Into the Fire
Despite a few bumps as they navigate their first steps into the working world, new grads have no doubts about their chosen career paths

By Beth Ulrich, Ed.D., RN, and Michelle Paolucci
January 6, 2003

Mark had handled five or six codes in the ER so far. And, as a student nurse just months ago, he had never even seen a code. But the veteran nurses were aware he needed experience, so they made sure he was involved whenever a code arrived. He documented on codes; he pushed meds. He even had the opportunity to take a directing role during a recent code. Mark was starting to feel confident.

It was a busy day: The ER was down five nurses and no beds were available. "I think I am getting this," he thought to himself as he buzzed around taking care of patients. Then, the "tombstone" arrived.

Mark is just one of a number of people who entered the nursing profession this summer. He is also one of a diverse group of new nurses that NURSEWEEK set out to follow in the first year working in the profession.

When we left our new nursing graduates in the first chapter of this series, most had experienced a mix of elation and trepidation (you can access the first installment of our new graduates' nursing odyssey, "Finding Their Way," on our Web site at www.nurseweek.com/news/features/02-07/graduates_print.html). Some pondered the enormity of the responsibility that nursing held for them and some just couldn't "think" anymore. Most just wanted to start their nursing careers.

The interview

As our new graduates looked for jobs, they kept diaries to document their interviews, noting what they liked and disliked. Among the positive items were organization, informality-such as when the interviewer did not sit behind a desk-being given scenarios to test their knowledge, being able to talk with staff on the unit for which they were interviewing, and being provided with information about the hospital and the unit.

On the negative side were interviewers who were late, interviewers and recruiters who did not follow up with the new graduate, and interviewers who transmitted the feeling that the interview was an imposition.

One new graduate said: "When I arrived for the interview, it appeared that I had inconvenienced the entire staff. Although I had an appointment, I waited for 45 minutes to be seen by Human Resources. Then, when they called the unit for me to meet with the manager, I again was given the impression that I was inconveniencing them."

Another said that the manager interviewing her brought up personal information about some of her employees and kept saying that she (the manager) wasn't the favorite person on the unit right now. Obviously, in neither of these two cases did the new graduate take the job when it was offered.

But although some of the new nurses had bad interview experiences, others were so eager just to get started that they worked through their disappointments.

Orientation

Jennifer, a new nurse living in Michigan, found her first months on the job a refreshing change from the waiting period between school and taking the boards. Like most of the new nurses we talked to, Jennifer was going through an orientation program at her hospital. She said she was disappointed that her orientation was not for new grads only, but that the nurses on the NICU unit she was working with were helpful and encouraging.

"The nurses on the unit are very welcoming and answer my questions. I have received a great deal of advice from many of them," she said.

The wait after she graduated was nerve-racking for Katie from Ohio as well. When it came time for orientation at her new job, she was relieved. "I felt as though my whole life was on hold," she said. Once there, she had nothing but good things to say about her hospital.

"The biggest thing that has surprised me is the overall positive and uplifting attitude throughout the whole hospital. It seems like the hospital has done everything it can to make life easier on the nurses," she said.

Katie is also on an internship at her hospital, with a six-month orientation.

Rebekah, a new nurse working at a small hospital in Illinois, has had to make the transition from training at a fast-paced medical center in Chicago to a smaller hospital in the suburbs.

"What surprised me the most was the day I saw my first metal bedpan," the new nurse said. "I thought it was a joke."

But she also was surprised at how the small hospital manages to keep up with medical technology where it counts.

"The small hospital does a wonderful job staying up with medical advances, while keeping what works for them," she said.

Bait and switch

Most new nurses we talked to appreciated the opportunity to be a part of longer orientations geared toward new grads, but some were not as happy with their programs. Orientation, when it involved mostly classroom activities, was boring and disheartening. The new grads came out of school excited about being nurses and ready to care for patients, only to end up in a classroom for weeks.

When asked what they wished they had learned in school, their wish list ranged from how to communicate with physicians to simple tasks such as how to tie restraints or administer IV push drugs.

"I wish so many of our tests had not been multiple choice," one new nurse said. "I think I would have had a better concept of how to care for a patient with a certain disease if the answer wasn't sitting directly in front of me because in real life, there are no multiple choices."

Other new graduates said they did not feel well prepared by their new employers either.

"I was told that, during my orientation, my preceptor would have a smaller patient load to allow time for [my] orientation to policies and procedures," said Erin, a disillusioned new nurse from Colorado.

Erin found it frustrating that she was left on her own while her preceptor was admitting new patients.

"There have been only a few days where we have discharged several of our patients and been left with three or four patients. My preceptor has had to take on one or more admissions every day," she said.

With nine weeks on the floor under her belt, Erin told us she did not feel ready to take on patients on her own. "I have seen a new nurse who graduated in December having to give blood to three of her five patients. To me, that is very scary. I am very nervous to start working on my own," she said.

Erin said that even though she is told that as a new nurse she won't have to take on a patient load on her own, she doesn't believe it.

Some new nurses found that in the moment they rose to the challenge, even if they didn't think they were ready. The training they received in school and the little experience on their new units were enough when it needed to be.

As Mark saw EMS approaching, he acted quickly to move a stable patient out of a bed to make way for the new arrival. They had brought the patient in from an isolated part of the county. Mark got a quick history from the EMS staff as they rushed the patient into the ER. They told him they had given the patient three "nitros" on the way. They ran a 12-lead on him showing an ST elevation, commonly known as a "tombstone," because it usually indicated death was near.

Mark took the patient's history. Both the patient's father and brother had died of heart attacks. Midsentence, the patient arched his back, holding his chest. His face was grimaced. The nurse quickly marked the time on the patient's chart. 18:22.

"Check the EKG," he said to himself. "V-fib!" He screamed for the doctor as he simultaneously put his hands on the defibrillator pads and placed them on the patient's chest. The doctor arrived. Other nurses came to Mark's aid and started chest compressions.

"Shock him," the doctor said firmly to Mark. They achieved a good sinus rhythm on the first shock. Mark looked at his watch and it was only 18:24. Just two minutes had passed. He was still shaking, but he was glad he just happened to be at the nurses station when the "tombstone" arrived.

Making a difference

Not all of the new nurses we talked to had the type of opportunity that Mark had in his first few months, but many said they still felt just as proud and validated that they had become a nurse. Few had regrets about their career choice.

Julia, a new nurse from Arizona, pointed out that despite the dire situation of the nursing shortage in her state, she still feels inspired by the nurses she knows, even if they are burned-out and frustrated.

"The most important thing I've experienced is that this is a tremendous opportunity to make a difference in the profession," she said.

When it came time for Julia's pinning ceremony, she chose to be pinned by three nurses who she said influenced and reinforced her career commitment throughout her education. With 50 years' nursing experience between them and diverse educations and nurse training (diploma, technical and bachelor's), Julia said these nurses inspired her with their compassion, commitment and caring. She said it is their example that makes her challenge seem small.

"I'm thinking my biggest challenge will be to keep my focus on professionalism and remember that the reason I chose nursing as a profession is because I know I will make a difference," she said.

Later in his shift, Mark went to the CCU to visit the man who had coded right in front of him. The man's family showed him their appreciation. As Mark watched the family, he felt a warm feeling wash over him. It was nice to see the family so happy and to know that he was a part of why that was possible. It was so nice to see the right things done, to make a difference. "That's why I got into nursing and why I wanted to work in the ER, to make a difference," he thought to himself.

Contact Michelle Paolucci at michellep@nurseweek.com