Nursing school is a monster of a program that asks you to take two years and learn how to question physicians, advocate for strangers, dive into the most devastating tragedy of your patients medical condition, consider the nebulous web of social dynamics at play, protect the patients safety and never do harm; and do all this for 4-6 patients at a time with unending empathy, consideration, and compassion. By the end of such rigorous training, you walk away feeling pretty confident about certain things and terrified of other things. Each is different between new grads, the things that excite us or terrify us.  What nursing school does not do is teach you how to function successfully in a new work environment as a new hire as a new grad.  From day one you will see things happen that don't make sense to you in your NCLEX programmed mind. Shortcuts, short-hand, prioritization, cutting off family conversations mid-sentence, multitasking, and countless other nuances of personal practice that skirt the edge of policy and may be things that nursing school said were not OK. The following is intended for the new grad RN who may be struggling with their new job and trying to be successful when the target of what’s right keeps moving.  First of all: You are not alone.  We have all been there and most nurses can relate directly to your experience, even the nurses that are doing the things that trouble you. Second: Remember, it gets better. 

Be New, Be You: 

For you to judge so critically the unique practice of your preceptor (outside of obvious safety concerns, for these please go straight to your manager), is to call into question the experience and skill earned over years of making mistakes and learning. The average nurse uses all kinds of tricks to keep themselves on task and on point between patient and doctor and family and facility and manager demands.  Begin your job with an open mind, and try and learn how and why these less-then-optimal strategies are used.  A nurse probably prioritizes breaks over patient care because before you came, the hospital cracked down on breaks and obeying the law with regard to labor. The nurse might choose to do an assessment later with a bed bath because other patients are more time sensitive and the hallway assessment is an art you have not yet developed. Perhaps the chatter at the station is excessive, the focus on med pass instead of education, and family updates are not as consistent as they should be.  When you see things you want to be better at, then be better at them, but do not assume you know better than your more experienced nurses. How they practice is a highly evolved and specialized set of skills so nuanced we have a term for it; "your way of doing things" or more appropriately, "your practice" BE NEW: Let yourself be taught, and hold your criticism for a time when you can be contextualized and constructive if you have issues. BE YOU: Decide what you want to be better at, and be better. Make your practice what you want it to be. Just like any education, your mentor and preceptor are the teachers whose job it is to present information. It is your job to synthesize that information into meaningful and adaptable knowledge for the service of your patient.  

Dedication to Your Practice is Paramount: 

You may have hoped that when you got out of nursing school you would be done grinding books and staying up late memorizing drug interactions and body parts.  This could not be farther from the truth.  In school, your study was for an abstract goal that one day you could have a job. And when you didn't, that mean teacher or clinical instructor would ruin your entire future by lowering your grade. These are small potatoes, my friend.  Now, when you don't know that drug interaction, or don't know what that body part does, or can't remember what those chief complaints mean: someone's life is in your hands.  Your ignorance can literally and permanently hurt someone by either directly adding to a problem or failing to recognize it.  

My Mistake

I had a patient who was a GI bleed. He came to me a few hours before the change of shift from the ED. He was having a BM and was very uncomfortable. I cleaned him up and tried to make him comfortable, but he was very vulgar and mean. Fresh out of prison with no real support network, he was the poster child of "waste of oxygen".  But I wanted to be a great nurse, and I wasn't going to let this criminal be the one who jaded me. So I was companionate, and I cleaned him, and as he would have another bowel movement, I cleaned him again. Warm wipes and fresh bedding each time. After three bed changes, I was time to get ready for report. I gave report to the next shift, proud that I had given this man a taste of dignity and respect that I believe everyone should get. The next day I learned that he died. Because he was a cancer patient, his blood transfusions had to be specially prepared, further delaying the necessary and life-saving therapy. He went to a special nuclear medicine test to try and find where the bleeding was coming from, and he died.  This man's death was certainly not entirely my fault, his recovery would have been difficult, to say the least. But what did it do to save his life? There are things that you just don't know and don't understand until it is your turn to make the call. When you become lazy as I did with your practice as a nurse, you miss all the little red flags of what the real priority is. I should have let that man sit in his stool, and made a phone call, asked for help, ordered blood early or made sure it was ready, had labs drawn, really almost anything other than what I did would have given him a chance to live another day.  For me, that was the day I decided I would every day grind and study and learn to become the best nurse I can.  

Every day at work as a new grad, you will see and hear things you have never experienced before. You must write these things down. A journal of your first year is a huge asset for two reasons: It will be therapeutic to process your days as you perpetually feel like a failure. This is a normal process and if you can see your progress and learn from past experience you will fast track your emotional stability in this very demanding field. Secondly, you should devote about 4 hours a week to review your experience and learn what you didn't know. Connect that patient, their presentation, that situation, and your course of action to the pathophysiology, and best practice, and industry recommendations. Next time you should anticipate the correct decision instead of impeding it.  

Surround Yourself With Good Ideas:

As early as possible, become a full blown member of at least one or two professional organizations related to where you work. AACN, ENA, ASTNA are three that I belong to due to my critical and transport care career. I am flooded with improvements in practice, conferences, case studies, and other information that keeps me current and stimulated in my job. This is part of being in this profession. It's inexpensive given the discounts on material, lectures, CE's and conferences you get.  It's a must! 

Always be a student of things you don't understand. Stay comfortable being uncomfortable by finding ways to challenge yourself and grow your knowledge. If you don't like neurology, take a class. If you don't like pediatrics, shadow the department or get your PALS and NRP.  Life is uncomfortable, and when it gets really uncomfortable, people go to the hospital. If you can't handle your own sense of being uncomfortable, how can you ever hope to engage a patient to get beyond a colostomy, or an amputation, or a rectal exam? Make courage your normal in your own life, and it will be genuine and more companionate in your work.  

Politics: 

The story I tell people is that Nursing, for the sake of argument, and to highlight a historically dark underbelly of the job; is that a long time ago a bunch of women were tired of being treated as doctors' secretaries. So they got together and decided that they didn't have to be doctors to know what was good for a patient.  So they came up with their own "Nursing Diagnosis", often times as parallel but also in conflict with a physician's diagnosis. Heart failure is a doctors diagnosis by labs and x-ray. Nurses call that, "Fluid Volume Excess", and we do things like listening to lung sounds, take off the tight sox's that leave indentations and elevate extremities so that the swelling is in their thighs and armpits instead of their shins and wrists. With that diagnosis, you restrict patients water intake, but that is not always the right thing to do. So after creating a whole subset of treatments and treatment plans, nurses started getting degrees. First Associates, then Bachelors, now you can become a Doctor of Nursing (oxymoron.. not anymore). This striated and hierarchical system had CNA's who later became LVN's, who later became RN's, each with progressively more responsibility.  Today many nurses, maybe even you, have Masters degrees in Nursing with no patient care experience outside of clinical rotations.  Emphasis on education instead of clinical experience is a remnant of that old world thinking; “I’m just as smart as you even though I’m not a doctor.”  Ask any doctor worth their salt and they’ll tell you that good nurses often are the driver for great care.  Simply by our experience and close contact with patients, we are able to keep a close watch and direct our patient's course of healing.  I encourage you to continue your education as far as you can but do not be so foolish to believe you are a better nurse because of your degree.  A great nurse is someone who knows how to be in the real word with tangible problems and deliver tangible solutions. Your education is fertile soil for great practice, but the experience is the rain that brings your practice to blossom. 

Today, new nurses often think they know better.  Not so long ago this was never an issue thanks to an aggressive hazing process.  For decades we would "eat our young", because those who had it hard, give it hard.  This kind of double standard socialization got out of control, especially since as a society we have become more sensible and sensitive.  Difficult-to-access and hard-to-impress fraternities used to be something aspired to and drove many to try harder in the wake of the industrial revolution when a challenge was equated to opportunity.  Today, we focus on inclusion, eliminating biases, and promoting equal access.  Lucky for you newer nurses, in today's hospitals you see encouraging and supportive new grad programs that seek education first.  What you experience as hazing is usually just correction and promotion of good practice. Please see above "Be new, Be you" 

The rules of how to play nice in the sandbox have not changed, though.  With the ever increasing pressure of budgets, your commitment to a department and teammates matters a lot. The more a department invests in you to be a great nurse, the more you must respect your part of the bargain.  Nurses today are like every other worker in that much has changed in the philosophy of employee loyalty.  No one sticks around for 30 years for a gold watch.  Remember that this industry is not in a nursing shortage; it is an experienced nurse shortage.  Keep bouncing around and you'll have lots of exposure but no experience and a lot of explaining to potential employers why you didn't return on the hospital's investment. 

Pushing to Hard:

Not all nurses are made equal, and you least of all.  The new ideas you bring, your enthusiasm and creativity are the fuel to move our industry forward.  But you must remember that at first, no one is getting on your boat. You have no boat.  The hospital has decades and hundreds of millions of dollars in inertia for the goals and directions it has.  If you want to make it better, you must first be patient and prepare to play the long game.  Become a part of the current system so that you have a voice and a context for what you want to do first. Otherwise, you are just making noise and frustrating people, no matter how sexy your ideas are.  

If you want to work in some department other than where you are, be honest with yourself about it, and stay silent to your peers. Excellence, where you are, will get you farther than talking about what you would rather be doing. 

Accept the duplicity of circumstance: 

Life is very complex, and in medicine, we are face to face with some very complex situations. A patient may want to be DNR, but the Power of Attorney won't let them go.  A patient healing from a botched home abortion is next to a patient who despite all precautions lost their 3rd child.  The juxtaposition of circumstance, the double meaning in a situation; these you must be sensitive to.  To loose a child is a blessing for one, devastating to another.  Being intubated is unacceptable to one, pleaded for by another.  There are similar duplicities of circumstance with regard to how you interact with your peers and navigate the nursing gauntlet. Remember these concepts;

1. Asking for help means that you can't to it;  and can also mean that you are a collaborator without pride or arrogance who prioritizes safe practice.   
2. Offering to help means that you are a team player; and that someone else looks like they are struggling. 
3. Enthusiasm for a future goal can mean that your current work isn't good enough, and others who don't have similar future goals may feel insulted as you think they are lesser than you.
4. When things are chaotic, change and progress are very difficult. Create a sense of stability and be someone others can depend on. Then your influence and power to enact change will have some teeth. 
5. Be honest about what you want to do: if you work in a job that is not your first pick; decide to quit or decide to stay. Comparing the "other" job to this one is like comparing your old girlfriend to the new one.  It stops any chance of you growing or learning to love your new job. Be fully present where you are; either decide to leave or decide to stay (even if just for now).

Being a new grad is an amazing adventure.  You are entering a field that changes so fast that what you learned in school may already be against policy or best practice.  Accept that this is a dynamic and challenging field, and it will give back to you a sense of accomplishment, fulfillment, and purpose.

Final Thoughts: Show Me The Money

The part that no one talks about is the financial benefit of being a nurse. Many nurses, including myself, have gone from making minimum wage to making more than our parents.  This sudden jump in income can be a blessing, but also a curse without discipline.  Remember the Lottery Winners Curse, when you are not careful with your money, you will lose it.  The easy solution is to create a strict budget. Here is how I do it:

Every hospital has a direct deposit option for paychecks. I direct deposit into one bank that I have no card for.  The same day I bill pay from that account a set amount that is less than my paychecks to an account at a different bank that I use as my "Primary Bank". From this set allotment, I pay bills, save, drink coffee, pay retirement, donate to charity, and plan for vacations. The amount that is let behind in the first bank is out of sight, out of mind, and never touched. You will be amazed how quickly you can save if you just don't spend.  There are no tricks, no games, and no easy wins. The only way to financial freedom is to have money instead of debt.  Work with your financial advisor (I mean, make sure you find one and get one ASAP). If you are like most new nurses who used to make half or a fourth of your new salary before nursing school, then give yourself a very modest raise and save the rest. Your goal should be to save half your income.  This way, every year you work, you could take a year off. Just let that sink into your mind for a minute. 

Lots of nurses run out and buy a house and a new car.  What you can afford now, what you really need, and what you want for tomorrow are things each of us learned in our own time.  If you start super strict and conservative, your only option is to spend more later. If you start generous and spend it all now, your only option is to spend less.  It is much harder to spend less later. 

Good luck and God Speed in your new career.  Remember in all your dealings, "Be Kind, Be Honest, Be What's Needed"