As the temperatures start to cool off and the kiddos all go back to school, the season for freshly graduated nurses starting out their careers has also commenced. You guys have worked WICKED HARD for YEARS at this point and you deserve a huge congrats!! You should be so proud of yourselves and know that you have chosen a career that will fulfill you entirely yet also challenge you beyond anything you ever thought you’d be a part of. I hate to tell you, but nursing school wasn’t the hardest part.
The next year or so you will be extremely uncomfortable and feel like you learned absolutely nothing during your obtainment of a college degree. THIS IS NORMAL!! I promise you, you know so much more than it feels like. No matter what, this first year of employment will be challenging, however, you will also learn so much more than you ever did in college and will lay the foundation for the type of nurse you want to be for the rest of your career.
When I say the “type” of nurse you want to be, I don’t mean OB or med/surg or cath lab or emergency…I mean more important things like compassionate, empathetic, loving, knowledgeable, etc. I want to tell you something that nobody told me at the start of my career until it was almost too late: it will be incredibly easy to become jaded. It’s even the accepted culture in many departments, specifically the ER for me. It is almost a celebrated mindset to roll your eyes and be annoyed when something you deem unworthy of your time, effort and space comes through the doors of your department.
Negativity has a way of swirling around the room like a cloud of smoke and overcoming everyone in its path. DON’T LET IT. I want you to realize that being jaded is a CHOICE. You control how you respond to every single situation going on in your life, including your career. You choose to be jaded and that feeling of being jaded is ON YOU. It took being YELLED at in front of my coworkers by my favorite charge nurse who I respect beyond measure to snap me out of my fog. I cried hysterically behind closed doors after she put me in my place, not because she was being mean and my feelings were hurt, but because she was 100% RIGHT and I was so ashamed of myself and what I’d let myself become. I still think about that night all the time and how incredibly grateful I am for her and the lesson she made me understand. If you’re jaded, you LET yourself be jaded. Don’t.
With the help of some of the most amazing nurses I have been privileged enough to work with, this post includes tons of incredible tips and guidance to help you start out your career ahead of the game. From keeping your head right when dealing with crap situations to knowing a seldom mentioned but WTF-just-happened side effect of a certain drug, you’ll be one step closer to becoming the best nurse possible! So sit back, turn on some Red Hot Chili Peppers and take a second to absorb some words of wisdom from a group of nurses who know a thing or two.
“Otherside”
Welcome to Orientation
First things first, feeling like you spent the last 2 years learning absolutely nothing and you are an idiot and will never be able to figure this nursing thing out on day 1 of your orientation is SO NORMAL. I promise you with everything I have, EVERYONE feels like this at first [and if someone doesn’t, they’re probably going to be the one to not ask questions and seriously hurt their patient].
Remember why you wanted to be a nurse in the first place. Write it down and put it somewhere you will see it often. There will always be bad days and sometimes there will be really, REALLY bad days; remember your WHY and you will be able to bounce back so much faster.
Introduce yourself to everyone and make an effort to befriend your coworkers. There is nothing like having amazing nurse friends to share stories and heartbreak with throughout your career. Plus, it’s fun having someone to send all those hilarious health-care related memes to.
Listen to your preceptor and be open to learning. The first year after nursing school takes a ton of effort and will include so much more learning than you realize. People notice IMMEDIATELY if you are not willing to take every single opportunity to learn and, spoiler alert, THEY DON’T LIKE IT!! Starting out acting like you know everything already will earn you even less points.
Find a mentor! This doesn’t have to be your preceptor necessarily, but even better if it is. Find someone who can be a friend, sounding board, cheerleader and advice-giver.
Find your nurse idol that you want to spend your career trying to emulate. This is the nurse that you want to be when you “grow up”. Pay close attention to what draws you to her and mimic those traits until it becomes second nature to your own behavior at work. One day you will get to be that person to another baby nurse.
Engage with other new grads during your residency! Create meet-up groups to discuss things you’ve learned, what you’re struggling with or what you’re killing it at. Or just meet up and drink, whatever works.
Above all else, know your resources!! You are never, ever going to know everything [although it may seem like some senior nurses are pretty dang close], but you CAN know where to find the information you are lacking. Also know who you can reliably ask questions to who will steer you in the right direction!
If there is a procedure you can watch, WATCH IT. If there is a procedure you can do, DO IT. If someone asks you to place a Foley catheter with them, go with and learn from them. Even if you have started 10 IVs already, go watch someone who has started 1000 and ask for their best pointers. Put in the effort and it will be rewarded!
Realize quickly that the real world is NOT like nursing school or your skills check offs. Things aren’t always going to be exactly by the book, but they HAVE to be done with the patient’s best interest in mind. There is a difference between cutting corners and working smarter, not harder. ED nurses are notorious for this mindset, but here’s a cold, hard, evidence-based [get ready to hear that term all the time] FACT: If it’s suppose to be a sterile procedure, you better do your damnedest to keep it sterile. It’s not the “ER way” or any other way for that matter to put your patient at risk for the sake of your convenience. And if I ever see you use the same IV needle for multiple sticks, hand to God, I will roundhouse that thing out of your hand. [Thank you for coming to my TED talk.]
Always ask questions about everything, especially medications! Know what you’re giving and why before you ever go into the patients room. Feel free to write things down and take them into the room with you. I did this all the time when I first started so I wouldn’t look dumb in front of my patients. Fake it in the sense that you want your patients to be confident in you. Don’t ever actually fake it and just hope something will work out; ASK QUESTIONS. You can kill someone with your screw up and although that is super intimidating to acknowledge, it’s true. Know what you’re doing or don’t do it. Simple as that.
Take criticism and corrections with grace and leave your ego at the door. Most nurses are not trying to make you feel stupid or hurt your feelings by telling you that you’re doing something wrong or that there’s a better way to do it. They just understanding the magnitude of how important your job is and how dangerous you could be without proper training and direction! If you’re not teachable, you’re not going to be very successful at anything in life.
When your orientation period ends and you are released on your own, you will be terrified all over again. This is totally normal!! Embrace the chaos and keep asking questions long after your orientation has concluded.
“By the Way”
Things You Might Want to Know
Be proactive and start immediately keeping close track of your certifications and continuing education hours. Keep it all organized in a folder so it’s easily accessible and you won’t have to scramble when things come due.
Don’t be afraid to talk to doctors; they’re just people! Once you take them off the pedestal of being an intimidating source of power, you can use them as the wealth of knowledge they are. I ask doctors SO MANY questions every single day at work; what about these labs makes you think the diagnosis is ___? Why are you doing this test instead of this test? Why are you giving X medication instead of Y medication? If it’s a doctor I don’t know well or who doesn’t know me well, I always start out by saying “I’m not questioning your decision, but I’d love to learn more about this. *Insert question here*” It makes it obvious you aren’t challenging them; you’re trying to learn from them.
On the other hand, make sure you have all the information related to why you’re calling prior to calling a physician. Make sure you know the most recent vital signs, lab values, medications given, etc. prior to calling. Some doctors get pissy on the phone because they are so busy and want you to utilize their time well. You can do this by knowing your stuff and being prepared.
On yet another hand, there is NO EXCUSE for a doctor to shout at you, belittle you or intimidate you. It is no longer something that is tolerated in work culture and it is never, ever okay!! Have thick skin, but don’t tolerate work-place bullying.
In the same thread, violence against healthcare workers is a very real and very scary thing. I have personally been punched, pushed, slapped, cussed out, threatened, groped, propositioned, insulted, scratched, spit at, body slammed against a door and had my neck lunged at to choke me…twice. This is not to be tolerated and should 100% be reported!! FILE LEGAL CHARGES!!!
Don’t let anyone make you feel like you’re being dramatic or causing problems by taking legal action against anyone and everyone who lays their hands on you during your career. We need to be heard and protected so that this mindset that it’s okay for patients to act this way towards us will END. We have a right to work in a safe and respectful environment regardless of how sick or in pain or scared or WHATEVER another human being is. We are not punching bags!
Trust your gut!! If something feels wrong, it probably is. The more time you have under your belt, the better your nursing “Spidey senses” will be able to hone in on dangerous or volatile situations. If a medication seems wrong or doesn’t make sense, ask questions until you fully understand the who, what, when, where and WHY of what you’re doing/administering/etc.! If a patient or family member makes you uncomfortable, take security or a coworker with you when you go see them.
Learn how to prioritize early on in your career! Start with your ABC assessment (airway, breathing, circulation) to determine what you need to do first and then go from there. You will often find yourself needing to ask for help and this is absolutely okay! Delegate when you need to and do it yourself when you can.
On the other hand, don’t over-delegate. Your CNA/tech can be your greatest asset!! Be warned: they will go out of their way to NOT help you if you are disrespectful of them and their time. Make friends with your CNAs and do the “dirty jobs” yourself when you can; you are just as capable of wiping a poopy butt as they are. Save their help for when you really need it!
Don’t break HIPPA!! It’s easier to do than you realize! When talking to someone on the phone, know what you’re allowed to tell them and what you aren’t. GET PERMISSION from the patient verbally before telling anyone anything. Be extra cautious of telling anyone on the phone anything even if they claim to be the POA [power of attorney]. You can’t verify who they are via telephone. If the patient is verbal, just transfer the call to a phone you can take to the patient and avoid the situation all together. If the media calls about a patient, know who to direct their call to and TELL THEM NOTHING. Know what you’re allowed to say when a patient is unable to give their permission; know what you’re allowed to post on social media [but be safe and just don’t post anything]. This is so important and a MAJOR fire-able offense.
Know what is and isn’t in your nursing scope of practice and realize what nurses are allowed to do can differ from facility to facility. For example, I wasn’t allowed to draw ABGs at my last hospital but I have been at every other place I’ve worked; similarly, I’ve been allowed to start EJs [IVs in the neck] at most facilities I’ve worked, but not the one I’m currently at. It’s always different and you want to make sure you aren’t breaking rules without even knowing.
Spend time and really listen to your patients; they often confide in you what they won’t to others. The nursing staff really does make or break a patient’s experience so showing your truly care about them is paramount. I recommend always sitting down to talk to them. This accomplishes several things: you get to take a load off for a second which is amazing when you’re swamped; it brings you closer to eye level with the patient which puts them at ease; it shows you have time for them and makes them feel heard and, overall, well cared for.
Don’t plan on leaving work on time most days; it does occasionally happen but just don’t plan on it and you won’t be disappointed.
Get all the certifications and education you can!! It will only improve your skills [both clinical and assessment] and increase your confidence! Plus it may help you find what niche of nursing truly lights your soul on fire and will, in turn, guide you towards the next chapter of your nursing journey. Never, ever stop learning!
You won’t like everyone you work with but let everyone be a source of learning/growing. If they’re the dumbest most incompetent nurse you’ve ever been forced to share oxygen with, let it teach you exactly what you don’t want to emulate in your professional life.
Respect your elders- they may be slower or complain incessantly about the charting system, but they are a wealth of knowledge in their own right; let them teach you a thing or two.
Time management takes time and practice; it will come. Acknowledge your mistakes and short-comings and then don’t repeat them. You won’t be perfect overnight [or ever, really…], but improvements will come in leaps and bounds in those first few years and you will be amazed to look back and see how far you’ve come.
Be a team player always! Offer to help out when you can and be willing to jump into the crap nobody else wants to do. We all have to take our turns taking care of the awful drunk frequent flyer that screams at everyone so just bite the bullet every once in a while and volunteer for it. We’re all in this together and knowing your team has your back is invaluable.
Be a patient advocate always always ALWAYS! Question orders that don’t make sense and make suggestions if you feel the patient isn’t getting everything they need to be best taken care of. There’s a reason why nursing is the #1 most trusted profession year after year!
This is sadly one of the most important things I can tell you: CHART LIKE YOU ARE ON A WITNESS STAND IN A HIGH PROFILE COURTROOM. If you don’t chart it, it didn’t happen! Make sure you paint a clear picture of what is happening with your patient at all times; absolutely chart that you got them a blanket, made up their bed and got them water. This is all important and you should get “credit” for this! Just don’t forget to also chart what they looked like when you were doing all these things for them [“Patient breathing non labored, skin warm and dry; alert and oriented in position of optimal comfort; call light in reach; no additional needs at this time.” — this is my go-to line in charting because it sums up my ABCs and shows the safety of my patient.] COVER YOUR ASS because if you think for one second that your hospital appointed lawyer has your best interest in mind and not the HOSPITAL’S best interest in mind, you’re kidding yourself.
“Dark Necessities”
Keeping Your Mind Right
Make it a priority to take time for yourself, especially when you need to decompress after a stressful situation. I remember being bothered by random things that no one warned me about when I first started nursing. I remember doing traumatic wound care on a patient and looking down to see blood all over my [gloved] hands; it just blew my mind that someone else’s life force was literally on my hands and it gave me pause to realize how massively important and real my job was. I’ll never forget that moment. I’ll never forget my first time doing CPR. I’ll never forget my first pediatric death. I had to find a healthy way to channel those emotions to help myself grow instead of suffocate under the weight of them; find your own method and stick to it.
Figure out a way to decompress after a code; cry in the break room for a minute, journal about it, talk to coworkers, listen to music loudly, dance, run, exercise, WHATEVER. After each code I am the primary for or even the ones I’m not if it effected me more than usual, I “talk” to that patient on my drive home. I OUT LOUD tell them that I hoped I did everything I could for them and served them well; I ask for forgiveness if I feel I didn’t do my best and I ask my equivalent of God to watch over their family/friends as they grieve. It helps me process and it helps me remember that this was a PERSON, not just another patient.
It’s okay to cry in front of a patient and their family when the situation is appropriate. It is not okay to break down to a point where you are taking attention, resources and focus off the patient and their family.
Find your work/life balance! I don’t care what your manager tells you, YOU DO NOT HAVE TO WORK ANYTHING PAST YOUR WORK DESCRIPTION HOURS. If you want to pick up overtime, awesome! If you’re burned out and need a break and only want to work your normal shifts, you’re 100% allowed to do this too! An exhausted nurse is not often a very good nurse.
Everyone reacts differently to death, trauma, blood/gore, pediatric emergencies, cancer patients, etc. We all have our own heartbreak and demons outside the walls of our work place so talk to your coworkers and know when to step up and help out [for example, if you have a coworker who lost a pregnancy recently, try to step up and take the 15 week pregnant vaginal bleed walking in the doors].
TAKE YOUR BREAKS!!!!! You’re not a hero for not eating lunch for the 13th shift in a row. Take your FULL break and get off the floor for awhile. There are so many studies that show the benefits of this!! Your coworkers can cover for you during this time and, let’s be honest, your patients will likely not even know you were gone. There’s no bonus points for being a martyr.
Wash your hands and clean your stethoscope and name badge CONSTANTLY. You will get so sick your first couple years of nursing while your immune system plays catch up! Don’t take your shoes home and change out of your scrubs as soon as you can! I have a lot of coworkers who take them off in the garage before going inside. It sounds weird but until you have the smell of a maggot infested wound stuck in the fibers of your clothing for 12 hours, you won’t understand the magnitude of it.
“Dosed”
Secrets of Common Drugs
Ativan is THICK, ya’ll. You’ll only try to give it IM through a 25G needle once!
Administer IM shots SLOWLY and hold the needle in place for a full 5 seconds prior to removing it. Also, ANCHOR the injection site really well to avoid unnecessary pain; I now give shots of everything [including Toradol which burns!] and am frequently told it was nearly pain-free. Your IM skills are super important!
Compazine can cause dystonic reactions that mimic Parkinson Disease or a stroke. It can also make a patient super agitated and want to rip out their IV and leave immediately even if they were perfectly calm before. Give it slowly and with Benadryl to avoid this! It is TERRIFYING if you don’t know this can happen.
Zofran isn’t without side effects. Too much of it can cause a prolonged QT, especially in children. I was literally in year FIVE of my career before someone told me this…
A lot of meds don’t mix with Lactated Ringer’s solution; double check before giving any IV pushes in it!
Vancomycin can cause “Red Man Syndrome” in some patients; their faces will turn bright red and a rash will form on their neck, face and upper torso. They sometimes also feel itchy and like their skin is burning. This doesn’t mean they can’t have the rest of the Vanco! Slow the infusion rate, tell the doctor, give Benadryl IV and keep monitoring the patient closely. They usually can tolerate the rest and will just be pre-medicated with Benadryl before their next infusion in the future.
Giving IV Dilaudid too fast can cause The Exorcist level projectile vomiting.
Giving IV Benadryl too fast can cause the patient’s vision to go black for a few seconds. This is obviously TERRIFYING for them!
Giving IV Decadron too fast weirdly causes a severe burning sensation to the butt/vagina and can also make the scalp feel like pins are sticking into it.
Giving IV contrast causes a warming sensation in the groin and up the back which, when laying flat, feels a lot like the patient just peed their pants.
Giving IV Lasix too fast can cause tinnitis.
Pay attention to how long you are suppose to push different medications over! They exist for a reason.
When administering IV Phenergan, MAKE SURE your IV is solid and NOT in a hand. If this stuff infiltrates, you’re going to have some big problems. If you’re giving it IM, make sure it is DEEP IM!
D-50 given through an IV can easily blow a vein; give it slowwww.
Don’t give Valium diluted in anything–it precipitates out too quickly and they don’t get any of the effects of the drug. Push it straight.
Get to know and love Ketamine! Make sure you warn anyone at the bedside that when the patient wakes up, they will act super weird. Kids often look around with blank expressions or they shout/wimper or hallucinate. Children and adults alike both twitch while they are sedated which can sometimes resemble a seizure but is NOT. The best way to bring someone out of a Ketamine sedation is with minimal stimulation in a quiet area with the lights dimmed. They tend to have a more gentle come-around this way.
Consider giving Narcan during a code; it isn’t part of the ACLS protocol but it won’t hurt anything.
“Sick Love”
Clinical Tid Bits
If your patient is super nauseated and you don’t have an order for any medication yet, have them sniff an alcohol pad.
Don’t forget to use Poison Control as a resource for overdoses including alcohol intoxication if you want! They can also be used for chemical exposures even when they aren’t ingested.
Febrile seizures can happen at any elevated temperature, not just extremely high ones. The seizure is brought on by how fast the temperature rises, not how high it gets.
Listen to YouTube videos to learn your lung sounds really well!
Subject every single person/child/etc. in your life to letting you palpate for their vein where you would likely start an IV. Also feel your own veins with the SAME finger as you would when starting an IV on a patient. Eventually you will train your finger to feel for a vein because, as you will soon learn, finding veins is all about palpating and barely about visualizing them.
Don’t ever let me catch you ripping the finger off your glove to start an IV or starting an IV on a baby without gloves. It’s NOT best practice, it’s dirty and you’re putting every single patient you do this to at risk. Learn how to palpate through your glove [pro tip: wear tighter gloves when you start IVs].
Always take an extra set of hands with you for Foley insertions and NG tube placements. The time you don’t is the time you will need it the most.
Always check a blood sugar ASAP when a patient presents with stroke-like symptoms. Hypoglycemia imitates strokes.
ALWAYS ALWAYS ALWAYS continue compressions while your Life Pack is charging!!! As soon as the shock is delivered, START COMPRESSIONS AGAIN IMMEDIATELY!!
Realize that most codes do not have happy endings and elderly people who get put on ventilators often don’t ever come off of them. Don’t be surprised to see seasoned staff less than happy that they “got them back” because they fully understand that there are much worse things than death and quality of life means a million times more than a palpable pulse.
Have INTEGRITY!! This is the drive to do the right thing even when no one else is watching. Own up to mistakes you make when no one sees if they could potentially harm a patient. Get a new piece of equipment if you drop it. Don’t reuse IV needles for multiple sticks. Maintain sterility if the procedure should be sterile. Get a new Foley catheter if you miss the urethra the first time.
Check your patient’s allergies ASAP! This is such an easy way to avoid a potentially serious medical mistake.
Never discredit a middle-age woman saying “I just don’t feel right.” STEMI patients this age/gender present with very mild, vague symptoms!
If you attempt to place a catheter on a female patient and are unsuccessful, leave the first catheter in place while you insert the new catheter so you know where NOT to go.
Put a U-bag on kiddos BEFORE they are stuck for labs; 9 times out of 10 they urinate when they get poked.
You guys chose a seriously AMAZING career path and I’m so excited for you to get started!! Learn everything you can and make it your mission to spread as much good into the world as possible. It sounds so cliche but being a nurse is a privilege–you get to be in someone’s life during their most vulnerable moments and be trusted to take care of them. In no other profession will a panicked young mom run up to you and thrust her limp baby into your arms. In no other profession will you start an IV and give medication that stops a child’s first seizure and then 5 minutes later be the only kind face a schizophrenic man has looked at in weeks.
You will see all kinds of kinds and experience the full spectrum of human emotion. You will cry with patients when they get diagnosed with cancer; you’ll laugh with patients when something awkward happens to them that they need you to fix; you’ll celebrate with patients when the tPA works and their speech returns. It’s going to be a beautiful, messy, traumatic, fulfilling ride and, baby, you’re going to love it.
<3 New Travels
**Special thanks for contributing content to: Blair, Alyssa, Carrie, Natasha, Nikki, Crystal, Cherish, Amanda, Corinne, Olivia, & Cameron