The First Year: So Much Learned, So Much To Learn

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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...

On Anxiety:

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.

The First Year: So Much Learned, So Much To Learn

On Anxiety:

On Critical Thinking:

On New Grads in the PACU:

Finally, On the Magical First Year of Nursing:

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