1. Moore, Amy DNP, FNP-C
  2. Parks, Kamie MSN, NP-C
  3. Beckling, April MSN-Ed, CMSRN

Article Content

New graduates are needed to fill an ever-growing shortage of clinical nurses in the US. According to the 2014 Robert Wood Johnson Foundation report, approximately one in five RNs will leave their job in the first year and over one-third will leave within the second year. The US Bureau of Labor Statistics employment projections predict employment of RNs will grow 19% from 2012 to 2022, with job openings for RNs projected to reach more than 1 million by 2022. The American Nurses Association forecasts that there will be more RN jobs available through 2022 than any other profession in the US.

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Although some nurses are retiring, many are leaving bedside care as a result of burnout. The complexity of patient conditions and overload in patient assignments, along with constant technology changes, contribute to increased stress and anxiety, as well as decreased job satisfaction. Novice nurses face these and many other challenges. We provide tips for new graduate nurses in their first year of employment.


Caring for complex patients

In an ever-changing healthcare environment, you may find it exhausting to care for patients whose medical conditions deteriorate suddenly or care for more patients than you're comfortable with. Multiple reasons account for higher acuity levels, which can be overwhelming for you as you enter the workforce. Limited finances and/or education about disease processes often result in patients waiting to seek help until they're in crisis, leading to an increase in disease complexity. Mental illnesses may also contribute to the difficulty of providing patient care, as can poor adherence with taking medications. You aren't alone in the stress. Even experienced nurses can be overwhelmed with the stresses of caring for patients with serious illnesses.


As a novice nurse, you must accept that you don't know everything. All nurses begin in the novice role. You've been taught to care for patients in multiple situations, but it's impossible to train for every scenario. Find an experienced nurse whom you trust to help you in the first year. Don't feel embarrassed to discuss patient situations if you're uncomfortable with manifestations, such as a change in health, progress of a patient, or a physician's order. You should be able to leave work each day knowing you did the best you could for each patient who received care from you.


New evidence-based practices can be difficult to keep up with when there are constant developments in medications, procedures, and treatments. Providing best practices should be a priority, but even experienced nurses have little time to research continually evolving guidelines. Continuing education is imperative for all nurses to stay up-to-date with the latest guidelines. Benefits to consider when applying for a job include the opportunity and funds to participate in continuing education (see Applying for your first nursing position). Some hospitals offer education, such as advanced cardiac life support, basic life support, pediatric advanced life support, critical care, and trauma courses. Some facilities also provide funds for specialty education that may be applicable to your area of practice. You may also consider online education to help keep you up-to-date with current practices.


Working through poor patient outcomes

Navigating the emotions caused by an unexpected patient death or complication is complex. Most nurses can vividly tell you about their first experience doing CPR and/or losing a patient. Debriefing and counseling are important tools for working through these emotions. Over 50% of nurses will experience their first patient death while a student. Unexpected deaths can be especially stressful for the new nurse and may result in strong emotions of disbelief, guilt, and anger.


When you experience the death of a patient, formal debriefing time will allow you to reflect on the situation and provide an outlet for emotions. Regular sleep and good nutrition are helpful, whereas coping with the use of alcohol or drugs isn't recommended. If you find that you're reliving the experience repeatedly or experiencing signs of depression, it's important to reach out for further counseling.


Balancing work, home, and life

As a compassionate nurse, you have the desire to provide the best care possible for your patients and their families. It's often difficult to provide optimal patient care in conjunction with balancing the necessary tasks, such as medication administration, assessments, documentation, and patient education. It may be difficult enough to acclimate to a 12-hour shift without the fact that it often turns into a 14-hour shift. You may become exhausted and even dread going to work on some days. Although the hours seem long, they sometimes aren't long enough to provide the exceptional care you were taught to give.


Taking breaks throughout the day is vital to help with fatigue. Simply having another nurse cover your patients for a short period during the day so you're able to sit and relax is important to allow rejuvenation of your mind. Fluid intake, meals, and rest are also an important part of caring for yourself. It may take a while to become accustomed to going to bed early or, if you're working the night shift, sleeping during the day. Understand that it takes time to adjust to 12-hour shifts.


Preplanning days off will help you accomplish weekly home necessities and family needs. The potential to experience stress and guilt may arise from not seeing young children who are in bed when you leave for the day and asleep when you get home. On days that you have off, you may feel that tasks such as cleaning the house, buying groceries, and washing clothes take over family time. Take time to care for yourself and spend time with family and friends.


Identifying with your mentor

The workflow of the hospital can be difficult to learn, especially if you're expected to take a full load of patients from the beginning. Seek an experienced nurse whom you trust to help you in your first few months of employment. This person should work with you until you're comfortable in your role. Simple things such as finding supplies, learning the phone system, and locating the staff restroom can be frustrating if you aren't appropriately oriented to the floor. Previous experience on the unit as a nursing student, aide, or tech can be a great advantage in orienting to the basic flow of the nursing unit, but may also result in a disadvantage if you're expected to handle more patients than you're prepared for.


Some facilities offer a year-long training program or residency program. This can be beneficial to prevent burnout and promote job satisfaction. You may have been assigned a mentor with limited nursing experience, further adding to your already increasing stress level. You may feel that the mentor is struggling to complete patient care and doesn't have the time or expertise to advise you when solicited. Nurses with different personalities may or may not work well together. Being paired with a mentor with whom you can't develop a cohesive relationship may also cause stress for both of you. If you find that you aren't comfortable with an assigned mentor for whatever reason, visit with your supervisor to see if there are other options. It should be acceptable to change mentors. Becoming involved with local, state, and national nursing organizations is an additional opportunity to seek out information and discuss concerns with experienced nurses.


Refrain from mentoring others before you're comfortable in your role. Nurses are often called on to take leadership roles early in their career, but this can result in quicker burnout. Take time to develop confidence in caring for patients before taking on the role of teaching others.


Improving care with technology

Technology changes can occur daily and may be particularly difficult for the nurse who isn't technologically savvy. The electronic health record (EHR) has been used for several years now to improve patient safety, patient care, and population health; however, it can also cause frustration for the new nurse. You may not have had the opportunity to document in the EHR as a student. The process of entering your data may be slow at first and frustrating as you're attempting to care for patients and document thoroughly. Attempting to remember the basics of nursing documentation while maneuvering in the EHR may feel tedious and cause you more anxiety. You may feel stressed to complete documentation during extremely busy days when patients' needs are a priority and you're unable to stop long enough to document care.


Documenting as you care for patients is essential to prevent errors, oversights, and sentinel events. Facilities often offer EHR training during orientation. Although this may be overwhelming during your first weeks of work, practice will ease the burden of documentation. If you continue to struggle with documentation, your mentor or the technology department may be able to assist you in developing concise methods of documenting to increase efficiency.


Being recognized

Some facilities offer career ladders and awards to recognize nurses for their hard work and dedication to optimal patient care. Being a part of this process can deter early burnout for new nurses (see Burnout red flags for new nurses). With your mentor, plan on becoming familiar with the opportunities and requirements to promote professional and personal growth in your nursing career. The positive recognition for a job well done boosts morale and the desire to continue to work in a difficult environment. Job satisfaction is key to prevent burnout as a nurse.


A rewarding career

Nursing can be one of the most rewarding careers but also one of the most brutal. Transitioning from being a student to your first job as a new graduate nurse is taxing both physically and mentally. Understanding that it takes time to become comfortable in your new role is critical. Seek support from your fellow clinical nurses and management and always speak up when necessary to protect yourself and your patients.


Applying for your first nursing position

Consider the following tips when applying for first-time nursing jobs:


* hospital location-long commutes can cause an increase in fatigue quickly


* nurse-to-patient ratios-know the expectations of how many patients you'll care for as a new nurse and when you should anticipate taking a full load of patients


* interest in the nursing unit-if you're interested in the type of nursing available, you may be more satisfied with staying on the unit; if you have limited experience in a specialty area, you may need a longer orientation period


* orientation program-investigate the type of orientation, including the length of the residency program and mentorship


* nursing cohesiveness-visit with nurses on the unit and look for nurses who are generally happy and glad to see you join their family


* advancement-consider how you'll advance in position on your unit and the type of support you can expect from administration, such as educational funding and continuing education.



consider this

Julie's fear as a student in her last semester is, "Am I ready?" She always wanted to be a nurse but now that she's about to graduate, she's having second thoughts about actually being responsible for caring for multiple patients without someone watching over her to double-check her work. Julie has applied to a unit where she's practiced as a student over the last year, but she admits to being concerned about the complexity of patients and the workload ratio. Julie has met several of the nurses who she feels could be good mentors while in school, but she's also heard a lot of complaining about the need for more nursing help on the units. Julie has witnessed two new graduate nurses leave within just a few months because of the stress, and multiple nurses on the unit have started graduate school in hopes of another career in nursing. Julie wonders if and how she'll survive the first year.

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Sydney has been an RN on a medical-surgical floor for 11 months. As a new RN, she's participated in a 1-week newly licensed nurse orientation, a residency program that meets 1 day a month for her first year of employment, and a 12-week orientation to her unit. During her orientation, she had three different preceptors, some of whom were travel nurses on the unit and not well versed in the hospital's routine policies. Sydney was also responsible for participating in a group evidence-based practice project that was to be implemented on her floor as required for her residency program. With only 10 months of nursing experience, Sydney was asked to precept her first nursing student and soon after was assigned a newly hired nurse to precept on her unit. Sydney states that she often feels overwhelmed at work with the high acuity of patients on her floor and the nurse-patient ratio of 1:5, flexing at times up to six patients under her care. This is in conjunction with working full-time hours, precepting students and new hires, and participating in her ongoing residency program. Sydney is already questioning whether she made the right choice of nursing as her career path and considering her options of moving to another unit, going back to school for an advanced degree, or changing career fields all together.




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