Advice for Transition From Nursing Student to Professional

Paper Dolls (First Communion diptych) by jparadisi

Last week asked me to respond to a new nurse’s post about the difficult transition from student to professional nurse. Other nurses also contributed advice and insights. Here’s what I said:

My first six months as a new grad nurse were so painful, I almost quit. More than twenty years later, I can laugh about it enough to post them on my blog, I was lucky to find a great mentor, but don’t wait to see if that happens for you. Accelerate your knowledge base by looking up your patients’ diagnoses in textbooks at home to compare what happened on your shift, and look for information you may have missed in school. Trade work for work with your coworkers by offering to take vitals or other tasks to make up for the time they take to help you. And don’t forget your other non-nursing colleagues as resources: Pharmacists can provide medication administration advice and check your math. Respiratory therapists can offer advice on airway management and options. Buy coffee for the people who often help you and cover their patients when they need a break. Most of all, be patient with yourself. Becoming a nurse is a process, and it takes time. There are no short cuts.

I’ve documented my transition on this blog. The posts are published as The Roz Stories and you can find them in the right-hand column under Categories (Regular Features).

What would you tell new nurses experiencing reality shock?

How I Became a Nurse Part II: Gatekeepers

Gate Keepers by jparadisi 2011

“Jules, you need to quit wasting your talents working with Sister Sebastian up there on the Pediatric unit. I want you transfer to Pediatric Intensive Care so I can train you. You’re a natural,” said Roz, when we finished our shift.

Roz found a way for me to float to PICU at least once a week. Soon, I was caring for stable patients with her backup. It was complex work, and I had a lot to learn. I loved it. I wondered what it would take to become staff. Roz encouraged me to ask Barbara, who managed both pediatrics and the PICU.

Barbara worked her way into nursing administration first as a pediatric RN and then in PICU. She and Roz had worked side by side in both units before Barbara became manager. They were friends. Roz and I sat in her office, discussing my transfer.

“Roz can’t say enough good things about your nursing, Juli. I’m happy to hear you’re doing well and I’m grateful for your help in the PICU. I think you will make an excellent PICU nurse, however, I’m reluctant to transfer you there so soon after graduation. You’ve been a nurse for less than six months, and I’m afraid that getting in over your head is a real possibility. I will feel more comfortable with the idea after you gain more experience. I don’t mean to discourage you, but for now the answer is no. Let‘s talk about it again after you‘ve been here a year.”

I was already in over my head on the pediatric unit, but I understood Barbara’s concerns. Since I floated so often, I knew it wouldn’t be long before she changed her mind. I decided not to push for the transfer at present.

What I didn’t count on was interference from Sister Sebastian. One evening I checked in on Peds before floating to PICU when once again she stopped me at the nurse’s desk.  “I see they scheduled you in the PICU tonight, however, it is not fair for them to have favorites. You cannot always be the nurse who goes down there. I am keeping you here tonight and I have sent Leah down to them instead. I have told Roz no.” Her wimpled face radiated with satisfaction as she spoke. She found pleasure in the self-assigned role of gate keeper. Her personal disappointments compelled her to block the way of others pursuing happiness. Now I know life is full of such people.

I wanted to argue with her that the other Peds nurses hated floating to PICU, but I knew it wouldn’t help. I took report on my assignment, realizing I was going to stay a Peds nurse for a very long time. During my break in the staff lounge, Roz called from PICU. “This isn’t the end of it,” she said.

Three days later, Barbara called me back to her office. Roz was already there, seated. Barbara started the conversation.

“Juli, Roz requests I transfer you to PICU. I have already explained my concerns. I still feel the same, but Roz has agreed that if I transfer you, she will take responsibility for your training in the PICU. She has committed to working the same schedule as you every shift for a year, to make sure that both you and your patients are safe. Do you still want to transfer?

I couldn’t believe Roz would commit herself like that for me. I agreed to the transfer, resolute that she would not regret her choice. Years later, after mentoring many new nurses myself, I fully understand Roz’s gift.  Her generosity is more overwhelming than the nursing unit she rescued me from. Life should be full of such people.

I thrived as a nurse in the PICU. I learned rapidly in the fast paced environment. Roz gave me a Pediatric Intensive Care Nursing textbook. I studied it at home and on breaks.

Roz was well respected by the PICU intensivist. Eventually, he trusted my nursing judgment nearly as much as hers. I was proud when he nicknamed us “The A Team.” I was going to stay in nursing after all.

Next week: How I Became a Nurse Part III

How I Became a Nurse Part I-It Could Not Have Begun Worse

The White That Binds (Pinning Ceremony) by jparadisi 2010

It could not have begun worse. I was not prepared for the difficult transition from student nurse to a full-time professional. My first job was working 12-hour night shifts in a high acuity pediatric unit. No one explained that during my two-week orientation I would work days, 7:00 am to 7:30 pm, not nights. The head nurse, Sister Sebastian, failed to see the humor in this misunderstanding, and sent me home when I showed up twelve hours late on my first day. She never liked me, and I was afraid of her.

The unit used a team-leading model, which meant two Registered Nurses managed 30+ sick children with two Licensed Vocational Nurses, if available, and a few Certified Nurses’ Aides. The LVNs could not start IVs or give IV medications. The CNAs took vital signs, and bathed and weighed the patients. The RN’s assessed each patient and new admission, started IVs, drew labs, hung IV medications, and resolved problems. Significant changes in a patient’s condition were phoned to their pediatrician ASAP, unless it could wait until morning. It was expected the RN knew the difference. If she was wrong there was a morning confrontation with Sister Sebastian.

After two weeks of orientation, I had patients, LVNs, and CNAs to manage. Six weeks later, I was occasionally charge nurse. The charge nurse took a full assignment. Ignorantly, I assumed these were realistic expectations for an inexperienced nurse. I worked hard to succeed, but failed miserably. When I made mistakes, Sister Sebastian glared at me during change of shift report. It was overwhelming. Often I would cry at home after shifts. Four months into it, I considered quitting nursing. Then I met Roz from the Pediatric Intensive Care Unit.

The PICU was experiencing a long period of low census. So Roz floated to Pediatrics and helped our chronically understaffed night shift. That first night, we teamed together to do patient care.  Roz was compassionate with patients, and highly skilled. She put them and their parents at ease with humor and a calm demeanor. She carried out several nursing tasks while thoroughly assessing a patient at the same time. I felt the rhythm. We worked together many shifts.

Roz changed my perception of nursing. She did everything my nursing instructors called unprofessional: she laughed a lot and loudly. She made irreverent jokes. She told stories on doctors and other nurses. She talked back to Sister Sebastian and advised me to do the same. We became friends.

Time passed. I arrived for work one night and as I approached the nurse’s desk, Sister Sebastian blocked my way, arms crossed in front of her chest. She said, “We don’t have enough patients tonight for you to work here. I was going to call you to stay home. However, the PICU is busy and they need a nurse to float. Roz asked for you. Try not to kill anyone there,” or something to that effect.

This surprised me. I appreciated Roz’s confidence, but I wasn’t sure I wouldn’t accidently kill somebody down there either. Most of the children were on ventilators, which I had only limited experience of in school. The PICU nurses managed complex IV drips. I was nervous, but believed Roz wouldn’t let me get into trouble. So I reported to the PICU.

The hospital housed a small, but high-powered PICU. As part of a Level Three Trauma Center, they treated every kind of pediatric emergency. All their beds were full this shift and most of the patients were unstable. Rather than giving me a patient to struggle with on my own, Roz assigned us together managing two unstable patients. Her strategy had me helping her with assessments, taking vitals signs, and giving the medications I was familiar with, while teaching me how to draw blood from the central and arterial lines for lab tests. She reinforced my suctioning skills with the ventilated patients. We shared charting in the nurse’s notes.

I loved intensive care nursing! Rather than scattering my attention on a floor full of patients, I found my strength was focusing on the intricate details of one or two critically ill patients. Following nursing tasks through to create a care plan I could assess and adjust rapidly suited me.  This kind of nursing made sense. Of course, I relied heavily on Roz, but by the end of the shift, I knew that PICU nursing was for me.

But how would I get to stay there?

Of Med Errors and Brain Farts

I read the physician’s order carefully, looked up the medication in the nurses’ drug book, and consulted with our pharmacist before I gave it.  While signing the medication administration record (MAR), I read the order again, and I did not see the same dose I had read the first time.

Immediately the blood in my feet rushed up to my ears and I was lost in pounding waves of white noise. Fuck, fuck, fuck, I made a med error, and it’s a serious one. Of course, I didn’t say these words out loud. Instead, I carried the patient’s chart and the empty, pre-filled syringe to the nurses’ station. Putting them in front of the charge nurse I said, “I think I just made a med error, a bad one. Look at the order and the syringe label. Tell me what I’ve done.” She stopped what she was doing. She read the order and examined the syringe. “You gave the right dose. You didn’t make a med error. Now breathe.” The pounding breakers of white noise in my ears subsided into the gentle lapping of my breathing. Another nurse came to my side saying, “I know exactly what you’re feeling.”

I felt relief. My patient was safe. It was a medication I am not very familiar with. That’s why I read the order carefully, looked it up, and consulted with our pharmacist. All I can determine about my confusion after giving the dose is that I had a brain fart. Somehow my eyes and my brain disconnected after I gave the medication, and the order unexplainably failed to make sense. That’s the best I can come up with: a brain fart.

Later, my coworkers told me their stories of making med errors. We all make them. I didn’t know that when I was a new grad.

It is unbelievable to me as I type this, but it is true: in nursing school  I had an instructor who told our class that she had never in her thirty year career, ever made a medication error. Never. And I was young, and shiny, and idealistic enough to believe her. Seriously, I did. So when I made a medication error during the first couple months of my new-grad job, I was sure that I was not cut out for nursing. At that time, my coworkers didn’t gather around offering support like they did recently. No, I was written up, and had to call the pediatrician and tell him that I had forgotten to hang a dose of ampicillin. He was more sympathetic than the day shift charge nurse back then. I made other medication errors too, nothing serious, but enough to consider quitting nursing during my first six months of practice.

Then I met one of the best nurses I have had the pleasure to work with. For some reason, she decided to mentor me. I confided to her that I considered quitting nursing, because I made med errors, and that my instructor never had.  She laughed.”If that instructor of yours never made a med error, then I’m thinking she’s too dumb to catch them. You are so crazy. Let me tell you about med errors…” She was a great nurse, not a perfect one.

She showed me how to string nursing tasks together like a pearl necklace, and eventually I gained the confidence needed to stay in nursing these past twenty-four years. I still make mistakes from time to time. I take responsibility for them. I learn from them. I am compassionate towards my coworkers when it happens to them. Nursing is not a risk-free profession.

And sometimes I have brain farts.

Whistle Blowers & Patient Advocates: When the Nurse Stands Alone

oil on unstreched canvas (detail) 2009 JParadisi

A colleague and I discussed the Winkler County Whistle Blowers case and our admiration for Registered Nurses Vicki Galle and Anne Mitchell. They brought the nurse’s role of patient safety advocate into the national spotlight.

My colleague is also a force to reckon with when it comes to patient advocacy. During our conversation she grew quiet and told me once, she had advocated for a patient without the support of her peers or administration.

The event occurred early in her nursing career, before she gained the skill and knowledge, which now empower her ability to act confidently as an advocate. In the end, she followed orders, even though they conflicted with her ethics. Decades later, she still regrets her choice.

I listened to her story, and tried to imagine her as a young nurse, uncertain and faced with a situation nursing school had not prepared her for. I imagined her alone and isolated, the only one in a nursing unit who felt, or more likely, spoke out loud the feeling that what was happening might not be best for the patient.

The Winkler County Whistle Blower case demonstrates that this kind of moral isolation still happens to nurses. However, it also demonstrates that nurses have developed resources for themselves and learned how to access them. These days, many hospitals have ethics committees and safety committees for reporting unsafe systems and behavior. Many hospitals have policies protecting nurses who refuse to administer treatments that conflict with their moral beliefs. Winkler County Memorial hospital fired Anne Mitchell and Vicki Galle when they used the hospital’s safety chain of command to protect patients, but the hospital and the doctor bringing charges against them found out this kind of punitive behavior is no longer tolerated by the court system or a majority of health care professionals. The Texas Nurses Association and the American Nurses Association said, “We are watching,” as did the Texas Medical Board. I’ve heard the conversations of doctors who ask why Dr. Arafile’s colleagues didn’t report his behavior. Why was the responsibility left to nurses? If any of these resources were available for my nurse colleague when she faced her dilemma decades ago, I would be surprised.

My heart breaks for that young nurse, facing an ethical dilemma alone and unsupported, with nowhere to turn. I told my colleague I hope she has forgiven that young, inexperienced, and frightened version of herself, with  her older, more experienced self’s compassion. I suggested that what she learned from that episode long ago has forged her into the warrior nurse advocate she is today, benefiting hundreds of patients during her long career as their advocate.