New Nurse Krystal
It was a couple of years ago, around three in the afternoon, another busy day on Tele. I dashed into the Supply Room to grab something and she was hunched in front of the supply cart, hands covering her face, crying. Not crying as in silent tears sliding down her cheeks but sobbing with shuddering sobs.
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“Krystal, what’s wrong?” She uncovered her face. It was splotchy and her eyes were swollen.
“I don’t know, I just..I don’t know I can’t keep up like everyone else” she started weeping again.
I put my arm around her.
“What’s going on? Tell me about your patients”
She was so distraught she could hardly form her words.
“One is getting blood but his IV infiltrated, I have to hang a heparin drip it’s my first time and there was the RRT and Jake (charge nurse) just gave me another admit from ED and the guy in 215A keeps getting out of bed I’m so afraid he’s going to fall”
“Is your RRT already in ICU?”
“The charge nurse <sob> is going to <sob> is going to get..”
“Going to what, Krystal? Send your unit of blood back? Get a sitter?”
I interrupted her “Krystal. Have you had lunch?”
“NOooo….I’m just..I’m a failure at being a nurse I didn’t know it was going to be like this..”
“Krystal. Krystal. It’s not you. It’s not you. What’s happening is something they don’t tell you in nursing school.”
I hesitated, but then blurted it out
It’s Nursing’s Dirty Little Secret
note: During this discourse, several nurses ran in and out, grabbing supplies and throwing Krystal a glance, some of which were fleetingly sympathetic. Some were not. One briefly patted her hand, but had to run as her own patient was not stable.
I went out to hunt down the Charge Nurse and found him sitting at the nurses station, seemingly oblivious. To his credit, he himself had less than two years nursing experience. Chances are he too, felt helpless and had no idea how to manage the situation, and so was avoiding it.
Krystal was two months out of orientation and judged herself a failure. She felt like she had made the biggest mistake of her life by choosing nursing. Her dream had turned into a nightmare.
How many other new nurses feel isolated in their struggle and drive to work with that sickening feeling of dread at the pit of their stomach?
New nurses are not prepared to care for a team of high acuity, complex patients with multiple co-morbidities. It’s no wonder they feel overwhelmed.
It’s widely agreed in the literature that nurses do not achieve initial competency until their second to third year.
But a six month old nurse is given the same patient load as a six year old nurse. It’s not uncommon for a brand new nurse to find him or herself working nights in ICU, surrounded by….other new nurses.
Connect the Dots
New nurses cannot yet connect the dots, but there is an expectation that they should.
In the taxonomy of learning new nurses are at the knowledge and understanding phase. Having knowledge is different from applying knowledge.
When nurses graduate, they are optimistically brimming over with book knowledge. But patients haven’t read the book and don’t follow algorhythms.
Pattern recognition, which is a construct of critical thinking, takes time, takes experience, and takes more than six months.
I’ll never forget being at the nurses’ station when I happened to look up into a pt’s room straight across the hall. He had “The Look”. At that same moment, his nurse walked by, glanced in, and kept on walking without a pause. I bolted, yelling for someone to get the crash cart.
She had not yet learned to recognize “The Look”.
Within nursing, calling another nurse “task-oriented” is a criticism. It means focusing on a task to the exclusion of seeing the big picture. This may be a fair criticism for an experienced nurse but not for a new nurse. It’s natural for nurses to be task oriented when they are first learning. It’s how we learn.
An earnest new nurse, intently focused on passing her 0900 meds and anxious because it’s now 0945, answers her phone. It’s Lab calling with a report of a potassium of 5.0. She says “I can’t take this now. I’m passing meds.” Dutifully she passes her meds, including potassium, to the patient. She calls Lab back. “What was it you wanted to tell me?”
She was too absorbed to receive or discern the importance of new incoming information.
When you are learning, the task at hand takes all of your concentration. A new nurse can’t be expected to multi- task while attempting to master the initial task. The notion of multi-tasking itself is currently debunked and is being replaced by the more descriptive term of cognitive stacking.
Yes, student nurses pass meds on patients during clinical rotations. But typically on two patients, not five, and while sheltered from the constant bombardment that staff nurses experience. And without an incessantly ringing phone in their pocket.
Nuances not Noticed
A new nurse may not yet recognize subtle changes in condition that can signal an impending deterioration in condition. A slight increase in heart rate in a post-op patient? It’s a red flag to an experienced nurse who is attune to early signs of sepsis, but isn’t even on the radar for a new nurse who is unquestioningly going to see that same patient as stable.
Read my article “The Spider Bite” about a patient who died in such a circumstance.
Sift Through the Chaff
Krystal’s post-op open heart patient is having runs of non-sustained Mobitz type I heart block, but his blood pressure is fine.
Krystal doesn’t yet know that post-op open heart patients experience transient and benign runs of heart blocks. She spends an inordinate amount of precious time calling the doctor.
First she has to ask other nurses if she should call the surgeon or the hospitalist or the cardiologist. Then she forgets to have the am lab results on hand when she reaches the doctor.
In the meantime, another of her patients with CHF had bilateral rales this morning. While able to assess and recognize rales, Krystal does not immediately look back to the previous shift to see if this is new or look at the twenty-four hour I&O to determine his fluid status. His IV is going at 100 mL/hr. At 0900 an RRT is called because he is in flash pulmonary edema.
The experienced nurse will have briefly but thoroughly assessed the patient with the rhythm block, keeping an eye on the situation. She/he would have already obtained and administered Lasix to the CHF patient, saline locked the IV, and moved on.
The IV on one of Krystal’s patients keeps alarming “downstream occlusion”. Krystal repeatedly goes in the room, looks at the line, the site, and pushes the alarm override. Finally another nurse comes in, flips back the covers and unfolds a kink in the line. Voila. Problem solved.
Later Krystal starts an IV on another patient. Pleased to have gotten flashback, she tapes it in place but realizes she pulled secondary IV tubing instead of primary. She makes a trip down the hall to the supply room. She returns and finally and deliberately gets the IV set up and running.
After a short time, it starts alarming and she keeps running in to check it. After multiple alarms and inspections, she realizes the site is swelling slightly. She discontinues the IV, goes to the supply room, and starts all over.
The experienced nurse knows when she first performed the stick that the site was no good, even with an initial weak flashback. She feels the almost imperceptible coolness of the tissue around the site when she runs a few drops in, and recognizes that something is just not right. She discontinues it and starts another IV right then, having brought in extra supplies.
Is it any wonder Krystal is so far behind?
No Other Industry
What if you got on board your transatlantic flight to France and the pilot announced “Welcome aboard! This is my first flight because someone called in sick and so they sent me over here. Usually I fly simulation helicopter flights but today I’m flying this big boy. Never flown one before but I’ve read the book. You know what they say… sink or swim, right? Oh wait, bad choice of words.”
Nurses are Complicit
Sadly, nurses are complicit in this culture.
Nurses themselves have made missing meals and bathroom breaks a badge of honor to compete for who has the worst assignment or works the hardest or is the most self-sacrificing.
Missing meals is not a badge of honor, it’s a violation of labor law. Nurses clock out for meals they don’t take and clock out again at end of shift while staying over to chart.
Often nurses don’t question the unrealistic expectations. If they’re drowning, it must be because they’re not good enough. They just have to run faster and work harder. They want to be seen as capable of handling it all by their watchful coworkers. They want to please their manager by doing it all, without complaint, without missing anything, and without overtime.
Nurse scorn other nurses who can’t keep up. They roll their eyes and dismiss them with the phrase “He/she just can’t cut it.” This phrase is sometimes used as the sole performance feedback by preceptors and even managers.
“You’re just not cutting it here in ICU. Maybe you should try Med Surg.”
Patient Acuity and Decreased Length of Stay
Increased patient acuity and decreased hospital stays contribute to staffing challenges.
A nurse assigned to five private rooms does not have 5 patients. As a result of rapid discharges and admits, she/he can have cared for six to eight or even more patients in one shift.
As an example of higher acuity, hospitals are required to identify their own “critical values” and have a process in place to deal with them. Several years ago, the glucometer machines at my hospital were set with the critical high level at 300. A few years ago, the critical high was upped to 500. Patients with a glucose of 500 used to be treated in the ICU. Now they are on Med Surg.
Nurses understand and emphasize that staffing issues are an ongoing concern that affects patient safety and nurse performance. Adequate nurse-to-patient ratios and safe patient outcomes are strongly linked.
An adequate nurse-to-patient-ratio must take into consideration the capacity and experience of the nurse as well as the acuity of the patient
Patient Safety and Nurse Safety Both Link to Staffing
It is proven that safe staffing ratios reduce untoward patient events. Safe staffing ratios:
- Reduce errors
- Decrease patient complications
- Decrease mortality
- Improve patient satisfaction
- Reduce nurse fatigue and burnout
- Improve retention and job satisfaction
The Astronomical Cost of Turnover
Are hospitals stepping over a dollar to pick up a dime? Could hospitals save money in the not-so-long run by retaining and investing in their nurses to help prevent costly HAIs, falls, and other untoward events?
According to the American Federation of State, County, and Municipal Employees, (AFSCME) “if a 400-nurse hospital with a 20 percent turnover rate is replacing 80 nurses per year, the direct costs might average $800,000 per year, but the true total costs are closer to $4 million.”
Hidden costs incurred by hospitals include use of agency nurses, sign-on bonuses, re-location costs, decreased productivity, and lower quality of care.
Progressive Responsibility for Better Patient Care
Rather than a one size fits all orientation, consider giving new nurses progressive clinical responsibility over their first year.
To make it financially feasible, new nurses could be hired at a lower rate which would increase as they gradually and safely become more productive. New nurses who cannot get jobs will jump at the chance of being employed and being supported.
Health care leaders have an opportunity to collaborate and develop solutions that will build a safer environment for patients and registered nurses. Leadership support and recognition are key to assuring an appropriate number and skill mix of registered nurses who deliver safe quality patient care.
I would welcome your thoughts on this topic. Is this nursing’s dirty little secret? Or is this the acceptable status quo?
Be sure to read Nurse-Patient Ratios: a Biased View.
Until next time,
Until next time friend,
AFSCME. The Cost of Failure. Retrieved June 2015 http://www.afscme.org/news/publications/health-care/solving-the-nursing-shortage/the-cost-of-failure
Benner, P. D. (2000). From novice to expert: Excellence and power in clinical nursing practice, commemorative edition. Upper Saddle River: Prentice Hall.
Duffield, C., Diers, D., O’Brien-Pallas, L., Aisbett, C., Roche, M., King, M., & Aisbett, K. (2011). Nursing staffing, nursing workload, the work environment and patient outcomes. Applied Nursing Research, 24(4), 244-255.
Garside, J. R., & Nhemachena, J. Z. (2013). A concept analysis of competence and its transition in nursing. Nurse education today, 33(5), 541-545.