With medical errors making national headlines, it is no secret that both training and experience are integral to success as a new nurse. Almost all nurses enter the field with a college degree, but recent research shows that novices make a large percentage of the errors caused by nurses. To avoid mistakes and build a strong foundation for your nursing career, here are three essential skills to prioritize during your first year as a nurse.
1) Developing Strong Instincts for Patient Safety
Patient safety is one of your primary responsibilities as a nurse. Safe medication administration is an imperative skill to master in your first year. You are the final check between the prescribing provider and the administration of a medication to the patient. If something feels “off”—maybe the dose seems too high based on doses you have given before or the medication doesn’t seem to fit your assessment of the patient—take a timeout and ensure the prescription is accurate. Mistakes happen even in computer-driven processes, whether a decimal point is missed, a duplicate therapy is accidentally prescribed, or a medication is placed in the wrong slot of a medication dispenser. Before giving any medication, ask yourself, “Are all of the correct pieces in place for me to give this medicine right now?”
Learning to safely calculate medication dosages goes far beyond a textbook. Learning tools like UWorld’s Clinical Med Math allow students to practice and perform dosage calculations without the risk of patient harm if they make a mistake. This tool is meant to be a hands-on resource to help students study for drug calculation exams during school, but it also provides fantastic experience to prepare you for real-world nursing.
Another major safety concern is patient falls. Precautions here may include rounding on older patients more frequently or enabling a bed alarm for high-fall risk patients. You should also utilize a mental checklist every time you walk into a patient’s room, such as:
Is the floor clear, especially the path to the bathroom?
Can the patient reach the call light?
Is the bed in the lowest position?
Adding these seemingly small things together develops a strong instinct for safety so when you enter a room, you automatically sense if something is out of place.
2) Forming Clinical Judgment
Your first year as a nurse builds clinical judgment on the foundation of all the knowledge you acquired in school. The ability to recognize potential or current complications that could cause harm is a strong asset to cultivate. This skill involves understanding the pathophysiology behind different disease processes and identifying the signs of improvement or decline. From there, the priority is determining the most important action you can take in the moment to ensure the best outcome for your patient. A textbook cannot teach you how to anticipate patient needs or develop clinical reasoning. You develop clinical judgment by applying your classroom knowledge to the actual patients in front of you.
As you refine your ability to assess patients and interpret clinical data, you reach the point where you can look at a patient and know something is not right—the monitors might look fine, but your assessment and instincts say otherwise. This is an important part of clinical judgment, and it is your job to dig deeper and advocate for your patients. Of course, this critical thinking must occur while also keeping up with scheduled medications at the same time that you are admitting a new patient and discharging another. Developing clinical judgment to juggle these moving pieces takes time.
3) Mastering Time Management
Time management is another key skill to learn in your first year of nursing. You should be able to look at your whole shift and plan a timeline based on medication schedules, planned procedures, and provider rounds. If all four of your patients have medications due at the same time, how do you organize your time so everyone receives their medications within an appropriate window? Many nurses have their own system of handwritten notes that they keep in their pocket to help organize their day. Asking to see your preceptor’s note system is a great way to get ideas during your clinical rotations in school or during the internship at your new job.
Structuring your day in the most efficient way possible helps develop a “clustered care” mindset where you complete a few tasks together so you don’t leave a room, only to return 15 minutes later. These organizational choices help you accomplish tasks in a seamless, resourceful way. The skill of effectively planning an entire shift comes with time. Do not be afraid to ask questions and learn from other nurses. Pay attention to colleagues who seem particularly organized and solicit their advice—even the smallest tip or trick can make your nursing practice stronger!
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.
Study
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.
Nursing school is difficult, no doubt, but it pales in comparison to the first year working as a nurse. New nurses face many obstacles they may not have even fathomed while in school. Whether you landed a position in your dream unit or had difficulty securing the first job, the first year out for any nurse is challenging.
Once out of school, many wonder if their first job will be anything like their professors taught. Unfortunately, it’s not, but there are ways to cope with learning the ropes of nursing. A nurse of just over one year, Kelsea Bice, BSN, RN, an emergency room staff nurse at MD Anderson Cancer Center in Houston, Texas, realized her first-year nurse training was much different than school. “Most came from preceptor roles. I found it extremely difficult to rationalize my book training with the experience of my preceptors and my own thoughts,” she recalls. “It was very overwhelming at times.” Although it can be overwhelming, here are some key points for newbie nurses to remember when transitioning from student nurse to nurse.
1. Remember that School and NCLEX Do Not Reflect the Real World
Many new graduates struggle with the sheltered environment of school and the hypothetical world of NCLEX when they are in their first job working with real patients. The ultimate goal of nursing school is to teach one how to pass NCLEX. A nurse’s first year on the job teaches the individual how to become a nurse. The two realms massively collide with the first job after school. “The most difficult part of the first year is taking critical thinking from a theoretical/hypothetical situation to a real person in a real bed in front of you,” states Bice.
As a student, the first-year nurse is not exposed to all of the internal policies and systems of a clinical facility. In a new environment, reports may be conducted differently from the ways one was previously exposed to, some common procedures may be completed in an unfamiliar manner, and, when a patient is crashing in a real-life setting, it isn’t always “textbook” like NCLEX. These nuances can be hard for new graduates to grasp without their own experiences to pull from. Once out of school, new nurses soon realize that patient ratios will often be higher than they were while in school. Nurses, especially new nurses, have to really work on honing their time-management skills. When asked how nursing schools can better prepare students, Arthandreale Nicholas, BSN, RN, a nurse at Harris Health Outpatient Medicine Clinic in Houston, Texas, says, “[M]ore clinical hours with realistic nurse-to-patient ratio staffing [are needed] so new nurses can be prepared to have more patients and develop time-management skills.” As any experienced nurse knows, time-management skills will improve with time.
Prioritization also serves a vital role in a nurse’s first year on the job. Prioritization and time management go hand-in-hand; once one is mastered, the other will become easier and vice versa. Nicholas, a nurse of five years, recalls her most valuable lesson in her first year was prioritization of duties. “Make sure to see sickest patients first and get meds passed ASAP,” she suggests. New nurses may not realize how long 12-hour shifts really are—or that they may not get the desired shift they want to work directly out of school. Typical 12-hour shifts turn out to be longer when you factor in commute times, codes at shift change, or a lengthy report. In addition, nursing schools don’t prepare students for difficulty finding their first job in an oversaturated market. Nicholas experienced long days and an undesirable shift firsthand; her commute to her first job, a neuro step-down unit, was 60 miles each way and she worked a “swingshift,” meaning she alternated between night and day shifts. “I only stayed at my first job for four months. The schedule with the commute made me very discouraged, so I actually went months without working until a local hospital gave me a chance,” says Nicholas. New nurses are ill-prepared for these realities since the average nursing school does not typically have students complete a full 12-hour clinical day. In addition, the clinical sites are typically in close proximity to the school.
2. Respect Your Elders
We’ve all heard the phrase “Nurses Eat Their Young” (or “N.E.T.Y.”) when referring to the way some seasoned nurses communicate with newer nurses. Sometimes, there are personality conflicts between people, but most of the time seasoned nurses are just frustrated with the newer generation thinking they know more than they actually do directly out of school. As the saying goes, “You don’t know what you don’t know.” Seasoned nurses on the unit have a wealth of information to share with you—just be willing to listen.
Bice has her own take on the relationship between newer and more experienced nurses: “Older or ‘more experienced’ nurses say new nurses are coming out of school really cocky or with bad attitudes, but I truly think that’s just the generation gap in the workforce showing through.” Bice believes new nurses can thrive in their first year with more encouragement from seasoned nurses. “I think if new nurses are nurtured through their orientation and supported and offered a safe environment to ask questions, make mistakes, and figure it out, they could be successful on any unit,” she adds.
Newer nurses should also understand that there are multiple ways to carry out nursing duties. Their preceptors may have a different way of doing certain asks. Not all nursing tasks are textbook like they were in school, and this may be a hard concept to grasp when just starting out. Be willing to understand why particular individuals carry out their nursing responsibilities the way they do. And if you don’t like it, put your own spin on it later. Be open to others’ opinions when you first start out—you may realize you have learned something you may not have known otherwise. Take it all as a learning experience.
3. Don’t Cause Waves
One of the quickest ways to become the unpopular nurse on the unit is to act like a know-it-all. No one cares that you had a 3.9 GPA in school or that you passed the NCLEX with 75 questions. All anyone—including colleagues, patients, and family members—really cares about is how you can safely and effectively deliver care to patients. Remember, the first job is to learn how to become a real nurse.
Another way to cause waves during the first year of nursing is to actively complain about your chosen profession. The story plays out time and time again—a new grad comes into the unit and continuously vocalizes how much he or she hates bedside nursing and declares plans to be out of there in one year—on to NP or CRNA school. Doing this usually causes a deep divide between you and other seasoned nurses on the unit. This may be where some of the N.E.T.Y. comes into play.
Newer nurses may feel isolated due to their inexperience, but it’s imperative to ask for help from others when needed. Nursing involves teamwork. In addition, starting a new job and attempting to be a martyr by making fellow coworkers look bad only actually makes you look bad in the long run. One day, you will be on the other end and won’t appreciate the lack of compassion. Everybody makes mistakes, and you don’t want to be thrown under the bus because of one. Learn to speak to your colleagues when a problem arises; it could uncover a learning experience for both of you.
4. Continue Your Education
Just because you have finished nursing school and passed your boards doesn’t mean your education should cease. The real education has actually just begun. Continuing education doesn’t mean you immediately go back to school for an advanced degree; it means continuing to learn in your new role. Jonanna Bryant, MSN, MS, RN, a veteran nurse of 24 years, who is currently working on her doctorate, wholeheartedly agrees. “Learning doesn’t stop after one leaves school, and you don’t have to return to school in order to learn,” she says. As a new nurse, you should be constantly looking up medications, medical terms, and diagnoses that you don’t know. It’s uncomfortable being asked a question for which you don’t know the answer. Not knowing the answers should bother you to the point that you want to seek additional knowledge.
It’s imperative that you continue to educate yourself in your chosen specialty—meaning that if you work in the ER, brush up on triage or work towards your trauma certification. Get your Basic Life Support and Advanced Cardiac Life Support certifications. Read nursing journals, re-read your nursing textbooks, and become involved in professional nursing organizations—anything that will enhance your knowledge base. The education of a nurse never stops.
In addition to learning job-specific skills, learn more about the roles of other health care professionals. Learn the role of a respiratory therapist, physical therapist, and radiation tech—these are all professionals you will work with on a daily basis. Education provides opportunities for you to grow not only as a nurse, but also as a person. Enhancing yourself through education makes you a better nurse and allows you to educate your patients, their family members, and your colleagues.
If you do eventually decide to go back to school for an advanced degree, make sure you master your role in your current position before doing so. Regardless of what some may say, an experienced nurse has an advantage when heading into graduate school. Concepts covered in grad school can be easily grasped with the experience one gains from working as a nurse.
5. Find a Mentor
Many nurses, if not all, may feel they were not adequately prepared for the real world even after finishing school and passing the NCLEX. The type of treatment new nurses receive in their first year can negatively or positively affect their overall career trajectory. This leaves a new nurse either loving the profession and wanting to stay in for the long haul or loathing the profession and trying to leave altogether.
“The first year was hard,” says Nicholas. “I honestly almost broke and thought about other career paths. I’m thankful for the good shifts and grateful patients who encouraged me to keep going.”
Potential challenges one may face in nursing should be discussed and support should be given to newer nurses, both in school before they graduate and on the job. Bice believes having more open, honest discussions with preceptors and other experienced nurses on the job would be beneficial. “Debriefing after incidents, like ‘what could I have done better?’ [and] ‘what will I do differently next time?’ This way, gaps in learning are realized and bridged,” she says.
New nurses should not only be oriented to their new career, but also mentored by seasoned nurses. A mentor serves as an experienced and trusted adviser. Mentorship should be a part of orientation for all nurses new to the profession. Bryant, a nurse consultant for the Centers for Medicare and Medicaid Services in Philadelphia, Pennsylvania, also believes in new nurses having a preceptor or mentor for the first year, “…someone who they will follow and be able to ask questions and talk to regarding concerns with their new job,” she says.
The first year of nursing is tough, but manageable with the right mindset. Bice advises the newer generation of nurses starting out to “chill out and listen,” which is in line with Bryant’s recommendations for the first year: “Pace yourself, be thorough, and communicate.” Nicholas wishes she could have told her first-year self to be “more confident” and to not be afraid to question orders she was unsure about. Use their advice to successfully integrate into your new role. Soon enough, you’ll be a seasoned nurse and will be able to give tips to the newbies on your unit.
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