Advice to new nurses, in a nutshell

I've trained or helped train a few new nurses, with some success, and I just heard from one (not trained by me) leaving orientation who is scared, so I thought I would barf up some pearls of wisdom that seem to have helped new nurses the most. Some read this blog, so perhaps they will add comments. I train ER nurses because I'm an ER nurse, but I learned a lot of this on the floor. I vividly remember one of my first shifts as a new RN on my own. I had four patients on a day shift, all four needed something relatively important right then, and I felt rooted to the floor with fear. I literally didn't know what to do next. I had an overwhelming feeling I was going to burst into tears and run screaming out of the unit. I picked the absolute wrong solution and just started picking tasks so I'd be doing SOMETHING.

Which leads me to the first and most important thing: if you find yourself running around blindly completing tasks to keep your head above water, STOP! You are screwed and cannot recover easily. So, no matter what you're doing, stop. Formulate a plan. Do not do a single thing until you have a plan. Unless someone is coding or crumping, STOP and put every patient you're responsible for on your horizon. Ponder, quickly, all the stuff you have going on for everyone. Prioritize however many tasks your short-term memory will hold (this number will expand fast). Now you have a plan. Now run around completing your tasks (if you've deemed this is the most important thing; sometimes it will be "I gotta pee or we're gonna have big issues").

Related: have a big picture. What is the patient there for? Yes, you need to consider the patient as a whole, but they're there for some reason. Focus on that reason. Chart on that reason. Chart on their responses to your interventions related to that reason. Patients can scatter your attention really fast whether you're new or not, but it's worse when you're new. Say this out loud right now: "I'm going to redirect you right now." These are your magic words. You are ignoring neither their story about the car wreck they had in 1978 nor their urgent need for fuzzy slippers. You are simply redirecting them to what you need to know in order to compile your big picture ("where is your chest pain?"). When you are a new nurse, you can miss the forest for the trees; when you walk into and out of a room, see in your mind's eye THE OBVIOUS. By this I mean, "what do I see that concerns me?" or whatever catch phrase you use. It's tempting to focus on what the patient wants you to focus on. That isn't necessarily the issue YOU will focus on. Example tied together from multiple incidents: child appears with parents stating the child has asthma, is wheezing, and her breathing treatments aren't working today. And indeed you hear audible wheezing (that's good! it's audible!). New-nurse response: whip out stethoscope and listen to lungs, anticipating nebulizer treatment, slam-dunk. Experienced-nurse response: child is moving air (so we don't need to wonk out about her airway just yet), is lethargic, and has slow cap refill. Child is shocky and about to crump. Big picture.

I probably made my last trainee nearly lose his mind. "What all is on your radar? What is your plan? Why?" We did the nursing process out loud all day long in this way.

You are going to be slow, too. Just get over thinking you're going to be a speed wizard. You're not. If someone is going to die because you're too slow, you will ask for help. Everyone else will have to wait, including physicians. That's unfortunately how it works. Overcome this to a large extent by checking in with the waiting patients, telling them where they are in your master plan, and assuring them that they are on your radar. I'm serious. This goes SUCH a long way. Then with each patient, BE WITH THAT PATIENT. Make them think they have your full attention. Apologize sincerely if you must be interrupted. These are ways I've found work well in lieu of falling over myself apologizing for making people wait. I don't see any problem with giving patients reasonable expectations of their wait times. I like that when I'm a customer. I still get pissed when I have to wait, but less so than when I also feel ignored. Physicians are generally somewhat mollified if you can at least tell them where the thing is they want NOW on your master list (that thing is number 4).

Get discharge vital signs. (That's kind of an inside joke, but seriously, don't send anyone away without checking them over to make sure something hasn't cropped up.)