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.

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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.

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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.

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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.