Challenges and joys.

square peg, round hole

Precepting new graduate nurses is challenging but also exhilarating. To guide a new nurse to a point of safe, confident, independent patient care requires a different level of critical thinking and relational skills. How do I delegate tasks and responsibility to my preceptee safely? How do I teach in a way that connects well with my preceptee’s learning style? How do I reassure the patient and family that they are safe in the care of these new hands under my watch?

Despite the challenges, it is inspiring to play an integral role in someone’s growth. I experience pride and joy watching my preceptees evolve from nervous trainees to skilled and compassionate novice nurses.

While I am always seeking to build up the new graduate nurse I’m precepting, the ultimate goal is always patient safety. There are rare times when new nurses have not not found the ‘right fit’ in our unit. We are a pediatric ICU unit in a level one trauma hospital. We care for very sick patients, are very fast-paced, and rarely have lulls in our census.

When a preceptee struggles.

I recently had a preceptee who struggled with the basics in caring for even our most stable patients. At the start of our shift, when we would go to the bedside to verify the proper medications were running at the ordered dosages and rates on the IV pumps, she would freeze and would not know how to find and verify this information. Despite practicing this over and over, with each new shift she would continue to freeze as though it were new information.

When the plans for our patients changed mid-shift, as they often did, she struggled to adapt, reprioritize, and perform her tasks without much hand-holding. I would repeatedly explain concepts, but with each shift she would posit questions as if she had never heard this information before. Because we seemed to get tied up repeating the same lessons each shift, she was falling further and further behind.

Hitting a wall.

As much as I tried to be gentle, encouraging, and honest in our debriefing at the end of our early shifts, and worked with our education manager to develop a plan for her growth, she simply could not move onto more independent practice with our most critically ill patients. We tried asking her to tell us what teaching methods might work more effectively, but nothing she suggested was helping her progress.

While she was humble and realistic about her struggles, often to the point of tears, she still could not overcome them, which began to add to her weight of discouragement. But she insisted on trying again and again. We tried giving her new preceptors, but the same patterns emerged. I appreciated and admired her tenacity, but it became clear after a few weeks that a different level of feedback was required. She was falling significantly behind and was not showing any signs of being able to move forward.

As I processed the issues with my manager, I began to realize that my responsibility was not only protecting patient safety as this new grad’s preceptor, but it was to gently, wisely, graciously precept this nurse out of our unit—all the while preserving her sense of self and vision for her career, and letting her know we were on her side. I knew I had done my best in trying to develop creative teaching methods for her. I felt I was patient, encouraging, and empathetic, and that I was also tough with her and pushed her to think independently as much as possible. But ultimately it was to no avail.

Facing the situation honestly is best for all.

Aside from my concern about her patients’ safety, I was worried at the injustice in continuing to encourage her to stay in a place where she could not succeed. We wanted to help her find a place where she could fit and thrive as a nurse, and also provide the safest and most competent care to her patients, wherever that might be.

Her place simply wasn’t in our unit, and I wanted her to know there was no shame in this. Through a number of painfully honest but gracious conversations on both sides, and with the collaboration of the other preceptors who also worked with her, she eventually reached the conclusion that this was in fact not the place for her.

If I’m honest, I would have loved to have been her “hero” as a preceptor, to have been the one who somehow figured out how to help overcome all her barriers so that she could stay and thrive in our unit.

But the precepting experience is not about the preceptor. It is and always will be primarily for the purpose of maximizing patient safety, which means helping preceptees to land and grow in the place where they can be the safest (and most fulfilled) nurses possible. This is our duty as nurses and as preceptors.