The blur that was my first day as a nurse came into sharp focus the moment I received my first instructions—Go find your preceptor; she's on the unit.
That morning my anxiety kept me from doing what was most important and on any other day most natural: pause, breathe, look around like a normal person, then act. Instead, I clumsily charged into my new world: a U-shaped medical ICU with faded blue walls and an elevated nurses’ station in the center. Two nurses talked, leaning against the high counter.
“I'm Amanda. I'm new. Are you my preceptor?” I blurted, oblivious to their conversation.
I don't remember smiles. I do remember you've-got-to-be-kidding-me sighs, followed by a quiet but deliberate “yes” from one of them, a woman whose calm and regal air contrasted with my own frazzled state. Then she offered a succinct, “Go do your assessments. I get in at six and already did mine. We've got a lot to do.”
In that moment I forgot all the trivialities that had filled my panicked brain—fears of getting lost, whether to pack my lunch, worrying if my badge would work. These no longer mattered. It was time to begin.
THE REAL NURSING WORLD
Concepts and foundations aside, nursing school did little to prepare me for the day-to-day reality of the bedside. I knew how to do the technical things on my first day, and could have performed tasks for 12 hours straight. But skills like giving organized hand-off report, speaking to families, or knowing when to push for an order from a resident and when to back off were not covered in my undergraduate lectures. Feeling vastly unprepared, I slowly learned the nuances of nursing that everyone else seemed to know. Looking back now, I believe that if I had had better preparation for the real nursing world, I might have avoided teetering on that terrifying tightrope of burnout and exhaustion my first year.
In Transition to Practice we hope to provide that preparation. In this first article, you'll find a discussion of first-day anxiety, advice on making the most of the early days at the bedside, and steps to take to ensure nursing preparedness.
First-day anxiety isn't a new concept. From peer-reviewed journals to message boards, nurses frequently write and talk about their feelings on the topic. Although there is no way out of the jitters you'll feel on your first day, you can work on these feelings in concrete ways.
First, embrace your anxiety. Expecting to feel anxious as your first shift begins, and practicing ways to handle it, will alleviate its potency. Nurse administrators and mindfulness experts Patricia Reid Ponte and Paula Koppel describe practicing mindfulness as akin to the practice of muscle conditioning through regular exercise: “[R]outinely engaging in mindfulness-based practices strengthens attention and self-awareness and makes apparent our cognitive tendency to filter experiences according to expectations and preconceptions.”1 Their successful stress-reduction mindfulness pilot for staff at the Dana-Farber Cancer Institute in Boston included evidence-based mindfulness practices such as meditation and use of the STOP technique (see Figure 1).
Naming your feelings, instead of fighting or ignoring them, is a concrete step toward mindfulness and a way of taking responsibility for how your emotions affect others.2 Moreover, it requires little effort. For example, when you find yourself sleepless and fearful that you'll make a medication error on your first day, or your first patient will code, tell yourself, “I am feeling anxious.” Labeling or naming your feelings actually decreases their magnitude—you will feel less anxious as a result.3, 4
Knowing how your anxiety affects your behavior is also helpful. For example, when I'm anxious, my mind races and my tongue isn't far behind. I talk when I shouldn't, I ask questions that aren't well planned, and sometimes I miss important observations as a result. Because I'm aware that my default is to interrogate when anxious, I am able to harness and direct my questions with purpose. If I hadn't acknowledged anxiety as the source of these behaviors, I wouldn't know how to control them.
Recognize that anxiety will follow you throughout your nursing career. When you get your first assignment, you'll have a heart rate worthy of a rapid response team. When you float for the first time, you'll have it again. You may have it when you wake up each day and prepare for work. You'll have it for a long time after your first mistake, and again after your first death. In her book The Shift, hospice nurse Theresa Brown writes about the low-level anxiety that greets her before each shift, linked to the first patient she saw die: “It's why I'm hiding under the covers: I'm afraid. Afraid of that moment when the rock slips and all hell breaks loose.”5 No, anxiety will not be the end of you; in fact, without a healthy dose of anxiety, your care may veer toward complacency. Greet your anxiety, expect it, name it, and you will rule it.
Chances are, the reality of your first day will overshadow your first-day fears. They may not show it, but most staff will be happy to have you, you'll likely be assigned easy patients or you'll observe, and you'll be paired with an experienced nurse buddy. A good orientation and preceptor will also help you start out on the right foot.
Nurse residency or training programs. Although there isn't a standardized training system for nurses like the one for medical residents,6 many hospitals have extensive orientation for new nurses. If possible, look for a facility that offers a nurse residency or fellowship that includes intensive simulation training, classes in critical thinking, and a long-term preceptorship period. The American Nurses Credentialing Center, the organization that awards specialty certifications and Magnet recognition, started a Practice Transition Accreditation Program to credential qualifying nurse residencies, and a Nursing Skills Competency Program to accredit new graduate competency curricula. Evidence indicates that participation in these programs has resulted in decreased 12-month turnover rates, and increased satisfaction and confidence among new graduates.7
You will also likely have a preceptor. A good nurse residency program will pair you with a preceptor during orientation, and should make sure your schedules match during your first weeks as a solo nurse. If this isn't something your manager guarantees, request it; maintaining close contact with the person responsible for your training is helpful and will lessen your anxiety during orientation, as well as afterward.
Unfortunately, having a preceptor doesn't guarantee that she or he will be a good preceptor or a good match for you. It is wise to consider this possibility, which is not unheard of, and bullying in nursing, sadly, is quite common.8 In her blog post for AJN's Off the Charts, experienced nurse and educator Christina Purpora provided an example of this when she wrote about the time she curtly dismissed a fellow nurse's call for help9:
“I was walking out of a patient's room when Emily greeted me by name, then said, “Ms. S. has one of the new iv pumps and the alarm keeps going off. I can't figure out what's wrong. Can you please help me?”"
“I felt annoyed at her for making one more demand on my time when I could barely keep up with my current assignment. Rolling my eyes, I curtly replied, “Emily, I think you can handle it. You had the in-service like everybody else.”"
The remainder of Purpora's story is focused on how Emily “stood her ground” and used conflict resolution tools to ensure her learning and her patient's safety.
No matter the setting, nursing is variable and unpredictable—and never more so than in your first days or weeks. Your manager may promise only a few patients for the first few weeks. Then again census may be high, someone may call in sick, or some other emergency might occur, and you could be assigned the same number of patients as your more experienced colleagues. While other nurses will be adept at navigating this flux, for you it will feel like a chaotic whirlwind.
When I look back on my first years of nursing, I remember thinking that the patients I cared for were deathly ill, sicker than patients in other ICUs. After some reflection, I realized that I was just new and in reality most units are the same. With experience, things level out.
Having a successful first day at a new job is partly a new nurse's responsibility and requires preparation. This entails basic, but very important, steps. These aren't based on research findings or recommended by major nursing organizations. They are the tips and tricks of the trade from experienced bedside nurses that I wish I had known on my first day.
Understand your workplace. Whether you are a new graduate starting on a medical ICU, as I did, or a school nurse in a rural district, it is in your interest to know the setting you'll be working in before showing up for your first shift. My first unit had a large population of AIDS patients who presented in septic shock, and an even bigger share of people with cerebrovascular emergencies because of untreated hypertension. Had I read up on these topics, I might have transitioned into my role feeling a little less confused.
Don't be overwhelmed. During the first tour of your unit, simply ask your new manager, “What three conditions are absolutely essential to know on this unit?”
Bring your lunch. Just do it, especially if you've never been on your new unit before and don't know the routine. Bring something that is easy to eat and high in protein if your diet allows. A new-grad friend of mine told me she survived her first year on hard-boiled eggs, simply because she could eat them in less than two minutes—the amount of time her patient load allowed. Having to leave the unit to buy food or prepare something complicated takes too much time away from work.
Always take a break, even if it's only for a few minutes. In the beginning, your tendency will be to work 12 hours straight. Although safe and successful units give their staff regular breaks, not every unit does this, so you must have your own plan. I once worked with a nurse who took a break every day at 11 am no matter what; he prepared for the time and reminded his colleagues. Because he unfailingly held to this standard, everyone knew this time was nonnegotiable. None of his patients died, nobody fell out of bed, and every night he went home on time because he prepared for all aspects of his work, including meeting his own needs.
Be organized. If you can't keep track of basic things—like your pen or ID badge—you'll miss out on important learning moments while you look for them. My first preceptor rolled her eyes at me during a busy shift after I had lost my pen for the second time. “Keep it in the same pocket. Always,” she taught me. Ten years later, I've yet to lose another pen. Apply the same rule to your ID badge, your phone, and your stethoscope, and you'll reserve your time and energy to focus on what counts.
Be flexible. Prioritize being flexible at work. If, for example, you and your preceptor don't get along, ask your manager to hold a meeting with the three of you. Be open to their criticism, but also to the possibility that you and your preceptor just might have different personalities. It's not wrong to ask for another preceptor—but you might consider adapting to the challenging one you already have.
My first preceptor was rigid and chilly when we first met. She ran my orientation like a boot camp. But unlike other nurses who had trained with her and requested other preceptors, I was determined to keep up. When she told me—in the first sentence she uttered—that she reported to work an hour earlier than required and completed all of her patients’ assessments before her colleagues even arrived, I made a mental note to set my alarm clock an hour earlier for my next shift. Because I was willing to do things her way instead of balk at her requests, I ended up having a preceptorship that has served me well to this day, and I still consider her my mentor and friend. Flexibility, although sometimes challenging, always pays.
Share your anxiety with your preceptor, charge nurse, or nursing educator up front. Stating clearly, “I'm feeling a bit anxious about this first day,” not only helps you by labeling your emotion (as stated above), it also makes the other person aware of your self-assessment, which might be skewed.
When I was a brand-new nurse, my preceptor told me not to orally suction my patient because she had a clot in her mouth that was compressing an area that had been bleeding. Later in the day I forgot this and suctioned the patient's mouth. Sure enough, she started to bleed. Since it was the first time I had seen blood on a white gown, I overestimated its volume and panicked. I yelled for my preceptor, who calmly reminded me of the original wound. The blood on my patient's gown was simply the clot I had dislodged plus a small amount of blood that had oozed. We suctioned it up, observed the patient for a minute, and agreed that everything was fine. My assessment of the amount of blood was wrong and so was my anxiety, which I then shared with my preceptor. Telling another nurse my feelings helped me see the reality of the situation.
Know the tools available to help you. Your employer likely has a recommended communication plan or safety strategy in place. So do organizations involved in improving work environments and quality and safety. For example, the Agency for Healthcare Research and Quality has a program called TeamSTEPPS, which teaches quality improvement behaviors in health care settings. One of their strategies to ensure clear communication in situations where safety might be at stake is to use “CUS” words—“I am Concerned! I am Uncomfortable! This is a Safety issue!”10 This use of standardized labels or assertive statements can cut through the busy pace of the unit, ensuring that your concern for your patients will be addressed by an experienced eye.
Nursing is a big job, bigger than knowing the length of a P wave or the correct gauge of a needle, and there's no way nursing school can prepare you for the enormity of what you'll experience your first year at the bedside. Entire branches of nursing science are devoted to a new graduate's transition to practice and at what point a novice becomes an expert, and much research attests to the many challenges and pitfalls of this process.
Victoria Gill, my infamous first preceptor, and an award-winning intensive care nurse and clinical educator, sums it up this way: “The first year of nursing is like building a sand castle next to the ocean. Each grain of sand needs to be not only strategically placed, but more importantly, always ready to take a hard hit from the water nearby.” With support, insight, and the tools necessary to perform this intricate task, your castle will withstand the waves, becoming stronger and better each time.