We all sat around in my living room, friends in the fight against those nursing school teachers who seemed hell-bent on making our lives miserable. There were about ten of us crammed into my small living room for this Saturday study group, and I was the de facto leader. I didn’t need to be there. I didn’t need much more than to glance through the notes to get good grades, but I wanted to help these on-the-bubble students pass. I taught what I knew. Everyone wanted to study with me because, well, test scores speak for themselves in nursing school.
Yes, I was one of those, and I always have been. Give me a book, and I can ace a test. It isn’t really genius. It’s just that I know how to take a test. Of course, I was immensely proud of my 4.0. I didn’t lord it over people, but I did feel rather smug I guess, rather superior. I felt this meant the nursing world was my oyster. I was cocky that I would breeze through orientation, but I certainly didn’t feel I knew it all. I also didn’t put my fellow students down. In fact, I enjoyed helping them, fighting the good fight to get them to pass.
One day, my teacher said something that made the bottom drop out of my stomach: “The best nurses are usually those in the middle of the pack. Those who score high tend to not do so well.”
Was she talking to me? She said it to the class, but was she talking to me?
Maybe I was paranoid, but it turns out that there was a kernel of truth in what she said.
When I interviewed out of nursing school, no one cared that I graduated at the top of my class, although I told them repeatedly. They were more interested in how I would handle a crisis and what sort of person I was and whether or not I would fit in with this culture. Despite my obvious hubris, I am actually someone who can work well with others, can care for patients, and can be a part of the team. The only thing is that my work in school didn’t matter a damn to them.
What really opened my eyes was orientation. I was lost. Everything I had learned was so much chaff. It came into play from time to time, but it really and truly did not matter.
I remember the first time I had four patients. It was a juggling act. The fact that I knew all the bones of the hand by heart was completely irrelevant. I needed to look at vital signs and know what they meant. I needed to know when to pass meds and when to chart. Most importantly, I needed to know when I didn’t know something, and I needed to ask for help.
Fortunately, questions have never been a problem for me, and I was able to become a safe nurse because of that. This 4.0 student spent more time with her preceptor or charge nurse than she did with her patients in the first year of nursing.
And still, all that book learning I had was merely peripheral. Sometimes, it came into play. I would know obscure things about electrolyte imbalances, for instance. I was also considered one of the go-to nurses with problems in my later years.
But my knowledge is not what makes me a good nurse.
I found that my personal sense of patient safety was the most important. My ability to handle more and more stress became the calling card of my practice. My life was about looking at a situation and making a decision. Do I call a doctor about this, or do I have the means to fix it myself? Do I delegate this responsibility, or do I do it myself? Should I ask for help, or do I know enough?
My mentors—my preceptor, my manager, the various charge nurses, and the more experienced nurses—made me into a nurse. It wasn’t that huge book I lugged around for so many years. It takes a village to raise a nurse. Not a textbook.
These are skills that are not measured by GPA. These are skills that I have but don’t come as easily to me as multiple-choice questions. The point is that if you are a 2.5 student, don’t worry. Your ability to pass tests and get good grades has nothing to do with real world nursing. Trust me. I’ve been there. I am a good nurse. I worked hard to become one, but it didn’t have anything to do with what I did in school. It was about a fabulous preceptor, a supportive group of experienced nurses, and hard work on my part.
Not graduating at the top of your class? You may just be the best nurse yet. If you are someone who can manage your time well, you will make a good nurse. If you are someone who can stare down a stressful situation and make decisions, you will be a good nurse.
Most importantly, if you can and will ask questions when you don’t know the answers—and accept that you know very few of the answers—you will be well on your way to becoming a fantastic nurse. If you just eked by in nursing school, don’t let it bother you. Take it from someone who has been there: It doesn’t matter at all.
One of the most commonly heard phrases right from day one of nursing school is “critical thinking.” The common consensus is that everyone has to develop sound critical thinking in order to be a safe and effective, registered nurse (RN). This necessity is magnified when it comes to critical care areas where one decision by the RN can change the patient’s outcome. Nursing has changed from a simple caregiving job to a complex and highly responsible profession. Hence, the role of nurses has changed from being task-oriented to a team-based, patient-centered approach with an emphasis on positive outcomes. Strong critical thinking skills will have the greatest impact on patient outcomes.
So, what is critical thinking and how do we develop this? A precise definition was proposed in a statement by Michael Scriven and Richard Paul at the Eighth Annual International Conference on Critical Thinking and Education Reform during the summer of 1987. “Critical thinking is the intellectually disciplined process of actively and skillfully conceptualizing, applying, analyzing, synthesizing, and/or evaluating information gathered from, or generated by, observation, experience, reflection, reasoning, or communication, as a guide to belief and action. In its exemplary form, it is based on universal intellectual values that transcend subject matter divisions: clarity, accuracy, precision, consistency, relevance, sound evidence, good reasons, depth, breadth, and fairness,” reads the document.
Simply put, critical thinking in nursing is a purposeful, logical process which results in powerful patient outcomes. “Critical thinking involves interpretation and analysis of the problem, reasoning to find a solution, applying, and finally evaluation of the outcomes,” according to a 2010 study published in the Journal of Nursing Education. This definition essentially covers the nursing process and reiterates that critical thinking builds upon a solid foundation of sound clinical knowledge. Critical thinking is the result of a combination of innate curiosity; a strong foundation of theoretical knowledge of human anatomy and physiology, disease processes, and normal and abnormal lab values; and an orientation for thinking on your feet. Combining this with a strong passion for patient care will produce positive patient outcomes. The critical thinking nurse has an open mind and draws heavily upon evidence-based research and past clinical experiences to solve patient problems.
How does one develop critical thinking skills? A good start is to develop an inquisitive mind, which leads to questioning, and a quest for knowledge and understanding of the complex nature of the human body and its functioning. A vital step in developing critical thinking for new nurses is to learn from those with a strong base of practical experience in the form of preceptors/colleagues. An open-minded nurse can learn valuable lessons from others’ critical thinking ability and will be able to practice for the good of their patients.
Critical thinking is self-guided and self-disciplined. Nursing interventions can be reasonably explained through evidence-based research studies and work experience. A strong sense of focus and discipline is also important for critical thinking to work. If thinking is unchecked, nurses can be easily misguided and deliver flawed patient care. A constant comparison of practice with best practices in the industry will help guide a nurse to think critically and improve care. This makes it easier to form habits which continue to have a positive impact on patients and colleagues. Every decision a critical thinking nurse makes affects not only the patient but also his or her families, coworkers, and self.
In summary, the take-home message for nurses is that critical thinking alone can’t ensure great patient care. A combination of open-mindedness, a solid foundational knowledge of disease processes, and continuous learning, coupled with a compassionate heart and great clinical preceptors, can ensure that every new nurse will be a critical thinker positively affecting outcomes at the bedside.
Here come brand-new nurses with their brand-new scrubs, clipboards, nursing shoes, and stethoscopes, eager to start the adventure as a nurse in the real world of nursing. Securing the very first job as a registered nurse is one of the most exciting—but also terrifying—events that any new graduate nurse experiences. No more simulation labs and clinicals, but real lives (and your license) are at stake. A recent report suggests that nearly 30% of new graduate nurses leave their job within the first year. You had been asking yourself if you would survive the nursing school. Now, you have to ask yourself this question: Am I going to survive the first year as a nurse? Here are some real-life tips from one new graduate nurse who just survived the first year working as a bedside nurse to another.
Cherish Your Orientation Period
New graduate nurse residency programs, such as Transition to Practice programs, are excellent opportunities to receive extended orientation periods, labs, and classes. It is true that often you may feel like you are back in school again with extended orientation time. However, it is critical for new graduate nurses to take this opportunity to learn, practice, and experience as much as they can during this period because once the orientation is over, you will be on your own without preceptors to back you up. After the first couple of shifts on your own, you may miss the orientation days.
When in Doubt, Ask!
The biggest mistake that a new graduate nurse can make is to assume things. “There is no such thing as a stupid question. We are not worried about new nurses asking endless questions regardless of the content, but we will be worried if a new graduate nurse has no questions,” says Jo Burney, who has more than 20 years of bedside nursing experience and frequently mentors and precepts new graduate nurses. Asking questions doesn’t make you look like an incompetent nurse at all. Providing inadequate, or unsafe, care because you weren’t sure what to do but didn’t ask questions about it will make you not only incompetent but also a reckless nurse.
Find Out the Good, the Bad, and the Ugly
Nurses are only human. There are experienced nurses who are excellent teachers and mentors to new nurses professionally and personally. However, there are also experienced nurses who have nothing to offer to you, meaning that they don’t want to teach you and you probably don’t want to learn anything from them either. New graduate nurses should be able spot these different types of nurses. If you haven’t figured it out on your own, ask your preceptor at the end of your orientation for a list of nurses who can be great resources around the unit.
Nursing school may be over, but the education continues. It is highly encouraged to study about the specialty of nursing that you are in, such as the common patient populations, diagnoses, medications, pathophysiologies, protocols, and policies. You may even consider opening the textbook that you said you would never open again after nursing school is over! Do so when you have downtime at work if you can’t make time outside of your work. Having the knowledge behind the nursing tasks you do will increase your ability to critically think and analyze the cases.
Be Personable, but Stay Away From the Drama
You don’t have to be best friends with your coworkers, but it doesn’t hurt to leave a good impression and to get along with them. Introduce yourself to the other nurses and nursing assistants and remember their names. Smile and greet! Simple and small courteous actions will make a difference. If it seems appropriate, you can also share personal things such as family and pets. You want to treat each nurse as an individual rather than just another nurse who happens to be working the same shift as you. However, never gossip or badmouth other nurses even if everyone else is talking and gossiping about a certain person in front of you.
It’s All About Listening
Listen to your patients and their family members. Listen to other nurses, nursing assistants, secretaries, providers, social workers, and other interdisciplinary team members. You can always learn something from anybody, whether it is how to transfer phone calls or how to program an IV pump, as long as you keep your ears and minds wide open for all the million things that you have to remember as a new graduate nurse.
The first year as a new graduate nurse will pass in the blink of an eye, and you will become a novice nurse who is somewhat comfortable but is still a little nervous with unfamiliar cases and emergent situations. You will be so very proud with that one year of bedside nursing experience under your belt, but the journey to become an experienced nurse will always continue.
There have always been challenges facing nursing students. What are the biggest ones today, and how can students deal with and overcome them? Some experts weigh in.
Frederick Richardson, a BSN student and the Breakthrough to Nursing director for the National Student Nurses’ Association, had no doubt about how much of his time would be taken up when he began attending nursing school. Yet, he says, this seems to be one of the toughest aspects of attending nursing school that students struggle with.
“One of the biggest issues that nursing students face is time—making time for everything,” explains Richardson. “Nursing school is very demanding, and when you add in the coursework, reading for homework, and the clinical work, there usually isn’t time for anything else.”
Richardson says that he was fortunate enough to learn about this before choosing to attend nursing school. His older brother had attended nursing school, and Richardson saw firsthand how often he didn’t see his brother during that time. “He would be at the library studying, at class, or at clinicals,” recalls Richardson. “When I’d see him, it would be late at night. And he would be out of the door first thing in the morning. At the time, I recognized that when I would get to nursing school, I would probably have a similar schedule, and sure enough, it’s been exactly the same way.”
To overcome this, Richardson says that students need to have perspective and be realistic regarding what they can accomplish in their lives while attending such vigorous programs. “Our schedules can get really hectic. But I think that when you get into nursing school, you have to recognize that you’re going to devote the majority of your time to your nursing program. A lot of students don’t realize that,” he says.
Students need to set their priorities straight and decide how they are going to organize their time. Richardson, for example, says that he had to learn how to plan his time, organize his life and tasks on a calendar, and then follow that calendar every single day. From his perspective, quite a lot of students expect to attend nursing school and still have an active social life and do everything they did before, like watch all their favorite television shows.
“I think that the trouble students run into is they believe they can have everything—do well in nursing school, have an active social life, et cetera. If they go in with that kind of view, I don’t think they’re going to survive nursing school,” says Richardson. “They’re going to have to sacrifice a lot of that time, but once you get into it, it gets a bit easier.”
Martha A. Dawson, DNP, MSN, FACHE, assistant professor and coordinator of Nursing and Health Systems Administration at the University of Alabama at Birmingham School of Nursing, as well as the current historian for the National Black Nurses Association, agrees that having enough time can be an issue for nursing students. Traditional nursing students still face challenges that relate to study time, finances, and part-time work. In addition to the challenges of traditional students, however, second degree nursing students, such as those in a BSN to MSN bridge or other accelerated degree program, may also have immediate family obligations, explains Dawson. For instance, some may be primary caregivers for older parents. “Many students in these new and emerging programs are older, and these added life demands can lead to both high stress and exhaustion,” she adds.
Money, Money, Money
Richardson and Dawson agree that financial issues can also be a big challenge for nursing students. Dawson says that with the varying nursing programs and the older student population in them, these students may have greater financial obligations besides school, like a mortgage. “The current economic climate is making it more difficult for students to gain access to scholarships, trainee grants, and other forms of funding without going further into debt,” says Dawson.
In addition to taking out loans to attend nursing school, Richardson says that there are a number of scholarships available for students. Believe it or not, though, not a lot of students are applying for them. “There are a good number of scholarships available,” says Richardson. “After speaking with some people who have scholarships or who fund scholarships for students, I’ve discovered that they’re not getting a lot of applications. One reason is because of the time. A lot of students don’t know that the scholarships exist, and a lot who know they exist feel like they don’t have the time to fill out the applications because of the high demand of nursing school.”
The reality, Richardson says, is that studying takes up so much of the students’ days that many don’t think they could take the time to do what some scholarships may require in their applications—like get a letter of recommendation, write three essays, get transcripts, and the like.
Recently, Richardson had a heart-to-heart talk with a student who was frustrated because of going to school, clinicals, and a part-time job. “I said, ‘If you took about three hours applying for a scholarship, you would get more money to help you out with your school fees,’” says Richardson. He continued to explain to the student that he was working twice as hard and putting in twice as many hours at his part-time job to make the same amount of money that he could get if he applied for a scholarship—which would ultimately free up more of his time. “It would help the student more in the long run,” says Richardson.
Along with not getting enough financial support, some nursing students don’t have as much family support, says Rebecca Harris-Smith, EdD, MSN, BA, dean of Nursing and Allied Health at South Louisiana Community College. “Nursing classrooms across the nation are filled with an intergenerational, multicultural group of students that range from millennials to baby boomers,” explains Harris-Smith. “This nontraditional classroom of students has many that are parents who frequently do not have siblings, parents, or other relatives to assist them with child care. The expense of child care, transportation, and after-hours coverage often impacts the nursing student’s classroom, clinical, and study time.”
Richardson says that family support and encouragement is often needed, but not every student has it. “I noticed immediately that I needed a lot of support,” says Richardson.
“In my personal experience, soft skills as they relate to interpersonal people skills have become an issue for nursing students. The ability to communicate both verbally and in writing appears to be a challenge,” says Harris-Smith. She says that because Gen Xers and millennials have grown up with a lot of technology, they have spent a lot of their early years communicating that way.
“Basic socialization has changed in that the younger generations would prefer to text over having a verbal conversation. The lack of appropriate communication skills has an impact on the students’ ability to work collaboratively with physicians, fellow nurses, and other members of the health care team,” explains Harris-Smith.
“Effective communication is essential due to the intra- and interprofessional team collaboration essential in the health care arena,” Harris-Smith explains. “Additionally, nursing students must learn flexibility, professionalism, and a strong work ethic—which are essential to the development of the new nurse graduate. Being able to adapt to an ever-changing environment is important as health care facilities have staffing issues often requiring nurses to work beyond their shifts.”
Challenges for Minority Students
Although the challenges for nursing students are often the same for students of color and those who aren’t, “students from underrepresented groups in the nursing profession and in society . . . have them on a much larger scale,” says Dawson. “There are barriers and biases that these students experience such as academic skills, perceived perceptions about their abilities, lack of faculty role models, limited peer support, and major financial issues that ‘majority’ students do not have to deal with on a daily basis. Many minority students also struggle with the very basics of housing and food.”
An additional burden that minority students face, says Harris-Smith, is that of access and equity in education. “A selective admission process is used by schools of nursing across the nation, and this very process can serve as a barrier for students of color. Academic profiling of students ensures admission of the most academically prepared students that rank highest among their peers, but students from underrepresented populations are often the first-generation college students that struggle with the issues of being the first in the family to attend college. This situation places a heavy burden on the student because s/he may be dealing with the pressure of being the ‘savior’ for the family. These students are generally not savvy enough to apply for multiple college programs, have difficulty completing financial aid forms, and generally come to college with limited resources,” says Harris-Smith.
“Nursing programs tend to address diversity in their mission statements but fail to explain how this is accomplished. Merely placing the statement in the mission statement does not explain how the school of nursing addresses the issue. To ensure transparency, each school of nursing could better address this issue by providing information on the way in which this mission is accomplished,” says Harris-Smith. For example, she says, schools could use a statement that’s more explanatory: This school of nursing addresses diversity via academic profiling of students but is careful to admit a diverse student body that resembles the demographics of the community in which we live.
“There is a need for schools of nursing to restructure their admission process to address the lack of the underrepresented students in attendance at their colleges and universities,” Harris-Smith adds.
Richardson says that’s why he is a part of the Breakthrough to Nursing committee because its goal is to increase diversity in the nursing profession. Another challenge he’s seen is that some minority students don’t last in nursing school because they have different ways of learning. “Culturally, students from different backgrounds learn differently. I’m a kinesthetic learner. If you show me how to start an IV, I will know how to start an IV more efficiently than reading three chapters about how to start an IV,” Richardson explains. “A lot of nursing school is geared toward your textbook. But a lot of students are visual, auditory, and kinesthetic learners.”
He says that there are also students from various cultural backgrounds who don’t know how to study. “For students who come from the other side of the world to America to learn, their views are different from yours, and when you have a different perspective, you’re able to become more aware. You’re able to see a different view. It actually makes us stronger and allows us to become smarter to look at the way that other people do things,” suggests Richardson.
“With diversity, we need to recognize and communicate to understand what the other person’s thinking is and allow them to realize that though their culture is different, it’s not a bad thing,” says Richardson. “It’s just a different view and perspective for them.”
With dozens and dozens of nursing specialties, some nurses take varied paths to end up in the specialty that is the best fit. Many try different health care situations or medical training before deciding that one area of nursing is the career where they will make the impact they want and will satisfy their professional goals.
Jose M. Maria, MS, FNP, RN, CEN, director of emergency services at Brookdale Hospital and Medical Center in Brooklyn, New York, says he came to emergency nursing after gaining training and experience as an EMT and paramedic. “Emergency medicine was the next logical choice in starting my nursing career,” he says. “I haven’t looked back since.”
Maria, a native of the Dominican Republic, says his specific EMS experience really gave him a solid foundation to know what he wanted and provided him with the essential capability for any emergency nurse. “It allowed me to develop the skills to adapt to any situation while keeping a cool head,” he says.
But emergency nurses also benefit from having more than a cool head and a great skill set, says Maria. The flexibility to move from one situation to another one that is entirely different is essential for a successful emergency nurse. And then there’s the part where you work your tail off. An emergency nurse who doesn’t complain about the task (or 20 tasks) at hand and does what’s needed will have a much easier time working in such a fast-paced environment.
And when it’s time to transition a patient to inpatient nurses, challenges remain. In fact, Maria says that transition point is one of the most challenging aspects of emergency nursing. “This is a common challenge at every organization I have been a part of,” he says.
Preparation and planning, as with any part of the emergency nurse’s job, can help. And finding out how other nurses work also helps inform your own practice. “I try to stay current in practice and use resources like ENA CONNECT and to speak with colleagues across the states,” says Maria. “Like many professions, preparation is key for success in the emergency department.”
But with those skills and responsibilities, emergency department nurses encounter a lot of critical and crisis situations to adapt to. For Maria, those situations reveal why he does what he does. “The most satisfying and most important part of my job is to save lives,” he says. “It’s a powerful and overwhelming feeling to have brought someone back from death and see them walking out of the hospital.”
Anyone considering emergency nursing as a career path can follow Maria’s advice to rotate through other specialties before deciding on the ED. Each area offers you a new set of experiences and training that will be useful in the emergency department.
“Because we see a wide range of complaints, we can actually help our patients,” he says. “Working in psychiatry for example, helps you build conflict resolutions skills, improve communication techniques, and builds patience needed in the acute psychiatric emergency. Working in the ICU, with their attention to detail, improves your documentation. Working on a medicine floor helps in time management skills. Working a surgical unit, improves your teaching techniques with patients.”
And while the emergency department is intense and fast, emergency nurses do find a way to offer each other the kind of support and camaraderie that is distinct. Their humor might even be considered dark, says Maria.
“People have a hard time understanding that even in the darkest of times, humor helps us deal with our internal anxiety about the cases we work,” he says.
When you’re a nursing student, thinking about your finances seems almost like a pointless task. With the immediacy of paying for school and the almost universal need for student loans that you pay back after graduation, thoughts of your future financial plans stay where they are – way in the future.
Believe it or not, this is actually a great time to think about your future and your finances, which includes retirement but also might include big-ticket things like a car, a house, travel, or additional educational costs. When you start working right after graduation, you’ll want to develop good financial habits right from the outset. If you can begin planning for your future early, you’ll be much better prepared.
You may not be able to set aside money when you’re still taking courses and during clinicals, but you can learn how to make good financial choices.
Set a Budget
As a nursing student, get comfortable with the funds you have, the funds you earn, and the amounts you owe. Don’t guess at how much your food costs are each month—add them up so you know. Use an online budget app like Mint (it’s free!) to calculate that in with your rent or mortgage, any insurance costs, student loan payments, transportation, and costs for entertainment, pets, or clothes.
Balance that with what you take home each month and you’ll get a good idea of your cash flow. If you get comfortable doing that early on, you’ll have an easier time making sure you make solid, financially stable decisions in the future.
Learn Where to Save
When you have a budget, you’ll know what you have and don’t have. You can figure out if you can cut back on one thing to make some extra money for something you want. Eliminating a take-out lunch once a week and you can easily save another $50 to $70 a month. Add that to an emergency fund until you have enough to cover three to six months of expenses. Then start putting it in a retirement fund. You’ll never notice the difference.
Pay Your Loans
This one is simple, but can be difficult. If you have student loans pay them on time every single time they are due. Defaulting on your student loans or being late on payments can wreak havoc with your credit score. And you’ll need good credit to secure a car loan, a loan for a home, or even future student loans if you return to school. Don’t let a mistake limit your life that much.
Plan Your Next Steps
Set some financial goals. Do you want to save $1,000 this year? Do you want to commit to saving 15 percent of your income? Figure out how much that breaks down to save each week and then do that. Either have it automatically withdrawn and placed in a different account or fund or do it yourself each payday. Setting concrete goals complete with amounts and the steps you have to take to reach your goal is half the battle.
Start implementing steps toward setting good financial behaviors now and you’ll be thankful years down the road.