The first year: So much learned, so much to learn
On the one-year anniversary of my first real nursing job, I share observations on what I have learned and where I hope to take my nursing career in the years ahead. Topics include critical thinking, sleepless nights, and feeling slow and stupid during the first year!
Today marks one year since I started my first real nursing job in the PACU. I mentioned this to my preceptor the other day, and she said she thought the year had flown by. I do, too, but it has been an ascending flight in many ways, and I wonder when I will hit my cruising altitude. While this is on my mind, I thought I'd jot down some things I've learned, and what I haven't learned yet but need to...
There were so many times--even after orientation was finished--that I found myself in abject terror. Days I dreaded going in for fear I'd get the scary patient and not know what to do and kill him or her through my ignorance. Nights I stayed awake for hours, huddled in a panic in my bed thinking of the patients I hadn't killed, but had I done everything I needed to? Why didn't I tell the doc this? Did I document that?
Soon after I started working, I received the following advice from an experienced floor nurse: that panic only lasts 6 months because a) you're too exhausted to lie awake at night, b) someone who knows what they are doing gets the patient after you're done with them, and c) you just don't care anymore.
While I don't agree with the third point per se, I get what she meant: my patients no longer occupy my mind for weeks after they leave my care.
Point two is the most helpful; as a phase I PACU nurse, I take my patients to the floor, the ICU, or phase II before they go home, and in all three places, another set of more experienced eyes will look at their dressing, another stethoscope will listen to their lungs, another set of vitals will be taken, another RN will explain what they need to do.
Point one is still hard, though. I may be exhausted, but when the mind starts racing, there is little to do but think of point two, roll over, and try to go back to sleep. And stop reading the obituaries.
On Critical Thinking:
They don't teach it in school. I don't care if you're in a direct-entry masters program like mine or in one of the last few diploma schools in the country; you are not going to learn critical thinking from a book or a teacher. There is this notion about BSN/MSN grads being better critical thinkers, but I don't subscribe to that; I think the only things that teach critical thinking are experience and curiosity.
I recently came to my own definition of critical thinking: knowing what questions to ask. You can ask me almost anything about my patients at this point, and I will either know the answer or know where to look for it in the EMR. But if I have to ask those questions myself, it is much harder to know where to start. "What could be causing this?" is an important one that I usually manage to think of, but I don't always know how to follow the trail with more questions. I read on the back of a book about critical thinking, "We see what we know." And I don't know much yet.
On New Grads in the PACU:
The jury is still out. In many ways, I am still a bit of an albatross, even after a year (I work per diem, so I could argue that I don't get the hours I need to be more independent, but that sounds lamer with each passing month). I am just starting to shadow call.
There are still drips I haven't had to use, so I know nothing about them. I can take almost any patient independently (and we frequently help each other with the really critical ones), but the organizational skills necessary to keep track of two patients across the room from each other while one is in agony and the other one needs a parade of labs and x-rays and phone calls are just not there. Those are skills I would have learned on the floor.
On the other hand, I was all thumbs in my short-lived floor nursing job, much worse than I am in my unit, and I certainly don't consider med-surg nursing a breeding ground for specialties; it is its own specialty, even if new grads frequently end up there. Really, I think new grads have a pretty good chance of feeling slow and stupid no matter where they end up, and even though the pace is brisk and the patients acute in the PACU, it also affords tons of opportunities to collaborate with other RNs and MDs. It's not a unit that is accustomed to nurses not being independent in their skills, though, and I am so grateful to my colleagues for adapting to teaching me rather than just doing it (more quickly) themselves.
Last week one of our most experienced nurses came to get me to remove a Foley, because it doesn't occur often in the PACU and I had not removed one since nursing school; earlier this year another nurse had me put one in. I know I've let the team down by not being able to take on a second patient or when I monopolize another nurse for 10 minutes because I have never programmed an epidural pump before.
They have taken me aside and nicely told me what I needed to hear but didn't want to hear: that I needed to step it up, that I was not thinking things through logically, that I was visibly nervous and making the patient nervous. Because I respect them and know that they want what is best for the patients, I listened, and thus I did not flunk out of orientation or get fired or get sent to work on another floor.
Finally, On the Magical First Year of Nursing:
It's a day on the calendar. Period. Sure, I am not a new grad anymore, but that does not mean I've transitioned from novice to genius. It is a process, this nursing business, and I do feel I'm making progress. I love that I can look at the cases for the day and know what I would do... for 90% of them. I love that I can recognize arrhythmias quickly and accurately... but I also love being able to page anesthesia when something looks too weird. I love being able to step in and help another nurse without having to be told what to do all the time. Mostly, I love taking care of patients. I love making the connection, knowing I've done something for them that really matters, whether it is supporting their airway or supporting them as they mourn the loss of a breast. I love setting up PCAs--isn't that weird?--and teaching the patients how to take charge of their own pain control. I love that the anesthesia and OR staff know who I am and no longer ask if I'm still in school. I could go on and on, but it's getting late, and I need to go get ready for work.Last edit by tnbutterfly on Sep 17, '13
About wannabecnl, MSN
Wannabecnl is a 2nd-career nurse who graduated in December of 2011 and has worked in the PACU for the past year.
Joined: Sep '09; Posts: 345; Likes: 605
Specialty: 4 year(s) of experience in PACU, presurgical testingSep 17, '13good luck been in your place before and now that I have 2.5 years behind me i still get those I feel like I am dumb situations, I work in a subacute/ nursing home place so when we see something abnormal we don't always know what to do about itSep 17, '13Great article! I am SO looking forward to the days when, for the most part, I feel like I'm in control and making progress with my patients, instead of just trying to get all my tasks complete. Who knows, maybe someone will even ask ME a question...Sep 17, '13Thanks for sharing this! As someone who's applying to direct entry programs, it was really interesting to read your account of your first year. Best of luck as you continue in your nursing careerSep 17, '13Great review, and good advice on critical thinking. I am a new grad about to embark on my first-ever real nursing job and I am equal parts scared & excited. Your self-eval helps me in several ways. I especially want to remember to 'learn (lots of new) something(s) every day' and to never forget to listen and ask questions. "The quality of your life (or work) can be determined by the quality of your questions," to paraphrase Tony Robbins. And it seems like you have a great attitude, which I definitely want to emulate! Thanks for setting a good example for a rookie to follow.Sep 17, '13Love your post. I'm sure it will help other new nurses out there. Thanks for sharing your insight with your fellow nurses. Best wishes to you in your nursing career.Sep 17, '13Thank you soo much for sharing. I'm a recent grad and sometimes I feel so dumb. haha. I have to keep telling myself its a process and what and how I learned it in school is not the same in the real world. I can't wait to get where you find yourself.
AND I especially can't wait to be able to say:
"I love that I can look at the cases for the day and know what I would do… for 90% of them. I love that I can recognize arrhythmias quickly and accurately… but I also love being able to page anesthesia when something looks too weird. I love being able to step in and help another nurse without having to be told what to do all the time."
But this too sums it all up for me and why I wanted to become a nurse: "I love taking care of patients. I love making the connection, knowing I’ve done something for them that really matters" God bless you always and thank you for being one of many nurses who truly do it for the patient. Take care.Sep 18, '13This is very encouraging, and I'm glad to hear that you're happy! I graduate in 2014 and nursing will be my 2nd career too! I know it's not going to be a cake walk the first few years, but after I gain experience it will be worth it!Sep 18, '13Great article. I agree that knowing what questions to ask is the basis of patient care. I am a new grad, 2 months into my training program for Med-Surg tele and about to be on my own. My current mantra is "good nurses are made, not born." New grads need help and mentors and it sounds as though your experience in the PACU has been full of great mentors. Good luck with year 2!!Sep 18, '13I applaud you!! I have no idea how new grads succeed in areas like PACU. ICU, CICU, PICU. There is SO much that I didn't know I didn't know. I work on an ortho unit with a short move to a URO/GYN ONC unit. I have been there 8 months; worked 8 months in LTC rehab. You definitely learn to recognized subtle things that tend to end up being issues.
I can't wait to see what I learn after another year. It males me feel better when I have veteran nurses that don't have all the answers and will look for them with you; are still curious after years of working.
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