Residency Hesitancy

When you hear the term residency, what comes to mind? I’d bet you immediately thought of the residents you saw on ER or Grey’s Anatomy or even House. A nursing residency is not the same as a traditional residency an MD or DO enters after their four years of medical school. This type of program is sought after by most new nurses as it provides an invaluable opportunity for a student to transition to a professional.

A typical residency program provides a new nurse with a cohort of other new graduates to form a bond with, as well as 10 to 12 weeks of evidence-based training accompanied by a preceptorship. You may be asking why this step is necessary or thinking that it seems like a waste of time. Honestly? Yes, a good portion of the residency classroom portion is like an abridged nursing school all over again; but, a residency program acts as a transitional stepping stone for new nurses.

No one will ever know everything, and being the perfectionist that I am, I had to quickly accept this fact of life. Throughout my time on the floor so far, I’ve learned the key is self confidence and the confidence in one’s own practice.

The residency program helps new nurses transition from a student to a professional, all while building a sound foundation where confidence can be fostered and skills can be fine-tuned.

I cannot speak for all programs, but the one I am a part of presents: countless case studies, mock scenarios, pharmacotherapy, evidence-based practices, certifications, team building, shadowing, and preceptorship.

- Epic Training

I can be the first to admit that a real code or rapid response is nothing like what you see in a scenario and you have to expect the unexpected. From my experience, “successful” codes are the epitome of controlled chaos; to the layperson, it seems like people have no idea what they’re doing and everyone is yelling at one another. To me, any successful event results in the saving of a life and advancing the level of care, that is all that matters. But I digress; the main take-away is that even though mock events do not fully prepare an individual for the real thing, they provide time to practice where the patient is not living and when you screw up, you can start over. Residency classes provide a safe space where it’s okay to fail, and sometimes failing is the quickest way to learn.

One of the most important parts of my residency program is preceptorship. For those who may not know, a preceptor is an experienced individual who facilitates their preceptee’s learning while in the workplace. In the nursing world, this is usually an experienced nurse who takes on the role of being a teacher while on the unit. The new nurse is taken under the wing of this coworker and is shown the ins and outs of the unit. This allows the new nurse to slowly incorporate all they have learned into practice. The Preceptor’s role is to ensure that the new nurse does not become overwhelmed or burnt out, prevent serious mistakes from being made, get feedback from the patients being cared for by the new nurse, and to provide teaching moments to the new nurse so that they can understand what happened and why.

Essentially, a preceptor program is a safeguard for the hospital as well as a transitioning period for a recent graduate who is becoming a novice nurse.

Having a quality preceptor is a ‘hit or miss’ situation; one can either have a preceptor who truly cares about mentorship or a preceptor who takes advantage of the new nurse and has them carry out most, if not all, of their daily tasks. Going through school, and trolling through social media, I heard horror stories from new nurses. Instances where the new nurse: felt abused, belittled, put down, had to do all the tasks the preceptor would have to do if they were not precepting, was left out of social team building, outcasted during breaks, and even new nurses having inappropriate relationships with their preceptor. Issues like these do not happen all over the place, but it’s concerning that they happen at all. As a nursing student, I experienced a good portion of what I have mentioned; I know for a fact that new nurses have had to live through what I have listed and much more.

I, for one, lucked out big time with the preceptor to whom I was assigned. When applying to this program, I was unaware of who my coworkers, let alone my preceptor, would be. Turns out, I already knew my mentor; I worked with her while I was a Patient Care Associate (PCA) at a different hospital before I began nursing school. My preceptor took me under her wing while I was a PCA because she saw my potential, even in times when I could not; this is honestly still true to this day.

Story Time: Poison IV

One instance where I needed my preceptor to fall back on involved an IV and some infiltration. Throughout the entirety of my residency program, I have not developed a sound confidence when it comes to hanging IV medication. Let’s be honest, seeing bubbles in the IV tubing, no matter how small, scares me and I always imagine the worst for my patient. I have been and continue to be extremely detail-oriented when it comes to hanging IV meds and spend way too much time finagling the tubing/IV pump to ensure there are no bubbles.

Having prefaced my fears of giving a patient an air embolism, this brings me to a patient I had who was admitted to an isolation room. When it comes to isolation rooms, one needs to limit themselves to the time spent in the room and working with the patient. Being my weak point, my preceptor wanted me to strengthen my medication administration abilities and entrusted me with the task of hanging a particular medication which has been known to cause infiltration. Recollecting my time spent in the pathophysiology and pharmacotherapy classes, knowledge of this medication only heightened my anxiety; being in an isolation room all gowned up and the temperature set to 80 degrees did not help either.

I was dripping in sweat trying to hang the medication, spike the bag, and prime the IV tubing. I flushed the catheter inserted in the patient with normal saline, hooked up the primed line, opened the clamp and started the pump...ten seconds go by and the pump alarm goes off with the message stating that there is, “air in the line”. At this point, I start to panic more, disconnect the patient from the tubing and start all over again to ensure that there is no air in the line. I hooked up the patient, unclamped, hit ‘run’...no alarm this time. I left the room to care for other patients and told my preceptor why it took me so long. I told her that I was afraid that air got into the patient’s vein and that now they are going to have an air embolism.

My preceptor obviously was more confident in me than I was and told me not to worry about it - the sign of a great preceptor.

About an hour goes by and the patient comes to their doorway and asks me to come in and look at their arm. At that moment, my heart must have skipped a beat; I thought that the air embolism fear became a reality.

I went into their room to assess the situation; lo and behold, their arm (at the IV site) was: painful, red, and swollen. I knew that I needed to stop the medication administration, contact IV therapy, and get help from my preceptor. I walked her through everything I did prior to the infiltration and everything I did to rectify the situation. She goes into the room to assess the patient and comes out to me to tell me that I did everything I was supposed to do. She told me that this particular medication has a tendency to infiltrate veins and cause this sort of reaction. Even though I felt traumatized by this small situation, my preceptor had my back and calmed my nerves to ensure that I knew this was not my fault.

Story Time: Deja Poo

This story will always resonate with me as it was the second of three rapid response calls I needed to make on my patients in one shift. Now, this happened when I had already completed my orientation and preceptorship: I was ‘on my own’. I had a very late admission, the patient was admitted due to syncopal episodes at home. This individual was extremely pleasant and I thoroughly enjoyed caring for them. I completed their admission to the unit, gave them their meds, took vitals, and let the patient try and get some sleep. At about 5:30 or so in the morning, I passed by the patient’s room and it smelled as if someone had a bowel movement. I get a page on my phone from the newly admitted patient advising that they had an accident.

When I turn the light on, the entire patient is covered, the bed is covered, and the floor is covered in stool; this was not just any stool, it was red and there was a concerning amount of blood. I tell the patient not to worry or be embarrassed, and that I will clean the mess and them up. I stand the patient up after gathering supplies and begin doing my best to clean them; I continue to ask the patient questions about GI issues or recent blood in stool. The patient advised me that they had to “go” again and the patient began to leak blood all over the bed and floor. I yelled for someone to assist me and ask for a rapid response to be called. It is at this point that the patient loses all color, becomes diaphoretic, and begins to fall so I sit them on the bed and do my best to hold them up. (This whole situation was reminiscent of the one described in “In it For the Long Fall” and gave me serious deja vu). Nurses and techs from my unit rush in to assist me, and the providers soon follow; the rapid response was successful and the patient’s status was normalized after a long episode of helping the patient. It is moments like this for which my preceptor prepared me.

I did not have my preceptor anymore but a whole team of nurses, techs, and providers who were there to help when I am unsure or need help.

Moments like the ones I share in this blog help me realize that every nurse is learning everyday; people are fallible and do not know everything. The most important lesson I learned was that it is okay to not know everything and it is okay to ask for help.

At the start of my program, I knew I had ‘people skills’, but my technical skills were borderline adequate. My preceptor was always there when I needed her, even when I did not want to admit that I needed help. She had enough confidence in my nursing practice that I was taking assignments of 4-5 patients at a time, passing and hanging meds independently, assessing patients, communicating with providers, and much more.

A preceptor is not there to necessarily hold your hand through the transitional phase of becoming a nurse, but more to ensure that the new nurse develops the needed confidence in their practice; to help a novice understand how to apply textbook knowledge to practical abilities.

Working on my self-confidence has been a difficult task for me for as long as I can remember; I am a perfectionist, suffer from imposter-syndrome, and have a difficult time believing in myself. This has been and will be an ongoing task I will work on while in the role of being a nurse. For all those starting new careers who have self-doubt, you are certainly not alone and I completely understand the struggle and fear. There is no simple solution, but I highly recommend finding a new job where your transition into the role is a priority of your employer. Instead of running myself into the ground as a new nurse with no help, I am able to run for help whenever I need it. I’m still running no matter what because, after all, Nursing is my Cardio.

- Certainly how I feel sometimes when new grads ask me for advice