Precepting, Part 3

Let's continue hearing all about the ways The New Grad (TNG) turned herself around, yeah? Okay!

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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.

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Part 4, up next to close out this little series. Please let me know if this helped anyone out there!