Posted in Tips and Advice

I get so many questions from students that are nearing graduation and wanted to share some of the most recent ones here with you in this Q&A. 

Q: How do you deal with everyone that tells you that you should start with at least one year working on a Med/Surg floor before going into a different area?

A: Nursing is hard enough without forcing yourself to work in a specialty you don’t enjoy. If Med/Surg isn’t your thing, then you simply don’t have to do it. There are plenty of facilities that will hire and train new nurses into other areas including oncology, labor & delivery, postpartum, pediatrics, emergency room, operating room, critical care, and psychiatric nursing. Will you learn a lot on a Med/Surg floor? Absolutely! But if you’re not happy in that environment, then my advice would be to follow your dreams and apply to the units that excite you. 

I started as a new grad in the MICU and know I would have floundered working on a Med/Surg floor. I simply don’t have the mental flexibility to juggle that many patients and knew that I wouldn’t thrive in that environment. Med/Surg nurses have the most incredible time management and prioritization skills, are comfortable in an environment where literally anything can happen, and are well-versed in a wide variety of hands-on clinical skills. If that sounds like you, then there’s a good chance you’ll make an awesome Med/Surg RN!

Q: I really want to work in the ER, but I only get six days of clinical and precepting in that department. What can I do to learn the skills I need in that short of time?

A: First of all, please know you are not alone. Most students who are graduating during the Covid-19 pandemic got extremely short-changed on their clinical hours. With that said, no one expects you to know everything you need to know when you show up on your first day of work in the ER. A good preceptor will understand that hands-on opportunities in nursing school are limited, even when all clinical hours are met. 

For example, as a student I placed exactly one Foley catheter, and many students never go the chance. I never placed an NGT on a real person until I was doing it “for real” as the patient’s nurse. And even today, after having worked as a nurse for more than 10 years, I encounter skills all the time that I’ve either never done before, or haven’t done in a really long time. 

The point is, there will always be room for learning in nursing. And acquiring hands-on skills is only part of that. The biggest skills you can develop in your very precious clinical hours in the ER (or anywhere for that matter) are going to be critical thinking, assessment, clinical decision making, safe medication administration, clear communication, and recognizing when your patient is in trouble.

Q:  What are our first months at the hospital going to be like with soooo little clinical experience? I’m in my final semester and we’ve only had med/surg clinicals and by the time I’m done, we will have had 17 days.

A: This dovetails onto what I said above. Without a lot of clinical hours, going to the hospital as the “real nurse” is going to feel very stressful and probably even overwhelming. My advice is to apply to as many nurse residency programs as possible. In a residency program, you’ll receive additional support and training, dedicated preceptors, and supplemental seminars or lectures. 

If you’re not able to start your career through a residency program, then you should have very direct conversations with the hiring manager. Ask about their expectations of new grad nurses, how long the training is, how they measure success, and what their plans are for  orienting new graduates that have had drastically reduced clinical experiences. 

Unfortunately, many hospitals have such dire need for nurses right now that orientation periods have been reduced. Combine that with reduced clinical hours, and you have a recipe for disaster. Be very cautious about choosing a job that does not provide adequate training. If you don’t feel that you can provide safe care in that environment, then you need to find someplace else to work that can support you during this critical transition period. Your allegiance is not to the hospital. It is to your patients and to your license. Always. 

With that said, your first months are probably going to feel like you’re starting over from scratch. It’s not unusual for new nurses to state they feel like they “know nothing” or that what they learned in nursing school didn’t prepare them for the realities of the job. Be kind to yourself, keep a clinical journal so you can learn from your experiences, and focus on learning and doing a little more every day. It won’t be easy, but neither was nursing school. I believe in you!

Q: What do you do/how do you decide if you have multiple job offers? How long is appropriate to ask for time to consider the offers?

A: This is an excellent question, and if  you’re not used to negotiating job offers, this can feel really awkward. The good news is, in a competitive market where hospitals are having trouble hiring enough staff, they definitely expect their applicants to have multiple offers. And it’s absolutely okay to be honest and up-front about it. 

If you have been offered a position, it is always appropriate to ask the hiring manager or HR representative for a few days to consider the offer. If you’re not sure what to say, you could try something like, “This is a very attractive offer. I am also expecting to hear from a couple of other facilities. May I ask when you need my decision?” A statement such as this one shows that you appreciate the offer, you are being transparent about your options, and want to show them the respect of getting back to them at an agreed-upon date.

If, for some reason, you are uncomfortable being that forthright or want to keep your multiple offers to yourself, you can simply say, “I appreciate the offer and would like to [talk it over with my spouse], [give it careful consideration], [verify that this works with my childcare situation]. Can I let you know my decision on Monday?”

Any employer that can’t give you a couple of days to consider an offer should be a red flag. If they are facing a time crunch for some reason…maybe the residency program starts on a particular day and it’s fast approaching, or maybe the unit is experiencing a dire need, then they should be honest about the need for a fast decision as well. Remember, a job offer is not just them offering you the position. It’s you deciding that you want to work with them, too! 

Q: How do you gain confidence walking into a patient’s room and doing EVERYTHING?

A: The confidence will come with time. The challenge is, new nurses think they need to feel this confidence immediately or they’re inadequate somehow. We all need to take a step back and remember our good friend, Patricia Benner. If your eyes glazed over in nursing school when people started talking about theorists, it’s time to refocus, because Benner’s work will help alleviate a lot of that stress. 

According to Benner’s theory, nurses go through a progression throughout their careers. We start as novices, then progress to advanced beginners, then we move up toward competency, then proficiency until finally becoming an expert.

Progression through these stages takes time. And new graduates express they feel “incompetent” when they’re just starting out. Well guess what? That’s exactly how you’re supposed to feel! Competency doesn’t come into play for a while. In fact, it takes about 12 months for the new nurse to progress from novice to advanced beginner, and the competent stage isn’t reached for two to three years. 

So my point is, give yourself some grace. Accept that this is part of a journey that will be ripe with learning at every single stage. 

Q: I’m afraid I don’t know how to talk to patients or what to even do. I haven’t had a lot of clinical experience, so I’m worried I’ll look like a bad nurse or I don’t know what I’m doing.

A: Honestly, this simply comes down to doing it over and over and over again. Here’s what I always tell students or new nurses:

Patients are just people. Talk to them like they’re regular people. Nursing school does a really bad job of this, in my opinion. In nursing school, all the ‘scripting’ or demo videos show the nurse speaking in a very formal way, saying, “Good morning Mr. Richardson. I’m Louise and I’ll be your nurse until 7pm. I’m going to assess your vital signs and then administer your morning medication. It will take about 15 minutes.” Who talks like that? No one talks like that. Talk to your patients like they are real people. I promise that just doing that will make you feel more confident because it feels more like YOU. And I don’t mean you need to talk to them like you would if you were at a party, but it doesn’t have to be this stilted, overly clinical form of communication. For example, my first interaction might look more like, “Hi there…I’m Mo…I’m your nurse today. How are you feeling this morning?”  See how that’s NORMAL conversation? And then they tell me they’re tired or in pain or whatever….and then we go from there. Like normal people.

Chances are, your patients are feeling way more vulnerable and nervous than you are. Conveying your anxiety is only going to make them feel worse. Even if you are terrified on the inside, always strive to keep a professional demeanor and neutral expression. And, if you don’t know what to do, always always always start with assessment. Get a set of VS, listen to lungs, look at wounds, ask about pain, check that your room safety equipment is working properly, etc…

Q: What specific areas should we focus our studies on for NCLEX?

A: When preparing for NCLEX, it’s important to develop a study plan that gives you plenty of time to review. How long you prepare for the NCLEX is up to you, but it’s best to take it within about two months of graduation while the vast amounts of information you learned in nursing school is still fresh. 

As for focusing your studying on specific areas, the only way to know for sure what those areas are is by doing a comprehensive practice assessment such as this one. This test provides you with a breakdown of your results so you know which areas require more intense studying.

Q: I have two offers. One is in a psych facility and one is on a Med-Surg/Tele unit. Psych has been my favorite by far and is somewhere I can really see myself staying. I want to pass up the Med-Surg offer and accept the position at the psych facility. But, I feel I would be making a huge mistake in my career if I did that and that I would lose my nursing skills. I don’t know how to decide.

A: Students worry so much about the hands-on skills, but there are so many valuable skills you have that have nothing to do with tools, devices and procedures. And, honestly, a good preceptor can teach you the “hands-on” type of skills in about five minutes. It’s the critical thinking, clinical judgment, assessment skills and communication skills that make you a NURSE…not whether or not you can place an IV or change a dressing. If you are offered multiple positions and one lights you up and the others do not, my advice is to follow your heart. Trust me on this one.

Q: What are some red flags to look for while interviewing?

A: No system for providing breaks. Ask the hiring manager, “How do you ensure nurses get their breaks? For example, do you have break relief RNs who cover all the breaks for the day?” If the manager tells you “the nurses cover each other” this is a huge red flag and a pretty good indicator there are going to be days when you won’t get a break. 

Not taking you on a tour of the unit, or not having a really good reason why they can’t accommodate a tour. While a tour is not always offered on a first interview, if you’re coming back for a second or third interview, a tour is usually part of the process. The manager wants to take you around, introduce you to key people and show off their unit. If they don’t do this, don’t offer, or say no…this could be a red flag.

The unit is mostly staffed by new nurses, new grads, or travelers. All of these things point to the unit having a staff retention problem. A question you can ask in the interview is, “What’s the skill level mix of your current staff? Do you have adequate experienced staff to teach and mentor a new hire?”

Rushing new grads through orientation. One of the worst things a manager can do is pull a new grad off orientation to take a patient assignment. And yes, it happens. And if it happens on one day the chances of it happening again are high. And before you know it, orientation is over and you just got severely short changed. Ask the hiring manager, “How long are new grads on orientation, and do you ever pull them off orientation to take an assignment when census is high?”

Mandatory overtime. Ask about scheduling requirements and if extra shifts or overtime are mandatory when unit census increases. A well-run unit should be able to manage its staffing needs without placing the burden on the nurses themselves. 

A high turnover rate. A high turnover rate and a lot of open positions could be a red flag, but keep in mind that units do go through phases. Sometimes it’s simply that the staff have been very loyal, worked there for 35 years, and then a handful all retired at the same time. If this is the case, the manager will probably explain why the unit had so many open positions. A simple question you can ask is, “How many positions are open at this time?” and possibly also, “How many new staff have you hired in the past six months?” 

Q: Should I look for a residency or internship program as my first job?

A: YES! I am a firm believer in nurse residency programs, and talk about their benefits more in this article here.

Q: How  do you keep a positive mindset about starting your career when so many people seem to be talking so negatively about working in nursing right now.

A: I’m not going to lie, nursing is hard right now. But the truth of the matter is, there are going to be negative people in nursing no matter where you go or when you go there. 

What I try to do is extend my compassion to that other person who is struggling and give them some grace. They are going through a hard time. No one wakes up thinking, “I’m going to hate my job and my life today.” And while it may be really easy to judge someone for that, we can’t possibly know what other people are feeling. At the same time, I also set boundaries so I don’t let someone else’s experience automatically become my own. 

My advice to you is go into your career with an open mind and heart. See what it’s like for yourself. You may love it. You may not. You won’t know until you actually do it. And if you find that you don’t love it, then I encourage you to look for other opportunities in nursing. There are so many avenues to explore if you are willing to do so and even think outside the box a little bit.

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To everyone graduating soon or who has recently graduated, I am cheering for you and so excited you are joining me in this incredible profession. Click here for more tips and information for new grads. You’ve got this!

PS Want to this listen to Q&A on the go? Tune in to episode 209 of the Straight A Nursing podcast wherever you get your podcasts. With over 200 episodes, there’s a ton of content ready and waiting to help you study for your NCLEX. 🙂