Saturday, November 21, 2009

Well, that was a bipolar two days.


I have two preceptors. I worked with one on Wednesday and the other on Thursday of this week.

Preceptor the First is....difficult to approach. She's a fantastic nurse, a very nice person; I like her a lot. I'm nervous about working with her, though, because she combines OCD-ness with such a huge amount of personal reserve that it's difficult to approach her with problems or questions. We're in the middle of testing a new computer system in the CCU, so a lot of the questions I had for her were computer-charting-related. Instead of having me fly the box and learn by doing, she would simply take over and chart *for* me as I watched, then expect me to be able to replicate the motions when it was time to do so.

I don't learn that way, sadly. I *used* to, but seven years of hands-on learning has ruined my brain for anything else, and it's probably too late to get a brain transplant and still pass my classroom final exam.

Wednesday ended with an emergent intubation to which I was invited (like Queen Victoria "invited" people to show up in the throne room) by the charge. Rudely. As in, I was in the middle of something else that was just a little bit important, there were already eight people in the room (two docs, three RTs, three nurses), and I got snarled at to come in and start an IV.

Which is fine. I can start IVs all day, with my hands behind my back, in my sleep, you name it. The particular IV I had to start was in the hand, and the dude I was starting it on was elderly, very fragile, and had extremely large veins. In a situation like that, I use the technique I learned years ago of putting the hand way below the heart and starting the IV without a tourniquet, as filling the vein tends to make it easier to blow.

I had gotten a nice, fat, 18-gauge IV into a hand vein when the CN rushed over, grabbed the dude's hand, and said sharply, "What the hell are you doing?" The vein, of course, blew. She then reminded me how to start an IV properly (ie, her way) and gave me a lecture on not losing my head in stressful situations. I looked at her levelly and said, "I have led a code before, you know."

Then I went away after the dude was intubated, started two impossible IVs for another nurse, and was told I needed to apologize to the CN by my preceptor.

It was a bad day. It was such a bad day that I vented to both my Brother In BFE and Sister Rat about it, then went to bed in tears. It was one of those days when you feel you're trying to run up a staircase coated with pig fat while somebody yanks on the scruff of your neck at odd times, making you lose your footing.

Thursday was different. Preceptor the Second is a total goofball. I am a total goofball. Neither one of us have any filters to speak of, so we'll talk about farting over lunch (note: I thought the nurses on my old floor were filterless. I was wrong), do yoga poses in the nurses' station, and eat cake when it presents itself, then be sugar-rushed all day. Besides that, she's detail-oriented in the same way I am, without being totally OCD about small things.

It was still a day when I felt like I was completely behind. I would've drowned had it not been for her help entering orders and turning patients and dealing with the second-largest bowel explosion I've ever seen, but it was a *good* day. A patient who'd been heavily sedated and intubated the day before got better, and I admitted-then-discharged one patient and admitted another (and actually got the swing of getting somebody into an ICU bed, wahoo!).

The charge nurse from the day before was mercifully absent, so I got to send her an apologetic email, doing the last ten meters on my belly.

It is hard to learn new things when you're a new nurse. It's harder--*much* harder--to go from being an expert to being a newbie at something. Your pride takes a hit, your ego gets involved, and you end up trying to prove things when you really don't have to. That much I learned from Wednesday. I learned from Thursday that a preceptor who's just as loony as her intern can make a hell of a difference in terms of that intern setting her (massive) ego aside and actually learning stuff and being humble enough not to freak out about it.

It's amazing what a difference personality makes. With Preceptor the First, I'm a little afraid to ask questions, for fear that she'll swoop in and just plain take over. With Preceptor the Second, nothing's off-limits and I have no fear of looking stupid. Both of them are excellent instructors; there's just the ease of meshing personalities with PtS. I'm learning two different ways of going about things, which is valuable: if one thing doesn't work, I can try the other and it might just make things happen. I certainly don't want to drop PtF as a trainer, but I do find myself a little more tense on those days and a little more wary of what might happen.

Years ago when I was first starting nursing, I got a crazy patient--and I mean *crazy*, as in, I've not had anybody to match her since--and she and I did not get along. This of course caused much hand-wringing with my boss, my preceptor, and the educator for the department. Because I was a new nurse, I couldn't simply say, "This person is a fucking nutjob and I refused to play her game, therefore, she decided to report me." Instead, there was a long meeting with all three of my superiors during which I finally had to come up with some deep psychological reason why I couldn't get along with this person (I said she reminded me of my then, now thankfully dead, mother in law) and listen to a whole bunch of bullshit about how I needed to set personal feelings aside in dealing with people who were nuts.

I had worked for three years at that point in an industry known for being a target for wackjobs, and had actually been a target, personally, for some of those wackjobs. Yet none of that counted. I was PISSED. I was treated as though this job was my first rodeo, and none of my previous experience was taken into account. The ability to call out a nutjob and treat that nutjob as such was taken away from me, and I had to take the fall for somebody else's inability to be a sane human being.

That's kind of what's going on now. It's assumed that I have the technical skill to deal with any number of problems. In terms of the personal angle, though, pretty much everybody assumes that I'm a complete n00b with no clue. It happens more with PtF and the charge nurse than it does with PtS, but that's not their fault; they're trying to make me the best critical-care nurse I can be. It's up to me to lose the ego, gain the patience, and prove that I can do this without completely losing my head and holding somebody's smoking entrails up before their dying eyes.

Which means I will need much more cake.


Maha said...

I can imagine going from an expert to a newbie to be really tough. I felt like that when I started nursing school and my preceptors got angry at me for knowing a whole hell of a lot about pathophysiology and pharmacology because that was the emphasis of my previous degree. But in a way it was good - I got to apply my previous knowledge in a new way so it worked out well..

I love this sentence: "...and prove I can do this without completely losing my head and holding somebody's smoking entrails before thier dying eyes". The mental image is at once completely badass and utterly hillarious!

And cake is not just a delicious baked good. It's a coping mechanism. Especially chocolate cake.

gorochan said...

I changed floors as a fairly new nurse, and one of my preceptors tested me on meds. Things like prilosec and insulin and what they do. I was a little offended and surprised, but sucked it up and rattled them off. Then she said she'd recently been orienting someone who didn't know the different types of insulin (!!), which at my hospital are even in different brands of insulin pens so we don't screw it up, color coded and everything. I realized she was just trying to assess my learning needs, as she didn't know where I was with knowledge. Today she and I get on pretty well, she openly compliments me on random stuff, which I appreciate, and it's nice to work with her. What a change from when I started. Once she learned she could trust me the relationship changed.
Of course with PtF you can try to tell her you learn better by doing, but don't expect to get that kind of guidance from her. Rely on her strengths and get other skills from PtS.

bobbie said...

I've always thought that hell had a special place for pipples like PtF...
LOVE me PtS's!!!

Anne said...

I fired my preceptor when I was first starting out. She was a good nurse, but her style and lack of patience made me go home and cry nightly. She had done the same with other new grads, and after me was no longer allowed to precept. New preceptor, and I did just fine.
Sometimes it isn't you.

yr sis said...

Taking instruction isn't the same thing as taking abuse.

Racing over to anyone, jolting the needle inside the vein, and yelling "What the hell are you doing?" is wrong. I don't care what job we're talking about and I don't care what experience level either. Yes, sometimes fast action and raised voices are necessary when human health is involved. But would that behavior have been appropriate with a newbie? No. Was it appropriate with you? No.

"House" aside, instruction is not abuse, and vice versa. Preceptors are human. But instruction is not abuse.

Anonymous said...

Yeah. What everybody else said.
It ain't about you, sister. Just kill 'er with kindness and try to salvage from the relationship whatever you can in the way of education, etc.

Anonymous said...

I'm with yr sis.

The old girls in ICU need to get a grip.

shrimplate said...

Nobody touches me when I am conducting the Sacrament of Obtaining The Intravenous Access. Or they get The Elbow In Their Eye sly passive-aggressive "oh, did I do that? my bad" move.

I agree with the above comment that it was really wrong for that nurse to mess up your stick. Smoking entrails, indeed.

You're doing great. Just don't forget to remind yourself that it's not you, it's them. They can't help it; they're fucked up.

Anonymous said...

I'm actually a bit sorry you apologized to the charge, though I can understand the reasons you might want to... her behaviour was nasty, and she sounds like a bully. I had a very similar situation as a very new grad,a trauma with extremely poor veins, and Much More "Experienced" Nurse yanked out the patent IV I had just started, stating I "would never get the line."

The patient died very soon afterwards --- he had some weird coagulopathy. I'm not saying he died because Much More "Experienced" Nurse was an idiot, but I have often wondered if his outcome might have been different.

Rat said...

You go with the 18g BABY. If the patient was me and I was awake and lucid enough, I would have told the hooch where to get off. I say, the rule of thumb in vet medicine anyway is you place the largest catheter that you think you can place without blowing the vein. If dude had 18g veins in his put in an 18g. I had an idiot charge nurse who couldn't put a 24g into MY hand and blew not 1, not 2, but 3 veins before the doctor came in and said "forget it, we will start her on orals." Where were you when I needed you..... *sigh*

Take deep breaths. Scream into pillows. Hit something SOFT. And go on to the next day.... That's all I've got to say. I can only HOPE that if I have to be hospitalized again (which, seeing as though they took all the problem parts out, is slim) I should have you as a nurse. I would give her a piece of my mind. And you know that ain't a good thing.... :)

City Girl Marj said...

It's always luck of the draw on who your preceptors are going to be, isn't it? In the two ORs where I've worked, there is no consistency on who is going to be your preceptor. That's when you just learn to say, "OK" to whaever they're teaching you, even when you come in with experience. Tough to bite your tongue, but sometimes it's the best option. I call it "buying peace." :)

Hang in there!!!

Unknown said...

I'm not a nurse, but I hate conflict. I hope your apologetic email included something to the effect of teach me, don't take over... :) Next time she takes over (and probably rolls here eyes), ask her to please stop. Your way of learning is hands on, not watching. Perhaps put it in such a way that you are trying to be respectful of her time.

She's a total hooch, though - and I like what everyone else said. :P