Paths to nursing specialty?

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    Hi, folks. Just wanted to get some feedback from new and experienced nurses on this one.

    I've just started my 400-hour clinical immersion in the PACU and LOVE IT. It was what I wanted and applied for, and so far it seems like I have found my niche. I have a long way to go, but it's a journey I will enjoy, at least through the end of school: it appears that most PACUs won't hire new grads. My preceptor said that if I could find a hospital with a residency or strong orientation program, that might be the exception. I know there might be other exceptions if I do a great job, but frankly, right now I'm just trying to get through this last year of school and will revisit that in the fall when I get ready to graduate.

    Here's the question, though: what IS the best route to the PACU? Or any other specialty, for that matter? When I look at the experience of the PACU nurses I've met, it varies widely. Some worked med-surg, MANY worked ICU, others were on special units like cardiac or in the ED, and a few came from LTC. I'm not here to debate the advantage of getting experience before working in the PACU (I debated that in a previous post!), but I'm a bit frustrated at the apparent lack of a "track" to enter this or any other specialty area.

    Nursing as a profession struggles with the issue of a single educational path (AD vs. BSN vs. direct entry MSN like mine). I think this issue is just as important. When a person decides to become a cardiothoracic surgeon, the path is clear: 4-year college, 4 years of med school, general surgery internship and residency, then specialized training in CT. If the person wants to be a nephrologist, the path is school, then internal medicine residency, then fellowship in nephrology. Very clear, very cut and dried.

    In nursing, there either is an optimal way to get the experience necessary to work in a specialty area or else it doesn't matter. When some folks tell me that new grads CAN work in the PACU and everyone else recommends a different path to get there, I start to wonder if this is tradition, or people thinking their path is best, or if there is some basis to it. Yes, I'm looking for the evidence base. I'm more than happy to work in the ICU for a year if it will in fact be the best preparation for me to work in the PACU. If there is a better path, I want to be on that one. But how do I know? ASPAN has developed a position statement regarding the AD vs. BSN issue, but I can't find any such document delineating the best way to become a perianesthesia nurse!

    This isn't limited to PACU. What about the NICU? As a mom of a former preemie, the idea of a new grad in the NICU is horrifying, yet a classmate of mine is doing his immersion in the NICU and I think he'll be brilliant. What would best prepare him for a career in the NICU--adult ICU? Pedi? OB/nursery? Or just being in the NICU with a strong mentor and preceptor? One area that does seem to follow a specific path is RNFA; one starts as an OR nurse with scrub and circulating experience, CNOR, then a preceptorship with a surgeon, etc. Why aren't there more paths like this?

    In my opinion as a student, having more clearly delineated professional pathways would simplify matters for those interested in specialties. It seems that many nurses meander their way into their current specialty, which can be a wonderful process full of rich experience. However, I know where I want to go, but I don't know quite how to get there.
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  4. 4 Comments so far...

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    I agree with you that its kind of confusing to navigate the waters of how to break into a new specialty. Even as an experienced nurse its not always easy to get someone to hire you in a different type of nursing. And yet I've managed to switch from CT surgery to hospice/home care to med surg and tele to CVICU and a lot of it depends on good interviewing skills. I always said I wanted to try many different things because otherwise how would I know I had found my true niche in nursing? So now I've found myself back in a cardiovascular environment and that's where I belong. That's kind of one of the beauties of nursing, huh? You can try something new without having to go back to school as long as you can find a unit willing to take the time to train you.

    As someone that went into a specialty area right out of school and lost a great deal of hair trying to deal with the stress of learning how to function as a new nurse (time mgmt, dealing with physicians, getting proficient at IVs/tubes/drains/etc without supervision and guidance) AND the additional stress of ACLS, VADs, temp pacemakers, ECGs, tele, you get the point...
    all I can say is I feel like I would have been much better served by a formal orientation geared to new grads. You can be successful without this but IMO its harder and probably less safe for the patients (we've all realized too late we did something we shouldn't have or missed something that shouldn't have been missed, luckily for most of us it causes little to no harm to the patient and becomes a good learning experience).

    So, not really an answer to your question - there are lots of routes to get into any specialty - which you already knew. I can tell you I did a project on this for my Masters - the literature seems to support that new grads are most successful in ICU environments when they are part of a formally structured, strong orientation that is geared towards new nurses. You would think it would be similar in other specialties but I have no clue if evidence supports my supposition because I focused on intensive care.

    So in my long winded, meandering answer...my advice to anyone new to nursing would be to search online for a new grad program specifically designed for their desired specialty. I know this won't work for everyone and there are other routes you can go to be successful (as a person that's been there done that). My gut reaction: I think if we actually took steps to standardize entry into various specialties, we'd be risking limiting our career options. Some places just don't have the resources to develop programs to bring a new grad into a specialty and not having a "Standard entry" gives those places the flexibility to still hire who they want and train at their discretion. I'll be watching this thread to see if I change my mind since its not something I've given a lot of thought to and I could possibly be persuaded to another position.

    Anyway, good post, its food for thought.
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    My opinion is that if a new grad knows what specialty of nursing they want to go in, they should be able to go directly to that path. Everyone is different and some may take awhile to find what area of nursing works with their strengths and interests. I don't agree with people who say you must do med-surg first for example, because that requires a completely different time-management and nursing process than having say ER patients or ICU patients. All nursing experience gained will be important to take with you no matter what specialty you go to, but I don't see why someone should settle on a path that just delays them to the specialty they really want.

    I work in NICU and went there directly as a new grad and don't regret the path I took. I know of great NICU nurses who also came in as new grads, and others who came from a background of OB, low risk nursery, adult trauma, pediatrics, etc.
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    I have no idea what courses are available in your country; in mine, there is an Anaesthetic and Recovery Room Nursing course, but you would have to find out if there is anything of that sort where you live.

    If you go into the PACU forum under "specialties", you will read numerous posts regarding new grads entering the field, and many conflicting opinions on the levels of experience required. I would suggest that you soak up as much as you can learn about airway management and anaesthetic agents, and if your preceptor allows you to do so, recover patients yourself under supervision; I'm a true believer in the value of "hands-on."
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    To add to what others have said, I think you've got a little bit of an advantage having 400 hours of immersion in the PACU. Divide 400 by 8. That's equal to 50 8hour shifts!! Emphasize this when you go for interviews! Also, make connections! Get in good with those other nurses and docs

    Also, what about talking to the manager of the unit that you're on? Ask her/him what they look for when hiring nurses for their unit. Express your interest and ask for tips! Who knows, maybe someone on the PACU is thinking of retiring and they'd be interested in an eager/enthusiastic new grad to replace them. Use those people skills Good luck!!!
    RNperdiem likes this.


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