Monday, May 03, 2010

OMG WTF AM I DOING HERE? A guide to your first months as a nurse (with special thanks to Pip)

When I was a new-new nurse, like my first six months on the job, I would show up way early for work every morning and pray in the hospital chapel that I wouldn't kill somebody. I was scared--constantly terrified--of all the mistakes I could make, of how little I knew, of how easy it was to screw up and do damage.

Slowly, those feelings went away. It took about a year and a half before I could say "I'm a nurse" without feeling like a fraud. Watching other new nurses go through orientation after me really helped--it showed me exactly how many people are watching your every move as an RN.

So, and with full thanks to Faithful Minon Pip, who said, "Yo, dude, you need to write a 'surviving as a nurse' post", here are tips for Surviving As A New Nurse, Dude. Yo:

1. Pee.

This is the single most important piece of advice I have for new nurses. Right after report, but before you hit the floor, pee. Emptying your bladder will clear your mind and take one small worry away. With any luck, it'll be hours before you need to pee again (unless you're me) and you'll have a chance to get things done before then.

2. You are not going to kill anybody. No, really, you're not.

There are three reasons for this, so I will subset them under the main point:

A. Humans can take an unbelievable amount of damage before they keel over.

You're unlikely to do the sort of damage it would take to kill somebody yourself; it generally takes a fair number of tiny mistakes that add up. At every stage of the way, there's the chance to ask questions, to catch problems, and to stop bad things from happening. Your job, therefore, is to be The Elephant's Child and ask questions about anything you don't completely understand and feel comfortable with.

B. Everybody is looking over your shoulder.

Yeah, you as the RN have ultimate accountability and responsibility for what happens, but remember: you have other nurses, pharmacists, and docs checking you all the time. Lean on them. See "asking questions", above.

C. Humans can take an unbelievable amount of damage before they keel over.

This is exactly the first point, but I'd like to take a different tack on it: I have had patients with potassium or magnesium or calcium or pH levels that were totally incompatible with life, and those patients weren't even all that sick. I have had patients with blood pressures that would make your eyes bug out and others with pressures that made me wonder if they were perfusing everything. I have had patients missing legs, arms, and (once) half of a body. All of those folks lived, and they all did mostly fine. It's all about what that person is used to. For some people, walking around with a calcium of 5.3 is totally legit.

3. The First Rule Of Nursing Is: If You Have To Fuck With It, It's Wrong*.

There was a story years ago about a new nurse in my orientation class who ran oral contrast through a central line, thus injuring (but not killing) her patient (see, we really can take a lot!). In order to do that, she had to set up a Rube Goldbergian series of tubes and connectors, find a certain type of syringe that would fit the end of it, and then administer the oral contrast bit by bit, because it's very thick stuff.

Think of how much she had to fuck with that to make it work. If you're having to force something to make sense or work, STOP. Look around. Ask if you're doing it right. Medical equipment, med-administration rules, and protocols are so bulletproof these days that it's work to screw them up.

4. Find somebody whose shoulder you can cry on.

This might be a preceptor, a fellow orientee, a more experienced nurse, or your mom. Whoever it is, find that person and use them as a sounding board for when you do something really stoopid. You *will* do stoopid things now and again--all nurses do, all through their careers--and it's important that you find someone who understands and can make you feel like less of a donkey.

5. Remember that things will get easier.

It's hard at first to get your skills and time-management and organization down. You might miss lunch or end up with a bladder infection, but that will change. Eventually, some things will become so second-nature that you'll have to double-check to make sure you did them. Eventually, changing a bed with a patient in it will be simple. And eventually, you'll have time for lunch. Don't despair.

6. Don't be afraid to ask for help.

Delegation is a beautiful thing. Find the people who are willing to help you and lean on them.

7. Don't be afraid to ask questions, even stupid ones.

I ask questions all the time, sometimes the same ones over and over in a shift. Nobody thinks I'm an idiot. Obsessive-compulsive, yes, and perhaps with a little short-term memory deficit, but not stupid. They do it too. Questions are good.

8. Be kind to the techs and the unit secretary, for they will save your ass someday.

This one needs no explanation.

9. Likewise, be kind to the doctors, for mostly they love to teach and are fairly nice people.

If you find one who's a jerk, avoid him or her at all costs until you feel more confident. Nothing will make you fade faster than being yelled at by an asshole with "MD" after his/her name.

10. And do find time to be kind to yourself.

You didn't spring fully-fledged from some god's forehead, and neither did any other nurse currently in existence. Even Cherry Ames screwed up now and then, and she learned things every day of her career. You will, too. Be easy on yourself: you've taken on a very tough job, in a challenging, rapidly-changing profession, and the whole of it is something that nobody but another nurse could really understand.

*Funny story about Jo's First Rule Of Nursing: I had a student precepting with me the other week in the CCU, and I told her as we started, "Remember: the first rule of nursing is, 'if you have to fuck with it, it's wrong'." She immediately said, "Oh, my gosh! You read Head Nurse, too! I love that blog!" I concurred solemnly that the writer was a damn genius, the crafter of elegant and spare prose without equal in the world today, and then we went on with our day.


Penny Mitchell said...

I totally agree with what you wrote about the writer of Head Nurse.


Loki said...

Do not ever stop writing.


Uro*MA said...

jo, i agree, please don't ever stop writing.. I love reading your posts! Also, i vehemently agree with #9, given that i have had the honor of working with a said asshole, MD. Keep far away until you are more than comfortable to hold your own. This has saved me a few times from wanting to smack said MD but, none the less when the time was right... so was i and all he could do was scoff... You rock jo!

bobbie said...

LMAO about the writer of that blog!!! I hope she keeps on keeping on too ~

bobbie's first law of nursing ~ if it ain't broke, don't fix it.
bobbie's second law of nursing ~ never make work for yourself...

After that ~ it's all "The Laws of the House of God"... I STILL love that book!!!

C. Chen said...

Rule #8 is universally applicable, especially to interns. I learned that one early on in my intern year, and my stat radiology orders usually do get done stat as a result.

Anonymous said...

This is now printed and on my fridge!

Pip said...

Thank you, this turned out an amazing post and will definitely be referring to it once I start nursing school! Im with everyone else, if you stop writing, how will we all cope?? Think of us!! :)
Thanks again xx

Joy K. said...

Rule #1 is vitally important for teachers, too. Never pass up an opportunity.

messymimi said...

My fear (terror) of someday killing someone is what kept me from going into medicine, although I always loved the idea.

Great advice, and #8 applies to every person you will meet. You never know, as the mouse said to the lion, when a favor will be returned.

So, when will you start working on a book? I will pre-order.

#1 Dinosaur said...

All equally true for med students and doctors. Linked here.

Anonymous said...

Wellllll... I guess you've just revealed your identity. Lol.

As a tech, thanks for #8. There have been several times of me catching something "not right" with the pt, i.e., the pt's diaphoretic, skin's cold and clammy, not alert... I suspect hypoglycemia, check the blood sugar, and sure enough, it's 29. Or finding a pt on the floor. Or one whose pulled out their chest tube, I cover it with vaseline guaze. I'm currently in nursing school and I've run through several nurses that don't appreciate PCTs/US, and I solemnly swear to never be like them once I get my license.


Sara said...

love it, as always ... wish i could be a tenth of the nurse (and writer) that you are!

i would add two things:

#1. pee AND drink water! its important to stay hydrated so you can stay awake and alert.

#8. be nice to all the hospital employees. they may not save your ass to the same degree as a tech or US, but you never know when you'll need an environmental services tech to clean a patient's room quickly or a food service worker to translate.

please, please, don't stop writing.

Jeff said...

Stoked to find your blog - working on knocking pre-req's out so I can start my BSN program next Fall (2011). Leaving a full-time job in corporate (blah) culture so I can do something that matters. At age 30, seems like a good time to switch to a career I can pour myself into.

Thanks for speaking to the new guys... and us soon-to-be new guys :)

Looking forward to future posts!

Unknown said...

OMG thanks man! I'm wondering when I graduate how the hell I'm going to remember all this stuff...this totally made me feel better! :)

Anonymous said...

I am a new grad who recently accepted a position in a nursing home. I read the philosophy, mission statement, and also the employee handbook of the organization. I thought about my answers to possible questions. Yet, during the interview they DID NOT ask me one question! I was hired! I was excited and also dumb founded at the same time. I was so shocked all my questions I was going to ask suddenly vanished and I only asked them a few questions.

After the excitement wore off I realized oh my gosh! The RN director didn't fully explain where I will be and the orientation process. She said it would be about three weeks! To me that is short! Now I am freaking out, I will be doing a night shift in a Nursing home so that probably means I will be alone! Just me no other nurse, no doctor, no pharmacist, nada! Just me!
Now, I am thinking of everything that can go possibly wrong, all the little mistakes I am most likely going to do. I need to find out the chain of command. I really hope I have a good preceptor and not another nurse who has only eight months of experience.