By "this," I mean put my coworker/family member/BFF and I together in the trauma bays the other day. She's a psych shit magnet. I'm a hot-mess-then-crash shit magnet. With our powers combined, it was a disaster of a day.
When change of shift rolled around, I swear I heard at least nine people go "oh my god, they put you two up here together? Dafuq were they thinking?!"
Good to know our reputation is holding strong...
Thursday, June 28, 2018
Tuesday, June 12, 2018
Precepting, Part 4
Thank you guys for the feedback on the previous few posts. I appreciate hearing the reactions to my teaching style, and based on your responses it seems I should stick with what works!
I'm so very happy that The New Grad is doing better. She is a completely different person than the one I inherited - she's much more confident, she gets her work done, and most importantly she is able to manage critical patients.
We had one shift near the end of her reorientation where I got to witness it all click together. For HIPAA reasons, I can't even share the basics of the trauma we took care of, but suffice to say it was real bad. I took over charting since it was a giant cluster and didn't have time to teach, but I made her the primary taskmaster (I know, I know...after all my talk of how she needed to direct and not task...) because I wanted her to be right in the mix of blood and trauma surgeons and chaos and also because we're all probably going to be called into court over this sad case.
TNG just...got it. I don't know exactly what went through her head, but she absolutely nailed everything she did. She put in a clutch IV. She dropped an OG tube and foley, right in the mix of RT's taping up an ET tube and XR getting their shots. She verified and helped give emergent blood. She grabbed the monitor and extra IV pole to get the patient to the OR. I didn't direct her to do any of these things - she just did them. She listened to the verbal orders from physicians, identified needs for the patient, verbalized her actions so I could chart them, and managed to function in a trauma room that was packed with staff. It was beautiful.
We got the chance to debrief afterwards, and when I asked her what changed she just sort of shrugged and said she kept reassessing and doing what was most important at that moment. I could have cried.
She was on her own just a couple shifts later, and it's been going tremendously well. Just the other day, she relayed to me the most recent shitshow she took care of: while giving blood to a severely anemic patient, another patient of hers coded. It was an out-of-the-blue code, where they went from fine and talking to CPR. She did everything right - her charting leading up to the code was impeccable, and showed that she had been in the room multiple times, had the patient on the monitor, and reassessed him frequently. When the code was in progress, she documented everything well, called out for things she needed people to do, kept track of times for code medications, and made time afterwards to console the family. Our director singled her out later for the outstanding work and documentation she did. When I asked TNG how she felt afterwards, she said she was freaking out inside but just kept doing what she needed to do - and let's be real, that's all critical care ER nursing really is at first, isn't it?
I am truly honored to have made a difference in her career. I've precepted before and felt that I did a decent job but turning around what seemed to be an unsalvageable situation makes me realize that I'm actually pretty good at this. Much of the credit has to go to TNG though - she's the one who kept at it, listened, learned, and pulled through.
I'm so, so proud of her.
Thanks for listening, y'all.
I'm so very happy that The New Grad is doing better. She is a completely different person than the one I inherited - she's much more confident, she gets her work done, and most importantly she is able to manage critical patients.
We had one shift near the end of her reorientation where I got to witness it all click together. For HIPAA reasons, I can't even share the basics of the trauma we took care of, but suffice to say it was real bad. I took over charting since it was a giant cluster and didn't have time to teach, but I made her the primary taskmaster (I know, I know...after all my talk of how she needed to direct and not task...) because I wanted her to be right in the mix of blood and trauma surgeons and chaos and also because we're all probably going to be called into court over this sad case.
TNG just...got it. I don't know exactly what went through her head, but she absolutely nailed everything she did. She put in a clutch IV. She dropped an OG tube and foley, right in the mix of RT's taping up an ET tube and XR getting their shots. She verified and helped give emergent blood. She grabbed the monitor and extra IV pole to get the patient to the OR. I didn't direct her to do any of these things - she just did them. She listened to the verbal orders from physicians, identified needs for the patient, verbalized her actions so I could chart them, and managed to function in a trauma room that was packed with staff. It was beautiful.
We got the chance to debrief afterwards, and when I asked her what changed she just sort of shrugged and said she kept reassessing and doing what was most important at that moment. I could have cried.
She was on her own just a couple shifts later, and it's been going tremendously well. Just the other day, she relayed to me the most recent shitshow she took care of: while giving blood to a severely anemic patient, another patient of hers coded. It was an out-of-the-blue code, where they went from fine and talking to CPR. She did everything right - her charting leading up to the code was impeccable, and showed that she had been in the room multiple times, had the patient on the monitor, and reassessed him frequently. When the code was in progress, she documented everything well, called out for things she needed people to do, kept track of times for code medications, and made time afterwards to console the family. Our director singled her out later for the outstanding work and documentation she did. When I asked TNG how she felt afterwards, she said she was freaking out inside but just kept doing what she needed to do - and let's be real, that's all critical care ER nursing really is at first, isn't it?
I am truly honored to have made a difference in her career. I've precepted before and felt that I did a decent job but turning around what seemed to be an unsalvageable situation makes me realize that I'm actually pretty good at this. Much of the credit has to go to TNG though - she's the one who kept at it, listened, learned, and pulled through.
I'm so, so proud of her.
Thanks for listening, y'all.
Saturday, June 9, 2018
Precepting, Part 3
Let's continue hearing all about the ways The New Grad (TNG) turned herself around, yeah? Okay!
***
I mentioned how TNG had pretty atrocious charting when I first got her, and this was my one big personal hurdle for her. I'm an over-charter, but it's saved my ass on many occasions. If a patient gets up to use the bathroom on their own, I document that they were able to do so. If someone has a brief bout of crushing chest pain, I do the ekg but also write a little narrative leading up to that. As my preceptor years ago taught me, "you should be able to know the story of any patient in this department just from reading the chart."
TNG pretty much charted an assessment and vitals, and that was it. I fixed this by having her follow the hourly rounding model pretty strictly. If she went into the room, the first thing I had her do was open the chart. Whatever she did in the room, she had to document before she left (unless things were emergent, of course). When TNG first started, she tended to talk to the patient for waaaaay too long, then try and go back out to the desk and chart everything. She'd inevitably get called away to something else, and things never got charted. Forcing her to chart in the room helped her to multi task, as she had to talk to them and also chart. It helped the patients feel better because they gave an answer and they could see that it was going into the record. I also had her free text many things, and all in the same note. This helps her have a running narrative of what's happening with the patient, and any interventions she took. When she goes to call report later, or talk to a doc over the phone, everything is in one spot.
Charting in the room also prompted her to go outside the basic focused exam - if she's gonna chart that other systems are WDL, it helps to actually be looking at the patient to verify that instead of clicking through in a hurry later. I also had her look at the same few things every single time she opened the chart - vitals, last documentation, and new orders. It was redundant a lot of the time, especially if the patient was simple, but it got her in the habit of always scanning the same places in the chart to highlight what she needed to do.
Opening the chart frequently also helped TNG do everything all at once - she'd look at the orders, and get everything done at once - IV, labs, fluid started, meds. The fewer times you have the leave the room for stuff, the more time you spend in the room with the patient. This rolls into another huge issue she had - delegation.
I too struggle with delegation sometimes. I've always felt that if I can do something, it's rude to find someone else and ask them to do it instead. Usually this works for me, but occasionally I guilt myself into doing everything and then all of a sudden I'm in the weeds. So I worked with her to delegate small tasks, and let her focus on the big picture. Need someone to drop blood off at the lab? She'd call me to do it. Does that patient in room 73 need a pillow? It can wait, or you can snag someone sitting at the desk to do it. When a patient who needed multiple tasks came in, she'd bring help in with her if it was available. This allowed her to meet her budgeted time for a patient, get the necessary charting done, spend more time on critical thinking and less time on simple tasks, and also made the patient happy because shit got done quickly.
The last big thing I can think of for my precepting strategies is something so obviously necessary, but sadly one that many preceptors don't do: share your own failures. I told her dozens of stories of me screwing up - of making a medication error, of forgetting to do something for a patient, of me missing an obvious diagnosis. I told her of all the times I cried on the way home from work my first year. I told her how overwhelmed I was, and of how I questioned if I was meant to be a nurse. I told her how I still have those feelings sometimes, and that the day those feelings go away completely is the day you truly become dangerous. She needed to know that her feelings of inadequacy in this job are not new - every single new graduate out there has them, and if an experienced nurse pretends they never felt it too they will make those feelings even worse. Also, what a shitty way to exert power over someone, right?
It's hard for new grads. They're in a job where all of a sudden they can accidentally kill somebody, and that's terrifying. The amount of information needed to be a competent nurse is HUGE. It's not something you graduate nursing school with and all of a sudden have your shit together. It takes time. A lot of time. The most you can do is continue to learn - keep an open mind, learn new tasks every day, read on your days off, listen to experienced nurses, ask questions of the physicians, always find out the "why" behind actions. Most importantly, know when to ask for help - because this job is tough, and the ER is a team who shouldn't let you fail.
If management had done her right during the first round of orientation, all of this wouldn't have been news to her.
***
Part 4, up next to close out this little series. Please let me know if this helped anyone out there!
***
I mentioned how TNG had pretty atrocious charting when I first got her, and this was my one big personal hurdle for her. I'm an over-charter, but it's saved my ass on many occasions. If a patient gets up to use the bathroom on their own, I document that they were able to do so. If someone has a brief bout of crushing chest pain, I do the ekg but also write a little narrative leading up to that. As my preceptor years ago taught me, "you should be able to know the story of any patient in this department just from reading the chart."
TNG pretty much charted an assessment and vitals, and that was it. I fixed this by having her follow the hourly rounding model pretty strictly. If she went into the room, the first thing I had her do was open the chart. Whatever she did in the room, she had to document before she left (unless things were emergent, of course). When TNG first started, she tended to talk to the patient for waaaaay too long, then try and go back out to the desk and chart everything. She'd inevitably get called away to something else, and things never got charted. Forcing her to chart in the room helped her to multi task, as she had to talk to them and also chart. It helped the patients feel better because they gave an answer and they could see that it was going into the record. I also had her free text many things, and all in the same note. This helps her have a running narrative of what's happening with the patient, and any interventions she took. When she goes to call report later, or talk to a doc over the phone, everything is in one spot.
Charting in the room also prompted her to go outside the basic focused exam - if she's gonna chart that other systems are WDL, it helps to actually be looking at the patient to verify that instead of clicking through in a hurry later. I also had her look at the same few things every single time she opened the chart - vitals, last documentation, and new orders. It was redundant a lot of the time, especially if the patient was simple, but it got her in the habit of always scanning the same places in the chart to highlight what she needed to do.
Opening the chart frequently also helped TNG do everything all at once - she'd look at the orders, and get everything done at once - IV, labs, fluid started, meds. The fewer times you have the leave the room for stuff, the more time you spend in the room with the patient. This rolls into another huge issue she had - delegation.
I too struggle with delegation sometimes. I've always felt that if I can do something, it's rude to find someone else and ask them to do it instead. Usually this works for me, but occasionally I guilt myself into doing everything and then all of a sudden I'm in the weeds. So I worked with her to delegate small tasks, and let her focus on the big picture. Need someone to drop blood off at the lab? She'd call me to do it. Does that patient in room 73 need a pillow? It can wait, or you can snag someone sitting at the desk to do it. When a patient who needed multiple tasks came in, she'd bring help in with her if it was available. This allowed her to meet her budgeted time for a patient, get the necessary charting done, spend more time on critical thinking and less time on simple tasks, and also made the patient happy because shit got done quickly.
The last big thing I can think of for my precepting strategies is something so obviously necessary, but sadly one that many preceptors don't do: share your own failures. I told her dozens of stories of me screwing up - of making a medication error, of forgetting to do something for a patient, of me missing an obvious diagnosis. I told her of all the times I cried on the way home from work my first year. I told her how overwhelmed I was, and of how I questioned if I was meant to be a nurse. I told her how I still have those feelings sometimes, and that the day those feelings go away completely is the day you truly become dangerous. She needed to know that her feelings of inadequacy in this job are not new - every single new graduate out there has them, and if an experienced nurse pretends they never felt it too they will make those feelings even worse. Also, what a shitty way to exert power over someone, right?
It's hard for new grads. They're in a job where all of a sudden they can accidentally kill somebody, and that's terrifying. The amount of information needed to be a competent nurse is HUGE. It's not something you graduate nursing school with and all of a sudden have your shit together. It takes time. A lot of time. The most you can do is continue to learn - keep an open mind, learn new tasks every day, read on your days off, listen to experienced nurses, ask questions of the physicians, always find out the "why" behind actions. Most importantly, know when to ask for help - because this job is tough, and the ER is a team who shouldn't let you fail.
If management had done her right during the first round of orientation, all of this wouldn't have been news to her.
***
Part 4, up next to close out this little series. Please let me know if this helped anyone out there!
Sunday, June 3, 2018
Precepting, Part 2
Where were we? Oh yes, I remember - setting a new grad up for failure, and then acting all butthurt when they fail.
Here's where I come in. Management pulls me aside and tells me that the department has a new grad who wasn't good enough, and they want to give her another six weeks of orientation before deciding to send her packing. Would I be so kind as to be her preceptor? Also, she'd start with me tomorrow!
I agreed, and the following day the new grad (TNG) showed up, and it was like a punch in the face.
She was...not good at nursing. I say that not to be mean, but as an honest assessment of her ability to be a good nurse. TNG lacked any sort of time management, or the ability to prioritize tasks. When a sick patient showed up, she recognized that they were sick but was completely frozen on the next steps. Her charting was atrocious. She was a monumentally flawed new grad, and she was now my problem.
***
It's not much of a spoiler alert to say that she wildly improved and is now on her own and doing fabulously. So instead of giving you all a blow by blow of her six weeks with me, I figured I'd lay out my precepting methods in case it might help someone else orient a new grad. Because I've gotta say - this might be my finest work ever, and I'm proud of being able to turn her around and even prouder of her for doing it.
***
We started her out with one patient, so she didn't have to work on prioritizing or time management between patients. She could do her triage and focused assessment, then all tasks needed. I found out that TNG was great at tasking. She was kickass at IVs, and good about putting patients on the monitor, getting them undressed, and talking to them. She had a great personality which made patients like her, which definitely helps. But oh man, the critical thinking was not there.
So I came up with a game, which was very non-creatively called Sick/Not Sick. When a new patient came in, she had one minute to lay eyes on the patient and tell me if they were sick or not sick, and why. Early on, it was a struggle to get her to identify why they were sick - not everyone has poor vitals, or textbook complaints. The ability to ID sick is more of a gut feeling, but by forcing her to identify why that gut feeling was present or not I was eventually able to make her think about all the differentials. Once we had differentials and potentially critical problems, I'd make her give me all the expected interventions for those problems. Over the six weeks, she went from being hesitant to pull basic differentials and interventions, to being able to reel off a list of multiple problems and anticipating how to fix each one.
TNG also struggled with time management. I worked to fix this by using a per-hour time frame since we use hourly rounding as a metric, and then budgeting time as needed. We get four patients at our facility - thus, each patient gets 15 minutes of your time per hour. If you have a sick patient who requires 30 minutes of time, your remaining three patients each get ten minutes.
I also forced TNG to keep her encounters brief (within reason - I never made her cut short necessary or kind interactions if the patient needed it), since in the world of ER nursing you never know what will come through your doors. If you need an IV started, don't delay it. Get it done now, round on your patient, and free up your time for the next thing. If there isn't a next thing, then you get to spend bonus time with a patient. But if there is a next thing, or a new ambulance patient who is a hot mess, then your work is done already and you're not in the weeds with simple tasks.
We also worked on prioritizing tasks. If you have a patient that needs something simple and another patient who is going to require a lot of your time, do the simple task first. Both patients will have their work done in the same overall amount of time, but the simple task patient will be happier quicker. In this same vein, she began to recognize that if you have a critical patient who needs all your time, the other patients will have to wait.
I gave TNG homework - specifically, this: the Emergency Severity Index resource guide. It takes a long time to become a proficient enough nurse to work out in triage, but this is a vital guide since every nurse has to triage their own ambulances, and also recognize when someone has been under-triaged and to make the necessary upgrades. Chapters 2-4 are the part I made her really study. This flowchart also goes back to her sick/not sick assessment:
Through all of this, I wanted to let TNG make mistakes. When you screw something up, it sticks into memory far better than someone else telling you how to do something. So, I let her screw things up - as long as the patient wasn't harmed or inconvenienced, of course. If she called report and forgot to tell the floor nurse something, I let her scramble to figure it out when they asked. When she was supposed to recheck a temp on a febrile patient but didn't, I let the doctor come find her to ask why vitals weren't updated (I had already rechecked it, for those wondering). If she was about to make a bigger mistake, I'd let her nearly make it then stop her from doing so - and pull her aside for teaching. I found that over time she became more aware of her actions, so that the mistakes she was making early on became nearly non-existent.
***
This is becoming quite a ridiculously long post, isn't it? I have a few more strategies I wanted to mention, but in the interest of keeping this post shorter I'll add the rest onto the Part 3 post.
Here's where I come in. Management pulls me aside and tells me that the department has a new grad who wasn't good enough, and they want to give her another six weeks of orientation before deciding to send her packing. Would I be so kind as to be her preceptor? Also, she'd start with me tomorrow!
I agreed, and the following day the new grad (TNG) showed up, and it was like a punch in the face.
She was...not good at nursing. I say that not to be mean, but as an honest assessment of her ability to be a good nurse. TNG lacked any sort of time management, or the ability to prioritize tasks. When a sick patient showed up, she recognized that they were sick but was completely frozen on the next steps. Her charting was atrocious. She was a monumentally flawed new grad, and she was now my problem.
***
It's not much of a spoiler alert to say that she wildly improved and is now on her own and doing fabulously. So instead of giving you all a blow by blow of her six weeks with me, I figured I'd lay out my precepting methods in case it might help someone else orient a new grad. Because I've gotta say - this might be my finest work ever, and I'm proud of being able to turn her around and even prouder of her for doing it.
***
We started her out with one patient, so she didn't have to work on prioritizing or time management between patients. She could do her triage and focused assessment, then all tasks needed. I found out that TNG was great at tasking. She was kickass at IVs, and good about putting patients on the monitor, getting them undressed, and talking to them. She had a great personality which made patients like her, which definitely helps. But oh man, the critical thinking was not there.
So I came up with a game, which was very non-creatively called Sick/Not Sick. When a new patient came in, she had one minute to lay eyes on the patient and tell me if they were sick or not sick, and why. Early on, it was a struggle to get her to identify why they were sick - not everyone has poor vitals, or textbook complaints. The ability to ID sick is more of a gut feeling, but by forcing her to identify why that gut feeling was present or not I was eventually able to make her think about all the differentials. Once we had differentials and potentially critical problems, I'd make her give me all the expected interventions for those problems. Over the six weeks, she went from being hesitant to pull basic differentials and interventions, to being able to reel off a list of multiple problems and anticipating how to fix each one.
TNG also struggled with time management. I worked to fix this by using a per-hour time frame since we use hourly rounding as a metric, and then budgeting time as needed. We get four patients at our facility - thus, each patient gets 15 minutes of your time per hour. If you have a sick patient who requires 30 minutes of time, your remaining three patients each get ten minutes.
I also forced TNG to keep her encounters brief (within reason - I never made her cut short necessary or kind interactions if the patient needed it), since in the world of ER nursing you never know what will come through your doors. If you need an IV started, don't delay it. Get it done now, round on your patient, and free up your time for the next thing. If there isn't a next thing, then you get to spend bonus time with a patient. But if there is a next thing, or a new ambulance patient who is a hot mess, then your work is done already and you're not in the weeds with simple tasks.
We also worked on prioritizing tasks. If you have a patient that needs something simple and another patient who is going to require a lot of your time, do the simple task first. Both patients will have their work done in the same overall amount of time, but the simple task patient will be happier quicker. In this same vein, she began to recognize that if you have a critical patient who needs all your time, the other patients will have to wait.
I gave TNG homework - specifically, this: the Emergency Severity Index resource guide. It takes a long time to become a proficient enough nurse to work out in triage, but this is a vital guide since every nurse has to triage their own ambulances, and also recognize when someone has been under-triaged and to make the necessary upgrades. Chapters 2-4 are the part I made her really study. This flowchart also goes back to her sick/not sick assessment:
Through all of this, I wanted to let TNG make mistakes. When you screw something up, it sticks into memory far better than someone else telling you how to do something. So, I let her screw things up - as long as the patient wasn't harmed or inconvenienced, of course. If she called report and forgot to tell the floor nurse something, I let her scramble to figure it out when they asked. When she was supposed to recheck a temp on a febrile patient but didn't, I let the doctor come find her to ask why vitals weren't updated (I had already rechecked it, for those wondering). If she was about to make a bigger mistake, I'd let her nearly make it then stop her from doing so - and pull her aside for teaching. I found that over time she became more aware of her actions, so that the mistakes she was making early on became nearly non-existent.
***
This is becoming quite a ridiculously long post, isn't it? I have a few more strategies I wanted to mention, but in the interest of keeping this post shorter I'll add the rest onto the Part 3 post.
Subscribe to:
Posts (Atom)
