1. Mason, Diana J. PhD, RN, FAAN


Our unwritten rules for new nurses threaten our survival.


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I was recently given the poem "Shoulders," by Naomi Shihab Nye, from her 1997 collection Red Suitcase.* In it, a man is crossing the street in the rain, carrying his son, "the world's most sensitive cargo," on his shoulder. The poem ends


We're not going to be able


to live in this world


if we're not willing to do what he's doing


with one another.



The road will only be wide.


The rain will never stop falling.



I read this poem as I contemplated writing this editorial about how we socialize new nurses.


I've heard many new nurses speak about their terror-vomiting before going to work, being unable to sleep-during the first months of what they hoped would be a long career. Such terror may be unavoidable. And it may be all too common, according to a study in this issue by Kovner and colleagues (page 58). In examining the literature these researchers found that new RNs left their first job within 18 months at rates that ranged from 7.5% to 70%, with the lower rate occurring after an intervention to empower staff nurses and the higher one in a small rural hospital where few orientation protocols were in place.


Kovner and colleagues report on the first national study of newly licensed RNs. Funded by the Robert Wood Johnson Foundation, the study will follow a cohort of new RNs for two years to provide more reliable data on turnover, as well as other information that's crucial to replacing retiring nurses. In this report, half of the 3,266 RN respondents either had already changed jobs or were ready for a change. About 40% said they received little guidance on how to work well at their facilities, and 62% said they had been verbally abused at work. Nonetheless, almost half said their job was "very much like the job I wanted."


All communities have their own values and rituals. These unwritten rules can be life sustaining, but nursing has a long-standing reputation for threatening its own survival by driving new nurses away. In the best nursing schools, students are able to say they don't know something, make mistakes, and ask for help. Then they come to the real world, where they're denigrated for acknowledging a mistake or showing uncertainty. "Your first year will be hell," "Prove yourself," and "We're not going to tell you the rules of this game, you'll have to learn them on your own"-these are the messages many new nurses receive.

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Can we change our tribal rituals? Here are three possibilities:


* Staff could meet with new nurses to talk about what the unit values and expects of the new employee. Is one of the rules doing whatever is necessary to keep patients safe? Errors are distressing for any nurse, but for new nurses, they can be utterly demoralizing.


* Managers could meet weekly with new nurses and ask, "How are you doing and how can we help you?" We should attend to the emotional aspects of being a new nurse with the same energy that we bring to evaluating the nurse's ability to pass medications.


* We could ask new nurses each week to list what is working well on the unit as well as what things they would change. A new nurse can challenge a unit to examine itself and identify ways to improve care. While we may like to complain about our institutions, we must remember that we are our institutions. Nurses have the power to work together and care for patients on a unit level.



Let's keep new nurses on our shoulders.


*Naomi Shihab Nye, excerpt from "Shoulders" from Red Suitcase. (C) 1994 by Naomi Shihab Nye. Reprinted with permission of BOA Editions, Ltd.: [Context Link]