m always looking for signs of success as well as signs of struggle.
Sometimes I am better at this than others….
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I have many responsibilities as a nurse preceptor. I need to teach, observe, and ensure my orientee is practicing safely. I need to be present and supportive, but I also need to avoid micro-managing. Essentially, I have to be able to keep an eye on what’s happening with the patient, while enabling you to become independent. It’s a delicate balance.
For example, at the beginning of orientation, I will be present in the room while you perform a detailed neuro exam. However, as things progress, I may not be in the room while the assessment is done, but yet I’m still observing from afar.
Another example, a patient has a BP above a set limit. In the beginning, I would immediately ask what we should do next, what medication would we give and why. Towards the end, I will be stepping back to see what happens. How was the issue addressed? How quickly did you address it?
Nearing the end of orientation brings about a slightly different challenge. It may appear to the nurses who do not precept that I am essentially a “free” nurse available to help anytime. However, reality is… this is a time when I’m pushing you.
You have a challenging assignment while I’m stepping back to see how you handle it. Are you putting the pieces together? Are there any learning opportunities that I missed, or skills that we need to hone in on before orientation is complete.
While it is extremely difficult for me to sit on my hands and not step in, it’s important that you and I both recognize any opportunities for improvement. Ideally, this is the time when you recognize all the progress you have made during orientation and feel ready to fly on your own!
The goal with the completion of orientation is not that you know everything or have seen everything. Rather, I want to see that you know your resources, recognize (and ask!) when you need help, and practice safely.
Juggling Competing Responsibilities
I can’t begin to tell you the number of times I have felt pulled in different directions. I’ve been a preceptor at the same time been the lead nurse. You deserve to feel completely supported, but sometimes I am also the only nurse in the unit capable of handling the “lead nurse” responsibilities. As the lead nurse, I’m the resource for other, less experienced, nurses on the unit. I’m also the nurse that manages the admissions and discharges. Additionally, the physicians look to me to keep up with the overall issues in the unit and provide them with whatever assistance is needed.
You may be a new orientee, but a patient in the unit crashes so another nurse needs help. While it may be possible for you to step in and help, sometimes (especially early in orientation) this will likely be a time where you need to be an observer. Patients will always come first, and sometimes finding a way for you to safely participate in an emergency is difficult. Especially in the heat of the moment.
Another challenge I face occurs when I am precepting on days the unit is short staffed. Here, I feel both a responsibility to you, as well as a responsibility to my co-workers. When the unit is short staffed, everyone feels extra pressure, and people often look to the most experienced nurse for help. Sometimes, that means that I may take on a patient in addition to your assignment. Although I try to take an “easy” patient, for reasons already discussed, it may not work out according to plan. Patient conditions change; that is the nature of critical care. Unfortunately, this is another scenario when I may have to focus on direct patient care rather than teaching.
These are just a few examples of the many times I have experienced conflicting responsibilities.
Supporting you is very important to me, so on days like these I often feel like I let you down. Although I do try to find the positive “teaching moments” in these challenging situations, I do not deal well with feeling like I did not do my job to the best of my ability.
Sometimes I am better at this than others….
Although I’ve just spent a great deal of time discussing the challenges I face as a preceptor, the last thing I want for you to think is that precepting is terrible. I assure you it is not. The personal satisfaction that I get when I see a new nurse thriving far outweighs every negative.
Every. Single. One.
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I just hope that you will grant me some patience and understanding on the days that I, myself, seem frustrated or overwhelmed. I do have days like that, but it is most likely NOT a reflection on you but rather related to one or more of the issues above. I do try to recognize when I am having a bad day and do my best to shelter my orientee. Nevertheless, I am human. I make mistakes.
Becoming a nurse, for me, has been one of my most rewarding experiences. Helping patients and their families through some of their most challenging times is both an honor and a privilege which I take very seriously.
The bottom line is that, I choose to precept because I enjoy teaching. I hope to help new nurses find the same joy and fulfillment in the nursing profession which I have found.
I wish you all happiness and success as you move ahead in your career! Maybe some day, you will be the one teaching the next generation!
Melissa Stafford, BSN RN CCRN SCRN graduated from nursing school in 2000, and after a short time on a medical surgical floor transitioned to neuro critical care. During her career, she has precepted multiple nurses, taught classes ranging from neurological/neurosurgical specific subjects to general critical care medicine, been involved in shared governance and resides as chair for nursing peer review. She has received various recognition’s, including the Great 100 Nurses of North Carolina and DAISY Award. Melissa enjoys spending time with family, painting, watching sports, visiting the beach whenever possible, and vacationing at Disney World.
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John Wallace says
Thank you so much for sharing Melissa. This is applicable not only to precepting in a neuro unit, but in many other critical care units as well. This gave me a better understanding and awareness of the struggles both me and my preceptors face every shift.