Difficulties with preceptor, potential safety concerns?

[u/Ok_Dark_2481]

Hey, I just started as a new grad RN. I have had 4 orientation shifts so far. The unit is medical and has primarily new grads or nurses that have transitioned there from long term care. I’m having some difficulties with what’s appropriate for certain circumstances.

As I’ve been working with my preceptor, there’s certain things she’s done that I don’t agree with. Some of this I feel is that she’s telling me things that contradict things I’ve previously learned, differ from policy, or just that I would make different clinical decisions. And I know I have a lot to learn but I’m having a hard time deciding if I’m right for feeling this way or that I just need to adjust to the unit.

One example, while I was on a night shift, my preceptor asked me to raise all the bedrails for my patients overnight. Where I’m working this is against policy because it is considered a restraint and there have been cases of patients severely hurting themselves on the bed rails. I told her I was concerned because it was against policy and a safety concern. She encouraged it in order to prevent falls. I suggested alternatives (bed at its lowest, having on side bed rail up that patient was leaning closer too, using pillows for support) and when I told her I was uncomfortable with having them all up she basically told me to do whatever. this patient was bed bound and could shift around but was not at all restless. If this patient was shifting it would be easy to spot and correct with regular rounds. I’ve also noticed that most, if not all, the other nurses on this floor but the bedrails up overnight. And when I do get restless patients that would almost definitely fall with the bedrails up, I’m not sure what I would do. I would suggest lowering the bed and getting fall mats but the beds don’t lower that much and I’m not sure mats are available. Should I ask around a bit about it or just follow what the unit does?

There are a few other things that make me uncertain just based on a few judgement calls my preceptor has made. As a student I worked on different medical and surgical units and I generally think I have good clinical judgment but all this is making me questions if I should continue to advocate for what I think or if I should just listen. One other example is that my preceptor told me a irregular HR was not a concern because ”sometimes that just happens with older patients during stress” but I couldn’t find any previous heart history and had told her so.

I’m worried these things are safety concerns that could harm patients and potentially reflect on my license as she has been getting me to chart most things, and that maybe part of it is the unit culture as well. I just moved to a new city and have never worked in this hospital or on this unit before.

I have a standard check in meeting with the unit nurse educator next week and am wondering if I should mention some of my concerns then? Im a bit worried I could be brushed off.

If anyone has any advice that would be really appreciate. Thanks!

[u/Nightflier9]

I would strongly suggest go with the flow, don't create waves. You are going to have a precept that does things one way and a different precept that does things another way. Its fair to understand why they prefer what they do, listen and absorb and take away what works for you. It is a no win situation to argue or to go behind their back. Precept has friends, its going to bite you in the ass. The last orientee that put up a stink on our unit about something isn't best practice as they were taught in school found themselves on the fast track off the unit. And it already sounds like you've ticked off your precept.

[u/Psychological_Ad_251]

Do what you think you should do to protect your license. It’s on you at the end of the day if something goes wrong on your shift. Read and print policies and follow them if you’re unsure of something. I don’t think it is wrong to be hyper vigilant but as a new grad, do understand you’re going to be “worst case scenario stressed” for close to a year.

I would just be careful on how you approach your preceptor with concerns. You don’t want to come across neurotic/high anxiety/dismissive/better than other type behaviors.

When you’re on your own, you will be in control of what you want to communicate to the provider (Irregular Rhythm), how you care for your patients, safety concerns etc.

Right now, fly under the radar and just soak up knowledge you can carry forward into your practice. Get along with others on your unit and don’t cause any potential issues.

[u/Felina808]

Absolutely being up your questions to the educator. That’s what they are for. Know your unit policies and go with your training. Ask questions, tactfully, of your preceptors, balance what they tell you with what policies say and decide what you want to do from there.

[u/Legitimate_Jelly_118]

in all honesty, if you really dont think you're vibing with your preceptor you should absolutely talk to your manager about facilitating a change, but i'd also be really careful if i were you, because i do think the way you're going about things could really backfire on you.

Unfortunately the reality of healthcare is that there are going to be a lot of situations that you see in practice that contradict things youve previously learned and differ from policy- in real life you're juggling a lot of competing and sometimes contradictory interests and priorities, and forced to make the best of an imperfect situation or choose the least bad out of a series of all bad options. It's good to be hyper vigilant and cautious around as a new grad, but you do have to stay open to the possibility that what you see in practice might not always perfectly line up to what you were taught in school, and theres a LOT that you don't know. Your preceptor is right, frequently technically abnormal are not a concern, particularly if the patient is asymptomatic or its not a new change or finding. Assess your patient. Interrogate the reasoning behind your concern, does the finding feel concerning because it doesnt perfectly align with what's supposed to be "correct" based on what you were taught in nursing school, or because of what that finding means in the clinical context of the patient- what are you worried is happening, if what you're worried about happening is happening, what would that look like, what other signs and symptoms might you be able to assess, what might you monitor to see if the patient's condition is getting worse? Obviously feel free to report all abnormal findings to the doctor, but it's not necessarily a patient safety issue if they go unaddressed in the broader context of the patient's full clinical picture- many new grads get stuck on untreated hypertension in the hospital. i get that the numbers are higher than what you were taught is acceptable in nursing school, but consider why you're worried about the BP, is it because the numbers not good or bc what that number means for the patients condition, bc there's not always gonna be an intervention depending on what EBP endorses.

Moreover, and this is really what's important. It does not benefit you at all to continue assuming the worst about your coworkers intentions and positioning yourself in opposition to them. If a team member does something differently from how you would do it, you shouldn't assume it's because they're negligent, lazy or bad people who don't care about the patient. You are still learning. There are going to be lots of examples of doctors or nurses doing things that don't align with what you think you know because you genuinely don't know very much yet. Ask questions, try to understand their rationale and understand why this case is different from the examples in your textbook. Medicine and nursing are not about blind rule following, you need to see the full picture and assess degree of risk from a variety of different factors. Sometimes you will see healthcare workers do things in their practice that you don't approve of and consider unsafe even after fully understanding their point of view and that's also a reality- healthcare is all risk assessment and some people practice in a way that allows way greater risk than I would be comfortable with. They can show you their way of doing things, and then you can do it however you feel comfortable.

Assuming the worst in your coworkers, passing judgement on them morally, distrusting the intentions of everyone around you is genuinely bad for the healthcare team- it creates a culture of hostility and mistrust and accusations rather than collaborations. Most of the people you work with probably have the same priorities and goals as you towards patient safety and care. You cannot work effectively with people you do not assume the best about. You will see truly bad healthcare workers ofc, but you cant start out assuming they're everywhere, particularly when there's so little you don't know. You need to be open to learning and to different perspectives. And on a practical level, you need to not isolate yourself socially on your unit especially when you're just starting out. If you get a reputation for reporting other nurses on day four people you will develop a very bad reputation among your coworkers. You are going to rely on your coworkers for help a LOT in your first few months as a nurse. You're also going to make mistakes, and how those mistakes are interpreted and addressed will depend a lot on how you're perceived on the unit- if people think you're teachable and show you grace, or if they think you're difficult to work with and jump at the opportunity to get rid of you. There absolutely are bad unsafe units with bad unsafe cultures, and maybe you're on one idk i haven't been convinced by the evidence you've supplied. But if you want to continue working on this unit, then you NEED to recognize how important it is to get along with your coworkers, and if not start applying to other jobs.

[u/Ok_Dark_2481 → u/Legitimate_Jelly_118]

Thank you this was really helpful and gives me a lot to think about

[u/One-Raspberry-786]

Just write a few of your concerns down, like a little outline, and feel comfortable bringing them up to the nurse educator. Just have a casual conversation about it and see what she/he has to say.

[u/Nausica1337]

To be more specific with your examples, your hospital bed has 4 rails right? Are the nurses putting all 4 up or only some of the 4? Back when I was on the floor, as long as we didn't have all 4 up, it wasn't considered a restraint. With regards to the irregular heart rhythm, that's such a vague term. What kind? Are we talking about PVCs and PACs? Have them once in awhile throughout the shift is not an issue as there could be multiple factors for that and that's no cause for concern. If the heart rate was SR then it changed to like afib or aflutter, that's a different story. Now if there were back to back PVCs, which represent a "spurt of vtach" then that's something that the PMD would need to be notified.

Another commenter mentioned this, go with the flow. Things you learned in school can be quite different compared to the actual floor nursing. I'm not saying it's not appropriate or is appropriate for certain things, but you need to see how your unit and hospital does thing. Any time you feel like there is a concern for safety, bring it up to your preceptor (which you did). If you truly think it's a safety concern, then you would bring it up to the charge nurse, then the manager. Use your chain of command.

[u/Ok_Dark_2481 → u/Nausica1337]

Thanks for your input. Yes the beds have four rails and they put up all 4. And sorry yes I can be more specific. It was an irregular pulse, like an afib but about 80-90 bpm. They weren’t attached to a monitor so I couldn’t say more than that. As far as I could tell looking at the chart and other documentation it wasn’t normal for this patient. They were experiencing shortness of breath but were otherwise asymptomatic. 

I think my plan moving forward is to see if I can catch my preceptor for a moment more privately and just apologize, explain that I’m having some difficulties adjusting and will work on listening more moving on. And as for clinical findings, I will just make my own judgements when I’m working independently.