Advanced Precepting, Part II

In my last post, I promised to tell the story of another preceptee who didn’t remain in the PICU after orientation.

A new grad, this preceptee showed lots of promise. She was smart, detail oriented, and learned quickly. She was also independent. So independent, that fresh out of school, she would assess her patient, decide what was needed, and call the intensivist for orders without discussing anything with her preceptor first. Sometimes, she was right. Sometimes, she focused on a symptom without looking at the larger picture of the patient’s overall status. And that would lead to another phone call  to the intensivist, in which the preceptor had to explain why the previous order needed revision. You can imagine how well that went over, when it became a pattern. Her tendency to act without notifying her preceptor also precluded the opportunity to group questions for the intensivist, and asking the other nurses on the shift if they needed to call with questions too. In our unit, we worked effectively with the intensivists by grouping questions together as often as possible, facilitating work flow between medicine and nursing. In return, the physicians agreed not to call with new orders or questions during change of shift report, unless it was necessary. Suddenly, nursing wasn’t holding up its end of the bargain.

Because I was a mentor in our unit, my colleagues came to me with their complaints about this preceptee. Her behavior was interpreted as contrary to a team approach, and it was. I had trouble getting nurses to precept her. She was aware of the growing hostility of the other nurses towards her, and in turn, became withdrawn, acting out with more Lone Ranger behavior and creating a vicious circle for herself.  She tried, really she did, but it was difficult for her. She was intelligent and competent enough, but her inability to work with a team hindered her success.

The difference between  problems and  dilemmas is:  problems have a resolution; dilemmas are ongoing and unresolvable. I was beginning to think I had a dilemma on my hands.

I took over her orientation. Each shift I outlined what our goals were, and reinforced the expectation I be notified before every phone call to the intensivist. If I was in the bathroom, momentarily unavailable, and she thought there was an emergency, she was to notify the charge nurse first.  It was difficult for her, but she tried. Conversely, I included her in every discussion I had with the intensivist, explained the rationale for changes in the care plan, and took lunch breaks with her. I reinforced I respected her as a colleague and friend. She needed to trust me too. It didn’t take long before I saw improvement.

Shortly after that, she came to me requesting a letter of recommendation. She was applying for an advanced practice nursing program. Completing the program would give her a position of autonomy I believe suited her. I wrote the letter. She was accepted into the program. I don’t know what became of her, but I respect her for following her heart.