When I graduated, and went through the internship program at my hospital, I knew I was going to the cardiac stepdown (caths, post CABG, NSTEMI medical, etc), because I was already a tech there and that's who hired me. But I did get to shadow a shift in the OR with an amazing circulating nurse - and I noted that they seemed to be such a good team in there, the work was highly technical, and the competence and camaraderie reminded me of a special military unit of which I had been a member a long time ago.

Now I have more than a year of floor nursing night shift on Cardiac Stepdown (ACLS qualified, tele, etc), as well as regular floating to CCU with only a few limits (no vents - no pressor drips if unstable, absolutely no levophed). I've also helped on over a dozen codes on my floor in the past year (half the time recording and calling out when epi and so on are due, half the time compressions/relief). So I am competent enough to not kill my patients and know enough to know when I am in over my head and get help. I have no delusions about the vast amount of "I Dont Know" still remaining in my head.

Here's the problem - I still look back at my OR rotations as a student and as an intern, and think I might be a better fit there.

I want a highly technical nature of work; I want a specificity of environment; I want a direct result in my work; and most of all, I want an "elbow-to-elbow" type of teamwork into which I can fit, a truly "we" and "us" environment. I miss this from my military days, and it seems to be mostly absent from night shift floor nursing -- you're on your own a lot.

Is this really the way it goes in the OR? I expect it to be "a different kind of hard" than the stepdown unit. But some people post as if its an Eat the Newbie situation, others not so much.

So - does it look like my reasons are good - and am I looking in the right place, the OR?

And if so, what is the best way to go about getting a starting job in OR?

Background: my 40 bed stepdown is no picnic because we are understaffed chronically, and now that we are a regional center, we get all kinds and seldom have open beds. Ratio is supposed to be 4, and 3 if critical drips are going (insulin, certain pressors). But anymore a typical night is 5 patients and often no tech help (night shift, short staffed is typical - and no techs because we have all our techs pulled as sitters). The care load for a patient typically includes drips like cardene, amiodarone, heparin - and seldom do we have a patient that isnt getting something - not just cardiac, but emerging sepsis patients as well. Its not unusual to see AMS+UTI come from a crappy nursing home -- after getting 1-2L bolus iand abx in the ER, they are arriving with tachycardic 120's, tachypnea 25 or so and BP something like 90/50 reported (which ends up 88/48 when we take it). There are also usually one on a BiPAP (typically COPD with PE/DVT), and possible a total care or one in restraints due to dementia (population is 70+% geriatric). I have dealt with this for about a year and seen quite a few nurses quit, and new ones come in (mainly travelers). I figure I am used to it, and if the ratio stays at 4 and I have a tech, I can do OK. Except when I have more than 2 who are trying constantly to get out of bed and are fall risks - sundowners, etc. Those nights have me drinking a glass of wine before bed when I get home at 9 AM.

But lately we are getting the psych admits, and I cannot deal with bipolars manic and off meds (cussing me like mad), schizophrenics refusing meds and screaming that I am trying to kill them when putting a NRB mask on them, and having 2-3 of them eat my shift to where I stay until 9 the next morning to catch up on charting. Even had one call 911 because the tech forgot her hospital phone in the room. its getting awfully old, and wearing me out emotionally - I never wanted to be a psych RN, it was very difficult in school so I considered that my warning. Now I am not sleeping well. and beginning to hate these patients and dread going in to work. I am not suited to psych med, and I knew it, and yet here I am.

I am looking for an exit - is the OR the right thing?

My first question is what were you focused on during your OR experiences? A lot of the people I've dealt with are not focusing on the duties of the nurse, but rather on the surgery itself. If that's the case for you, I think you should request another opportunity to shadow so that you can focus on the role of the nurse.

As for teamwork, that really depends on the OR's culture. Mine is a little split- our cardiac team is a small, designated team. Other OR staff don't float back to us. Because we're such a small group, we are cohesive and work great as a team. In the main OR, there are well over 50 staff members. Because it's extremely possible not to work with the same person twice in one week, they are nowhere near as cohesive. We know that if we don't stock our rooms, we're likely to be kicking ourselves the next day when we have to run for things that are normally in the room. So, we stock them. We help each other out- today, as the call person with a surgeon on vacation, I was a floater and not assigned to a particular room. I helped one of our two rooms get started- put in the foley while the circulator counted, helped position, and helped prep. Gave a morning break and then a lunch break. The other call person did the same in the other room. Now, the rest of the OR is different. If they don't have a case to do, they're hanging out in the lounge, on Facebook/eBay/site of choice. So, it really depends on the culture and on management and whether they crack down on poor behavior and teamwork.

I was in the OR 2 days - first for cardiac (CABG with 4 jumps), and second day was ortho (Hip replacement, then reset and did a knee).

Both times I stuck with the circulating RN, because that's what we were told to do as part of the internship OR rotation; approach it like we were learning the job. I know some of the others played tourist because they had no intention of going OR ever. Anyway, on the CABG (it was 7 hours start to finish, and we did get relief for lunch) we went in prior to procedure to check charts, verify H&P and consents (had to wait on anesthesia to sign - she was running late). For all the surgeries I helped put the pt on the table, watch them both nurses go thru the checklists and timeouts that they seemed to know by heart. With Orthos I helped the scrub tech get gowned up. Both of them had me do sponge and sharps counts along with them (I think they wanted to be sure I kept busy - they darned sure didn't look like they needed help), and I went to get fluids from the warmer a couple times. During the CABG was the only time I did something other than stay on the circulator's shoulder - I did observe the bypass machine and got a "this is how it works" from the tech, plus anesthesia let me take a look from his position at the CABG for a minute as the surgeon was setting up the second jump, and the FSA showed me how the robot worked on the harvest site. But mostly I stood/sat and ran with the circulating nurses, and the Cardiac one was kind enough to explain everything she was charting, so I actually had a clue what was going on when I went to the ortho surgeries (they were a lot bloodier, especially the hip replacement). I also helped "turn" the room, fetching equipment, etc, for ortho.

It sounds like OR could be a promising career for you. How to get started? If your hospital doesn't have or is willing to provide lateral opportunities, you need to find a good program. Ideally, you want a large teaching hospital with a minimum 8 months of orientation/internship - if you are serious, don't let pay or location deter you from a good program. My own program was over 8 months as I rotated through every service scrubbing (no techs made that easy at my first job) and circulating. In such an environment, unless you land on a specialty team, you will likely not feel comfortable for over a year. For myself personally, I would have been fine after a year and a half as a generalist (no specialty) but I wanted CVOR so it was close to three years before I hit the road for the next 20 years as a traveler. It turned out my hospital did an excellent job training me, and I still pull bits I learned from orientation for odd cases such as an emergency aneurysm clipping (craniotomy) or eye surgery.

You can also dip your feet into the water at a community hospital where you might have as little as 2/3 months orientation. That is OK, but... I have seen great nurses from such a background, but many of them were scrub techs before nursing school and so had a leg up. My bias towards teaching hospitals is clear, but there is little doubt that transitioning down in complexity is easier. Some of your possible choices will have to do with your career ambitions. And frankly, I was lucky - most people end up in certain careers by happenstance as did I (both nursing and surgery). My way is certainly not the only path.

I cannot comment about restricting choice to programs that utilize Periop 101. Nice to have an academic structure that is well tested, but the other aspects of a good orientation such as oversight by nurse educator and a motivated, competent, and supportive staff are probably more important.