Thursday, April 4, 2013

Advice for New Grad Nurses

The day has come! It's that first day that you are totally on your own at your first nursing job! No more clinical instructors! No more preceptors! No more agendas laid out for you! It's all you! It's a monumental day!

There's nothing between you and your patients now. You are solely responsible for your patients' care. You will be the eyes of the physician when he is not there. You are the advocate, the educator, the mercy-giver. You are the one the patient depends on. They will depend on your knowledge, your skill, your experience. Your decisions can mean their life or death. Your charting can mean your own professional life or death in litigation. And you will have nothing to depend on except that of what your instructors, preceptors, and teachers taught you...your experience.

No more clinical instructors. No more preceptors. No more agendas laid out for you. Its all you. It's a monumental day.

It's a paradoxical day.

The following story is my own. This is what happened to me on my personal version of that great day. I had gotten a job on a Telemetry unit in California and just finished a 3-month orientation for new grads. I had never been on my own before without another checking after me. Without someone as a resource. This is what happened:

I had gotten my report on my patients and started to make my rounds seeing each one...and doing my "head-to-toe" assessment like a good little nurse. I remember it was frantically busy. The other nurses were scurrying about like ants on an anthill. Patients were coming in on gurneys, the tele desk was alight with alarms and curly paper was being spat out in all different directions. The call light was continually screaming it's alarm, and no one was talking to each other.

My last patient to see was a post heart cath patient who had been out of his procedure for about 5 hours. The protocol back then was to have them lie completely flat with an 8-pound sand bag on their groin over the insertion site for 8 hours...applying pressure to the site to prevent bleeding. I entered his room and greeted him, and found him looking rather gape-eyed. "I don't think this is supposed to happen," he said. And looking down toward his groin there was blood lining his sheets. He lifted up the sandbag and blood spurted out of his groin like a broken water pipe, making an arch across the room. was my opportunity to apply all that I had learned. To be the one who "knows what to do." To make the choice that would make the difference between a critical situation, and everything being OK. Here it is. It all came down to this.

"Oh!" I exclaimed, "Let me go get the nurse!!"

Umm...Yes, I did that. I ran down the hallway and got the charge nurse who ran back to the room and applied pressure with her hands...and looked up at me like I was the complete idiot that I was. As soon as she looked at me, I realized, oh yeah, I AM the nurse. And quite frankly, I DID know what to do. I knew to apply pressure...I just...forgot. Or more accurately, I didn't put all the book-knowlege, the clinical experiences, etc, to a practical use. I could have probably gotten that answer right on a test, but in the real situation?...

And I'll tell you one thing... not a single care plan, out of the hundreds that I wrote in nursing school, helped me in that situation. Not a one.

Just saying.

So...I'm glad to say that I've grown over the years. I now know what to do when a patient is bleeding. :)

I tell you that story to make a point. I know that many nursing students come out of school with a specific specialty goal in mind, many being Labor and Delivery, and expect to go into it straight out of school. Many of you have contacted me for advice on how you can get in to L&D right away. I am glad that you all love my area so much, but you need to work on a Medical, Surgical, or Telemetry floor first. (Ah. I've just made some enemies.)

I'm afraid that in nursing school, you mostly learn how to take your boards You need to take the time to learn how to be a nurse. Go and put in some time on a Med/Surg or Telemetry unit. I would recommend at least two years to start. (Because it takes a year for you to figure things out, and another year before you truly can say that you're comfortable.) Once you've done this you'll have gained two very critical things. One being a good solid basic medical knowledge. (No, you haven't gained that in nursing school...not the kind I'm talking about.) The other being development of time management skills. Without these being mastered, no matter what you do, you will struggle. And let me just say that trying to nurse without having time management skills is like being a bull in a china shop. You'll hurt more than you help, and you just don't belong there. If you can't be good at time management, you will fail, plain and simple. L&D will teach you time management somewhat, but on a intermittent basis. Only a med/surg unit will force you to gain a grasp on having to keep up with constant infringements on your time and focus.

When you specialize, that's just it, your knowledge is special...exclusive. In other words, you know a lot about a little. So before you do that, take the time to know a little about a lot. You will be oh so much more effective.

A pregnant woman in labor is a whole different animal than a non-pregnant adolescent or adult patient on the floors. They have completely different body system functions going on, all of which fall into the category of "normal." When something happens that causes this abnormal "normalness" to become even more altered, the caregivers really need to be on their game. I have seen it time and time again, that a new grad nurse... who has limited experience and knowledge in the basics of Med/Surg...struggles. And what's more, they don't even know they are struggling. They just don't get it...and they don't know what they don't get.

Now, I've known some new grads who have gotten hired straight in to L&D. And some of them have done just fine. It is possible to do. Most L&D units, however, will at least make you do a stretch of time on the postpartum unit before coming to L&D. It's not easy to find an L&D unit that will hire new grads, so if you do want to go this route, I would recommend getting a job there as a tech, CNA, unit secretary, or of the like first, perhaps during nursing school, to get your foot in the door. I can pretty much say that it won't happen otherwise. At least not at a hospital at which you should or want to the long run.

So as Nike would say, "Just Do It!" Do the two years on the floor. Do it, and get really good at it. If you think that won't take two years, then I'm afraid you're overconfident. And one thing I can't stand is an overconfident, yet green nurse. That's a dangerous combination. Do it. Gain knowledge, get experience, become a resource. You'll hate it, but you won't regret it. And you will be better for it. Then, come to Labor and Delivery and you can focus on learning Labor and Delivery, and not trying to learn how to be a nurse as well.

And besides, you just can't call yourself a real nurse until you've had to digitally disimpact a 97-year-old woman with dementia, screaming like a banshee, saying, "AHHH!!! It's a wee cattle prod up me ars!!! GET IT OOUUUUT!!!!!" That's just good times.



  1. The basic things that we should remember as a nurse is to know our job and take by heart the meaning of health care. If you have that in mind, your body will voluntarily act as it is should be. God bless to all of us.

  2. It was really helpful reading your blog. I am a nursing student with 3 years experience as a med-surg CNA, but this semester is my first time working in a L&D unit. I am having a blast so far and I'm thinking about being an OB nurse. I totally agree though that at least 2-3 years of telemetry or med-surg background makes a big difference. Thanks for sharing!

  3. I did exactly what you did. I went to a telemetry unit first for 2 years and then went to L and D. It was such a good idea! I am so glad for that experience.

  4. I worked on a surgical oncology unit and just started L&D this week. Have only done 3-night shifts (with a preceptor of course) and I am already in love with my job! So much better to head into work not absolutely dreading it, however, I am glad for my prior experience. I cannot imagine starting out in L&D and still being intimated to start an IV or put in a foley. I have so many other things to learn and master now in addition to the basic nursing skills. Love reading your stories on this blog. :)

  5. thank's for your information i like it

  6. Depending on where you are, there are L&Ds that will hire new grads. Telling someone they need to be on med-surg before L&D is kind of stupid: they're two totally different animals, that really have nothing to do with each other. You will have an advantage if you can get your foot in the door before graduating.

    1. Now, now..."stupid" is a mean word. I think I explained quite adequately in my article why it is my opinion that a nurse should begin in Med-Surg and I hold to that point of view. Thank you for yours.

    2. There is no reason to waste time in med surg learning about flexiseal and colostomy pouch when I've NEVER seen any of that in l and d in the first place.

    3. Really? I have. There is something very scary about an L&D nurse having to put down an NG tube and not knowing the first thing about it. The median age of L&D patients is getting older, my friends. And with age comes health issues. Trust me when I say that NO ONE will ever say, "Gosh, I really wish I didn't know so much... I mean really... all this experience I have is way overrated!" Nope, never will. Why would you say "no" to having more knowledge?

  7. Let me say, why would I want to spend time in med surg when I never want to work there or anything like it? I do agree that it's a great starting point, but I know id be miserable and I don't want to do that to my patients.

    I just got a job as a new grad l and d nurse. I was a nurse apprentice in l and d for several months at a different hospital and it was stressful but fun! I know it will be challenging as a new grad but I'm glad to be starting in the field I've wanted the work in for so long!

    1. You have to choose your own journey, it's true. Congratulations on securing an L&D position. I wish you well.

    2. Really? If you "never want to work on a med/surg unit or anything like it, then you should not be a nurse. Regardless of where you work, the skills are the same. I hope that since you wrote this note, you have clearer vision! If you haven't, you will. Best of luck to you and your teammates!

  8. Labor and Delivery is not just mom's having babies. We care for two patients and their family. They can and often have medical problems that are often hidden and more difficult to treat. (Hypertension, diabetes, drug and alcohol abuse, medical and/or surgical complications). Furthermore, when we try to care for one of our patients (the mom), the other patient (the baby) is also affected by what we do or not do. Things can go bad very quickly and require you to intervene with confidence and efficiency. If you are a nurse who has never worked labor and delivery, please do not think that all we do is "play with babies all day". We are required to have multiple skills including triage, prenatal testing, labor and delivery patient care, fetal monitoring, newborn resuscitation, circulating and scrubbing in the OR, PACU, and med-surg skills. The doctors are usually not on the unit but in their offices and phone conversations are the standard of care. "Playing with babies"? I very rarely hold a baby as that is what I encourage the parents to do! I respect your skills, please do the same for the labor and delivery nurses!