Tag Archives: nursepreceptor

Staying Organized: Brains and Checklists

On my first day in Nursing Fundamentals Clinical, my instructor shared a typical schedule to follow when we’re on the floor and the expected flow of the day. My instructor explained how the nurse has to keep organized to ensure the nurse properly assesses each patient, gives medications on time, takes vital signs as needed, provides education, addresses orders, and documents care. One of my classmates asked how a nurse keeps track of everything, and my instructor responded, “Oh, I use my brain.”

My classmates looked at one another, perplexed. I wondered, “How will I hold all that information and remember everything I have to do in my brain?!?” Only later, with some further explanation from my instructor, did we realize the “brain” on which she was relying to stay organized is a document and not an organ in her body.

A nurse’s “brain” is a document that helps a nurse stay organized and allows the nurse to take notes for shift handoffs, doctor’s reports, or assessments. A nurse can also use a brain to track: treatment or surgery, when to give medications or perform additional tasks, inputs, and outputs, progression of care, or the completion of orders. Of course, the nurse documents care within a patient’s chart. However, a nurse’s “brain” serves as a mini notepad or planner for the nurse between charting.

In nursing school, I was exposed to and used various types of brains. There are numerous templates for brains available, and some are even free. During nursing school, I liked trying the brains offered by nursing.com. (With a subscription, the website provides a brainsheet database of 33 different brains, some focused on specialties like ICU, Peds, or L&D). Often, units in hospitals print specific brains for staff to use. However, it is the nurse’s preference that determines the brain a nurse uses. For instance, my preceptor never uses the unit’s pre-printed brains and writes out her brain every time she shifts. While nurses are not required to use a brain, I don’t believe I’ve ever met a nurse who doesn’t use one.

After attempting to use multiple brains, I decided to design my own. Some brains don’t have enough space, are not organized the way I want, or do not capture the information I need. As a new grad nurse, I find it difficult to track the completion of required charting or documentation unless I note it in my brain. No generic brain template is going to capture the documentation unique to my unit.

As I imagined what I wanted to include in the brain I was designing for myself, I read the book “The Checklist Manifesto: How to Get Things Right” by Atul Gawande. My husband received it as a gift, and he recommended the book to me. He thought it would interest me since the author was a surgeon exploring ways to make surgeries safer. The author worked with the World Health Organization (WHO) to develop a checklist to use for surgeries, to prevent errors (and ultimately, injuries or deaths due to preventable mistakes). It was a quick and fascinating read. He explored how other industries such as construction or airlines use checklists. As in surgery, errors in those industries can be fatal. At its worst, errors in construction or flying planes can be catastrophic and result in mass casualties. Yet, such errors are rare compared to mistakes in surgery. The book discusses how he and others developed a worldwide surgical checklist for WHO and what resulted. The author also shares when checklists are inappropriate and offers tips on developing them, even down to what font one should use. I enjoyed reading the book – it was a nice break from studying or reviewing nursing-related topics, yet I felt it was helpful to me as a nurse.

Considering what I learned from Atul Gawande, I placed a documentation checklist onto my brain template. Since I’ve set the documentation checklist in my brain, I’ve been more efficient in my charting. I can ensure I’ve completed the charting documentation for each patient without spending extra time combing through various sections of a patient’s chart to verify completion multiple times. My preceptor does not have to stay over later to complete missing documentation for our patients as she did earlier during my orientation and training. My checklist lets me know what I’ve done and what’s still missing during my shift. I know I’ve become more proficient at time management since starting orientation, but having the checklist helps me keep organized and manage my time. Plus, as a checklist gal, it feels satisfying when I cross off all the boxes in my checklist by the end of the shift.

The documentation checklist I added to my nursing brain

Are there checklists you use day to day that help you in your personal life or your work? Or, are there brains you’ve used that you like? I’d love to hear and learn what works for others!

Reflection: A Difficult Preceptor

I attended an ICU clinical rotation yesterday and experienced my most difficult nurse “preceptor” I’ve ever had. A preceptor is a nurse to whom you are assigned during your clinical rotation that serves as a teacher/mentor of sorts. I used quotes because technically during clinical rotations, you are assigned a nurse to follow/shadow/help but not all are “preceptors” or teachers. Even though this particular rotation is one that is directly tied to my Advanced Med-Surge Lab (we have been going to this hospital pre-pandemic and go to this hospital as students as part of our course requirements), the nurse to which I was assigned didn’t want the role of preceptor. The other nurses were already assigned students, clinic nurses, or had COVID cases, so this was the nurse they assigned to me.

My nurse was in a room with a patient when my instructor announced to her from across the patient’s room that I would be the student with her that day. After my instructor left, I entered the room to introduce myself to her and the patient, and the nurse “shushed” me. The nurse whispered she didn’t want me to agitate the patient as her heart rate goes up whenever she interacts with her. Ok. I wasn’t there earlier. Maybe she just spent all this time getting this patient’s heart rate under control. I didn’t want to undo that.

After we left the room, my nurse asked me to be completely transparent if I’m uncomfortable about performing any skills. She asked me to perform a number of tasks, including Foley care. I shared with her I had never performed Foley care on a live patient. I peformed the skill first semester (last summer) on mannequins. I’ve never had a patient that required me or my nurses to do this for a patient. (Not that Foley care didn’t occur when a Foley was present – CNA’s can peform Foley care. Also, many hospitals avoid the use of in-dwelling catheters due to risk of infection). While I go to open skills lab to continue to practice my skills, skills lab access has been suspended due to the pandemic. Even though I hadn’t practiced in a while, I knew I could do the skill and wanted to do it. However, because I shared I never did it on a live patient and wanted her to watch me to make sure I was doing it right, she did the task herself and declared, “I am not your teacher. I am not here to supervise you. YOU are here to help ME.”

Wow. Uh, ok. This is a great way for me to start my morning. I know how to do a lot of things, but I don’t get tons of experience doing certain skills on live patients. I’ve practiced numerous times on mannequins, read instructions, and watched videos. I’ve done lots of skills once or twice before on patients with a nurse or instructor present. However, I’m not super confident in all my nursing skills yet – even though I passed all my skills exams. I recognize that getting a pass in skills lab doesn’t necessarily translate to being flawless in doing the skill with real-life patients. I don’t want to do anything that could jeopardize a patient, which is why I just wanted to her to briefly oversee me.

Shortly after she performed Foley care, my nurse asked if could spike a bag and hang a Lactated Ringer’s (LR) solution. I said, “Yes, ” but as I was preparing and doing it, she stopped me and asked me to talk her through the process. I hadn’t even finished explaining when she stopped me again and took the bag and just did it herself. I was a little stunned as I’ve hung a number of IV’s already. She said I should hang the bag first before spiking it. I was used to spiking a bag before hanging it. I’m short and don’t want to have to reach up to the IV pole or adjust and readjust a pole every time I hang a bag. I am also used to checking an IV line and flushing it before connecting anything to it, but my nurse did not do this. She connected the line to the patient after priming it with LR and flushed it from a port upstream. I had never seen this before. As I was trying to assess the IV sites, my nurse motioned me to leave the patient alone, again with the intention of not wanting to bother the patient, I suppose.

Maybe half an hour later, the patient seemed agitated and kept raising her arm. It turns out the chuck (an absorbant pad typically placed underneath a patient’s hips) was wet by her left side. She had a Jackson-Pratt (JP) wound drain, so my nurse figured the drain was leaking, added a dry chuck on top of the wet one, and re-positioned the drain and patient. A little while later, when I was alone with the patient, the patient was agitated again. The chuck was wet again with clear liquid. I tried to find the leak. It couldn’t have been urine because she was connected to a Foley, and the patient’s urine was dark yellow. I couldn’t see a leak from the JP, and the liquid in the JP drain was red and serosanguinous. She had three IV sites on her left side, by where the leak was: her hand, her wrist, and her forearm. Two were running and one was on saline lock. Which one was leaking? I couldn’t find the leak so I placed a towel underneath her left hand to keep her dry and determine if the towel would get wet. If the towel would get wet, it was one way to confirm and isolate the leak to the IV sites. I couldn’t see where the drops of fluid coming directly from any line, but because of the pattern of the leak and where it was wet, I determined the leak was from IV site where my nurse connnected the LR.

When my nurse entered the room, I shared with her the site was leaking and asked if we could switch sites. She switched the LR to the other IV site not being used and then gave me a tip not to use a towel for a patient because it can cause skin breakdown versus a chuck. I silently wondered, “If she had flushed the line before connecting the LR, could we have discovered the leak sooner?” I asked if we should DC (discontinue) the IV site that was leaking and she said why would she if she could save it? When I later told my instructor about the leak and wondered how it could be saved, she said maybe it was kinked or not hooked up correctly. A leaking IV could be saved if the hub was replaced or reattached. I clarified with my instructor if I could do skills on patients, even though I’ve never before done it beyond skills lab. She said I could and shouldn’t need any supervision. With that assurance, I knew I had to give myself a pep talk to be more confident in my own skills and just do things I know how to do, even though I haven’t had a lot of practice doing it in real life.

I also clarified with my instructor if my process for hanging a bag (spiking before hanging) is acceptable – it was. I followed up with the my preceptor and asked, “Why did you stop me from hanging that LR bag?” The nurse shared I was talking too much and not “doing” enough, and she didn’t see me do an assessment. I was frustrated because this nurse asked me to talk her through things, didn’t allow me to do things I normally do, and kept discouraging me from interacting with the patient. I had an entire day in front of me, and I needed to find a way to ensure I was able to do things. So I talked less, did assessments without my nurse present, and eventually got to push IV meds, administer oral meds, empty urinal bags, colostomy bags, and JD drain, witness a CVAD (central venous accesss device) placement, and spike and prepare an NS bag. It didn’t feel good, but I fought to have a day where I could practice my skills and learn.

Around two in the afternoon, my nurse asked if I wanted to eat. She had kept offering me to go on break and eat all morning, but I kept turning her down. I finally agreed I should probably eat as it was now 2pm. She said I could leave early if I wanted and not return from lunch. I was leaving the floor around 3:30pm, so if I was gone one hour, I could just leave. However, I wasn’t planning to be gone an entire hour since most nurses get only half an hour. When I asked to verify if her lunch was only half an hour and how I wanted to match that (how else am I going to get used to the work schedule of a nurse?) she replied saying someting about time management and how she doesn’t know me or my schedule but that I should do what I need to do to manage my time. I explained I would return from my lunch and that I still wanted to learn and do things. We had a patient that had urinary retention so I anticipated needing to do a straight cath (in & out catheter) on the patient. I didn’t want to miss the opportunity to insert the catheter; I had never done this on a live patient.

I ate lunch and returned to the floor. The patient who was unable to pee refused the catheter. However, the same patient needed to have a CVAD inserted so we helped prepare the patient for the procedure and monitored him while the doctors inserted the device into a jugular vein. I held the patient’s hand, helped monitor him, and used therapeutic communication to keep the patient still and reassure the patient throughout the procedure.

I had to reflect on the day because while it was rough, I fought to have a valuable clinical experience, and I got it. It’s not often that students get to see a CVAD inserted and sutured to a patient. I wouldn’t have seen that if I left early, as my nurse seemed to encourage me to do. I also got to practice adjusting to different personalities. As a nurse, I’ll need to adapt and adjust to different conditions and personalities. My nurse kept saying multiple times throughout the day, “I am not your instructor”, but I took that in stride, accepted her feedback, adjusted, and performed more and more skills that day. I also learned I need to have more confidence in my own abilities.

My experience reminded me of a Winnie the Pooh quote from a book I’ve been reading my daughter “Pooh’s Grand Adventure”. Christopher Robin tells Pooh, “You’re braver than you believe, and stronger than you seem, and smarter than you think.” I have to remind myself of this. No growth is without challenges. I have to think that my difficult preceptorship experience just helped me to be stronger and forced me to reflect and be more confident in my abilities. Whether she wanted to teach me or not, I learned something.

One last thing my nurse told me before I left the floor. “Be kind when you’re preceptor. Always be kind”. Okay, I’ll remember that.