Bright Horizons
New graduates agree that the ups and downs of Year One have strengthened their confidence in nursing as a career (Last in a three-part series)

By Beth Ulrich, Ed.D., RN, and Michelle Paolucci
July 8, 2003

A muffled voice was on the other end of the phone. Jean, a new nurse, was the "nurse of the day," her first time taking all the medical calls for the public health department.

She thought about what she was told, "Remember: This is public health. We don't have emergencies. You can take a number, hang up, look up the answer and call them back."

The voice on the phone, in a panic, said, "There is blood all over the bathroom. I can't stop the bleeding." It sounded like an older woman who needed emergency care. Jean advised the person as she was trained: Hang up and call 911.

Later, Jean learned that the voice was a male friend of hers. She couldn't believe she didn't recognize him. She realized that because she was in professional mode, she never would have considered that one of her calls could be a family member or a friend.

She said she felt bad afterward, because in her former life she would have rushed over and picked up her friend and driven him to the hospital herself. But, it was the right thing to do, because her friend received the care he needed. He was treated and released from the local hospital.

For Jean, it was one of those moments in her first year as a nurse that marked for her that she actually had become a nurse. She realized she had crossed over to the "other side."

About a year ago Jean, along with 34 other 2002 nursing school graduates from across the country, agreed to take NURSEWEEK along on their journey in their first year as a nurse.

Many significant stops were made along the way: finals, graduation, boards, interviews and a lot of decision-making about what that first job would be. Our new grads, though, had options.

In journal-like fashion, they sent "dispatches" from the field-from the floors of hospitals, emergency departments and public health offices.

And, like Jean's pivotal moment, many of the nurses wrote about the moments when they had "the feeling" that they had become a nurse. For some, it was experiencing a patient's death for the first time or committing a medical error, but all had one thing in common: The experiences they had-the good and the bad-brought them more confidence that their decision to be a nurse was the right one.

This last installment in our Nursing Odyssey series offers some highlights of what the new grads told NURSEWEEK during their first year.

Reality sets in

We asked the new grads what they wished they had learned more of in nursing school. Most expressed their feelings of inadequacy when it came to clinical skills.

"More clinicals! IV therapy!" one new grad said. "And another thing I have come across that has been something I never got answered in school was what exactly can an LVN/LPN do?"

Another said, "Delegation and prioritizing are skills I think a lot of nursing students lack when we come out of school and then all of a sudden are expected to do it."

Some of the requests seemed specific and simple. "This is kind of dumb, but I wish that they would have taught us how to tie those restraints into the slipknot," one new grad said. "I have come into contact with that so many times, and I still don't think that I have it right. It's the little things that just make life so much easier."

In the first month, much of what we heard from these new grads reflected the natural anxiety that goes along with a first job. "Reality shock ... I thought that I had learned so much in school. The reality is that I will forever be learning!"

Personal growth

Checking in a few months later, we noticed the significance of whether a new grad had a consistent preceptor.

Preceptors clearly made a big difference in how well the new graduates developed confidence in their abilities-even in the first few months. New graduates who had preceptors and whose preceptors were consistent seemed to gain confidence more quickly and feel better about themselves as nurses.

Too often, however, preceptors were pulled to other assignments and the new graduates were left either without a preceptor or having to switch to a new preceptor. One participant said, "Sometimes your regular preceptor would not be scheduled on a day you were. This was the least helpful when it came to learning because all RNs have a different style in how they carry out the day's assignments. Whenever I was with a new preceptor, it was almost like starting all over again."

Anxiety levels fluctuated. In these first few months, our participants were still coming to terms with the fact that they no longer were students, but actual nurses.

This sentiment was expressed best by one grad who said, "This is such a strange feeling. I go from thinking, 'Yeah, I'm a registered nurse-not a student, grad nurse, intern, etc. A full-fledged registered nurse. I've got it going on.' "

She went on to say, realizing the other side of her new feelings of confidence was a test in humility, "Then last night, the charge nurse and I go into a patient's room and his heart rate is 40 and dropping, not breathing and the most amazing color of blue I have ever seen. She runs out of the room shouting, 'Call a code, call a code.' And I'm standing there like an idiot going, 'What do I do, what do I do?'

"I thought school was humbling enough, but apparently, I still need lots of humbling. I'm just taking it one day at a time."

Many family adjustments had to be made, too, once the new nurses made the transition from student to full-time nurse.

A lot of the participants were open in telling us what it was like to experience these adjustments.

One nurse said, "The past few months have been a period of a lot of personal growth. Since the end of school, I've moved out of my parents' house and have been introduced into the real world where working full time, bills and independence have come to life. I have had to make adjustments over the past few months-coming to terms with not having to go back to school at the end of summer, waking up at 5:30 a.m. to go to work four days a week and not seeing my best friends almost every day like I was able to when I was in school.

"I am overwhelmed at times. I like working and I love being with babies, but I miss being at home with my family. I have not seen my grandparents in a month. My house is always a mess. I don't cook very much anymore. I'm not as involved as I used to be. My poor husband can't sleep without me and most of the time I don't get enough sleep. I have trouble driving home because I am so sleepy. I'm still adjusting and I hope I can find a schedule at home we can live with."

A few surprises

What surprised these new nurses once they had a few more months on the job? Again, the issue of confidence was a big one, but they also made observations about the relationships nurses have with each other and the way they feel about their relationships with physicians.

One nurse said that she was surprised that she could do the job. "For so long, we as students and grad nurses work alongside someone and never think it's possible that we can actually do this job on our own," she said. "But, now that I am actually on my own, I know and feel I can do it on my own. That's a great feeling and it seems silly to have ever thought I could never do it."

"I am actually surprised at how well things are going so far," one new grad said. "I didn't know if I was really prepared to be on my own yet. But, things are going well and I am realizing that I was ready to do things myself."

"How the nurses work together as a team and are really there for each other," another nurse said. "I heard all of these horror stories about nurses eating their young and have seen it firsthand as a student. This unit is different and everyone has been very encouraging and helpful."

Many participants expressed the need for more training in how to deal with nurse-physician relationships. Several felt that they just were not respected. "The nurse-physician relationship is not that great; respect, respect, respect."

Two new nurses learned how important the nurse-physician relationship is when advocating for a patient. "Some doctors are downright rude to you," one nurse said. "I have learned that you definitely have to be assertive in order to be a patient advocate."

The other nurse said that she was surprised by how much she learned and the independence she acquired already in her practice as a nurse. "I have even stood up to doctors and questioned orders, something which I never thought I would do because of how new a nurse I was," she said.

'I love it'

"Did you make the right decision to be a nurse?" All of our participants said "Yes." The ups and downs in their first year seemed to strengthen rather than discourage them.

"Even though some days I come home exhausted and discouraged, other days I come home on top of the world and thinking, I am really good at this, and this really makes me happy. When people ask me if I like my job, I always say 'I love it' because I do.

"I love being able to interact with my patients on a daily basis and to get to know them and their families. I love being able to teach my patients and to sound like I know what I'm talking about. I love the fact that it's different every day and you never know what you're going to encounter at the beginning of each shift.

"I also love the flexibility of it. I love that my schedule is different all the time, and that I can make it as steady or as changing as I want. I also love that I can pick up extra shifts and that my doing so is making other people's lives easier. On good days, I really feel like I've made a difference in someone's life, and on not-so-good days, at least I know that I tried!"

Many found that nursing was even more than they had hoped for-more challenging and more rewarding. "Now that I'm actually doing nursing every day, I am so glad I decided to go into this profession. Since I've started my job, I've learned that nursing is so much more than what nursing school made it out to be.

"Nursing as a profession can be challenging, rewarding, frustrating, exhausting, exciting and much more. During nursing school, I don't think I ever understood what being a nurse entailed until now, when I've been able to experience it on a daily basis."

The theme of self-esteem was common in the responses of our participants. One nurse responded simply, "The rewards are more than I expected. The internal values, like self-worth, are even greater."

Contact Michelle Paolucci at michellep@nurseweek.com