How Long Before You Felt Expert as a Nurse?

[Pachinko]

I've been been a nurse for about 10 months. It was really hard in the beginning (REALLY hard, and demoralizing), but I've gotten better. Most nights I can roll through and get done what I need to get done and keep my patient safe. I'm still learning with every shift, but I'm getting better at asking the right questions and keeping my eyes open.

But I'll still have a night where I'm confronted with a ton of stuff I don't know about and end up making a stupid, obvious mistake or two. I notice that other, more experienced nurses are calmer and seem to be working more efficiently, while I'm running around like an idiot, staying after to chart, etc.

I know that you always have bad or overwhelming days no matter how long you're a nurse, but at what point did you feel expert enough to take it all in stride and know that you could handle whatever came your way? When did it become so instinctual that the fear new nurses feel went away?

[deeDawntee, RN]

Welcome to the humility of being a nurse. We all make mistakes. If anyone acts like they don't, I would be the most concerned and afraid of them, because it is a farce. If people aren't talking, it is because of their own shame of past mistakes, you can count on it.

You HAVE to be able to forgive yourself. You must be able to roll with the punches and keep going. It takes a very strong person to be humble and to allow imperfection. You do the best that you can. We are all "practicing" our profession. Practice, to me, implies attempting to perfect. Like a musician practices their instrument, to be good it takes practice.... same with Physicians.

Keep breathing, be careful, but don't let fear overwhelm you, you must keep it in check...follow your procedures and you will be ok and so will your patients!!

Another great question, by the way!!

[jjjoy, LPN]

I especially appreciate the comment about not making the same mistake twice, because that's sort of my problem. I'm feeling like I can't make the mistake once because someone may be hurt, depending on the mistake...

I've had a couple of extraordinarily generous and experienced nurses who talked freely about errors of the past (my favorite being the nurse who gave all of one pt's meds to the wrong pt...and this woman is one of my role models!)

Nursing is a second career for me, and I guess I'm still adjusting to the notion that mistakes in nu rsing are not like mistakes in marketing or retail or, basically, most other professions...I've never felt so ashamed of making mistakes at work nor so anxious about them.

I hear you, and would love to hear more feedback on how to mentally deal with mistakes and the fact that some will happen. Because there's the inherent conflict of an ideal to never make mistakes - it could harm your patients - and the fact that you have to make some mistakes as part of the learning process.

I remember asking in school questions like "What if this happens (some mistake such as give the wrong med)?" and the answer was usually "Don't make that mistake!" I'd get so frustrated because OF COURSE I'm going to be as careful and vigilant as I can but I tend to become paralyzed if I think I have to perform perfectly and if it's just some unknown chasm beyond each inevitable mistake.

But if I have some idea of how to deal with the bad "what if's?" then I tend to make fewer mistakes because I'm more mentally at ease. Of course, I can't foresee every possibility, but to at least have few examples to pull upon helps... so if a wrong med is given... ascertain the pot'l effect of the mistake, notify the charge nurse and MD and make any necessary interventions to hopefully correct the problem and minimize damage, write up an incident report after the patient is taken care of, etc.

Some people seem to fear that if they address the "what if's" of mistakes before they happen, and if they admit to learners that mistakes will happen and that most of them won't ultimately harm the patient (because they aren't that vital or quick action is taken), that it somehow gives a person the idea that it's okay to make that mistake or something like that.

I understand the potential dangers of making an even seemingly minor mistake in health care - that it could lead to pain, irreversible injury, death - and won't decrease my vigilance because of thinking "oh, that's not that important". But I need some understanding of how to realistically deal with human fallabilities, or else the fear of making a mistake will become paralyzing, leading to ineffectiveness.

[deeDawntee, RN]

I hear you, and would love to hear more feedback on how to mentally deal with mistakes and the fact that some will happen. Because there's the inherent conflict of an ideal to never make mistakes - it could harm your patients - and the fact that you have to make some mistakes as part of the learning process.

I remember asking in school questions like "What if this happens (some mistake such as give the wrong med)?" and the answer was usually "Don't make that mistake!" I'd get so frustrated because OF COURSE I'm going to be as careful and vigilant as I can but I tend to become paralyzed if I think I have to perform perfectly and if it's just some unknown chasm beyond each inevitable mistake.

But if I have some idea of how to deal with the bad "what if's?" then I tend to make fewer mistakes because I'm more mentally at ease. Of course, I can't foresee every possibility, but to at least have few examples to pull upon helps... so if a wrong med is given... ascertain the pot'l effect of the mistake, notify the charge nurse and MD and make any necessary interventions to hopefully correct the problem and minimize damage, write up an incident report after the patient is taken care of, etc.

Some people seem to fear that if they address the "what if's" of mistakes before they happen, and if they admit to learners that mistakes will happen and that most of them won't ultimately harm the patient (because they aren't that vital or quick action is taken), that it somehow gives a person the idea that it's okay to make that mistake or something like that.

I understand the potential dangers of making an even seemingly minor mistake in health care - that it could lead to pain, irreversible injury, death - and won't decrease my vigilance because of thinking "oh, that's not that important". But I need some understanding of how to realistically deal with human fallabilities, or else the fear of making a mistake will become paralyzing, leading to ineffectiveness.

You are definitely on the right track to dealing with potential errors!

There is a concerted effort in health care facilities to take some of the shame and stigma out of medication errors. Apparently, many go unreported, or even near misses go unreported because of people's fear and shame. The intent is to allow medication errors to be investigated from a system standpoint. Is there anything that is being done in the system that is allowing for medication errors to happen? Often checks and balances are instituted to offset some of the errors, or to allow for extra checks for medications that may cause more potential problems. (ie heparin or insulin) For the most part, you are not going to hurt or kill a patient unless you completely ignore procedures and protocols that are in place to protect the patients. Personally, in the almost 10 years I have been a nurse, I have heard of medication errors, but none have been critical errors. I know the statistics nationwide are terrifying, but most of the fatal errors are caused be Physicians.

I promise the fear that you are experiencing will lessen dramatically as you go on. There are plenty of nurses who have never really made an error except giving a medication late. Now that happens all the time, because we do the best we can and give the meds when we get to it. Technically that is an error, I suppose, but that just is the way it is. The two med errors I have made were wrong dosages in emergent situations. I was the only nurse on and once gave more Haldol IM than was ordered because I was in way too big of a hurry and I had an agitated patient freaking out and I doubled his dose. The other was giving too much IV Ativan for similar reasons. I felt like the worst nurse on the planet, because I really didn't know the impact, if I were to make those errors now, I would know that they were not life threatening and I would have a lot more compassion with myself.

The other potentially fatal error would be anaphylaxis from giving a patient a med they are allergic to if you mixed up two patients meds. and the only way I can think of that happening is if you pulled more than one patients meds out at the same time. I see nurses do it all the time, but I never have. Avoided that pitfall.

That is really all I can think of now. Perhaps you will get other feedback. I promise the fear you are experiencing now will begin to fade. Follow your procedures and you will do fine.

[babywhisperer]

Seems like 6 years before I was really comfortable. Like I really had a sense of systems and my checklist in my head that I used for initial assessment. Check the IV, it's your lifeline. Check the UOP and is there any edema? Any rales or wheezes? What's the quality of the pulses? What's the pt's sensorium like? Are the Vitals normal or what is askew? Always talk to them! You can make 5 min seem like 20 if you are focused on only them for that time and therefore setup your relationship from which to work during the shift and control the situation. Don't be adverse to haveing your own down and dirty checklist that you keep in your pocket to scan on each pt. It's very helpful and is good review if you need to know what you did w/ J Doe 4 weeks ago. Been a nurse for 31 years and still learn something new everyday (mostly about the culture of the unit @ this point) Hang in there and find a good mentor! The reasoning will get pared down and more succinct as you taylor it to your uses. Make it your own!

all the best

[maryloufu]

You know I am glad that you posted this thread. I have been a nurse for nearly a year and a half- and last month I was feeling better about my days, not feeling so freaked out- but the last two days I worked were so awful. I had a family that would just not leave me alone! I understand when your dear family member is sick and you are feeling powerless- but these people were clueless! I felt clueless as well- After giving the prn pain med just about every hour I was exhausted- never even thought of a PCA pump- which the oncoming nurse got immediately. I had a drink after that day and I rarely drink!

On the upside I did get 2 IVs on the first shot- and I was too worn down by my other patient to get nervous about trying!

Ah- well I guess the only thing to do is to just keep going and trying to never make the same mistake twice as some wise person said before.

Good luck- to both of us.:balloons:

[clee1]

An "expert" nurse does not exist.

I know nurses with 30 years experience, and they tell me that they learn something new each and every day.

An "expert nurse" is either a fool or a liar.

[Medic/Nurse, BSN, RN]

A few words about MISTAKES.

Yes, you will make them

Yes, I have made them.

Sometimes, they are bad.

Rarely, do they have any permanent consequences. (Thankfully!)

I think it was Pachinko and jjjjoy that have detailed posts on the "fear" of making a mistake. One even details how NO ONE else EVER mentions any MISTAKE so - maybe they are not making any. Hmmm.

I was recently joking with a friend that I thought it would be pretty therapeutic (and telling) if the next time "we" assembled - everyone had to share their 5 biggest dumb #$% moves! Yeah THOSE! (I work in a field where everyone tries to be the best and sometimes the tales get nearly mythical - no kidding) Most of the tales I hear started out with "Thank God we/I got there, you would believe what we had to do to __________, etc, etc...."

Mistakes do happen.

I have made my share. (and will continue to do so)

I do the absolute BEST I can, so that alone makes it a little "easier" to deal with.

So what can you do.

• Be studied and deliberate in your practices.

• I am into routine always and redundant checking for high risk issues

• When you do make a mistake - deal with the immediate. (Usually this means the PATIENT!) Remember to breathe, if necessary.

• Take care of the consequences IMMEDIATELY

• Paperwork and administrative issues CAN WAIT until the patient issues are resolved.

Main idea: Keep your focus. It is what it is. Do what you have to do and then move past it. Try not to get analysis paralysis on this - the what if's - you will just make yourself crazy.

Wanting to be a good, careful and accurate nurse is half the battle to getting there!

Good Luck.

Practice SAFE! (but what is that!?)

[llg, PhD, RN]

Here is what the research about expertise has to say about this question. (Mostly based on the work of Patricia Benner.)

It ususally takes 1-2 years after graduation for the nurse to reach the stage of "competence." At that point, the nurse feels that she can handle the daily workload and expectations. It's like breathing a sigh of relief and thinking, "Yes, I can do this job." So those of you in your first year of practice shouldn't expect that to happen for a little while.

Some nurses never develop beyond the competent phase. They mistake that feeling of comfort and competence for "expertise" and believe they have little left to learn. Others continue to develop -- particularly in the flexibility and complexity of their thinking more so than in the acquisition of more factual knowledge. Those people who recognize their ongoing needs for continued develop can go on to become experts. That usually takes another couple of years.

Experts are not the same thing as "know it alls." They do not know everything and recognize that fact. But they have a high level of knowledge and the ability to use that knowledge. They can handle complexity, ambiguity, and challenge in their work and perform well. I strongly suspect that some of the people in this thread who say they are not "experts" actually are experts. But as experts, they know enough and are wise enough to know that there is always more to learn.

[seenitallERnurse]

great question!

i feel for the newbies out there but you gotta keep plugging away.

in er, i actually do learn something new everyday--and i love it!

i'm so tired of "floor nsg" simply because i think nurses have so much responsibility, little help, and less time to get everything accomplished--not to mention the unforeseen interruptions from well-intentioned family members or just a change in the pt's condition. in my unit now, nurse/pt ratio is clearly defined but, being an er, we also have lots of teamwork. i'm not sure floor nurses have that luxury with their nurse/pt ratios set higher.

mistakes? i've made a few.

but know this, you do have safeguards in most hospitals--especially if jcaho comes through your institution. pharmacies are as careful as they can be packaging/labeling, the nurse has to check all the "rights" (time, pt, medicine, dose, route), and always stop and re-check orders if a pt legitimately questions a medicine you are offering them--trust them to flag an error, in other words.

i think it took a couple of years for me to feel "comfortable" but as hectic as nursing units are today, who could blame you for feeling so harried or overwhelmed?

keep plugging--and don't be afraid to ask questions.

[denashea1RN]

Thank you. As a new nurse, I am encouraged reading your post. Thank you! :)

[rita359]

I think EXPERT is probably not a good word to use as I can't imagine feeling expert in a field that is ever changing. It probably will take a year or so to feel more comfortable in your role. Each new role will require an adjustment period and each can and may throw you a curve ball which will make you feel less an expert.

[blueheaven]

I became more comfortable after a couple of years. I'm by no means an expert. I am always learning something on a daily basis. That's one thing I like about nursing, it's never static!